Pregnancy is an exhilarating time for many women. However, for people suffering with anxiety or depression, it can also be a time of great angst concerning their mental health treatment. Even women without a preexisting mental health condition can develop anxiety or depression while pregnant. In fact, 33% of women experiencing symptoms of perinatal mood and anxiety disorder (PMAD) never had a mental health issue beforehand.
Whether you are currently on medication or seeking medication for mental health issues, it is important to get clear and accurate information. Unfortunately, there is still a lot of stigma and misinformation around medication in pregnancy. Regardless, know you are not alone in this, approximately 20% of women will experience a PMAD. In response to growing awareness, more and more providers and communities are providing support.
How common are anxiety and depression during pregnancy?
PMADs can occur in any point during pregnancy. Perinatal refers to any period of time from conception to the first full year after birth. Postpartum refers to the first year after birth. Prenatal is during the actual pregnancy. Approximately one in five to seven women will experience a PMAD. Of those, many had preexisting conditions.
- Overall rate of PMAD during pregnancy 15-21%
- Postpartum Depression 20%
- Perinatal Depression amongst low income people and teens 60%
- Postpartum Anxiety 10%
- Perinatal Obsessive Compulsive Disorder 11%
- Perinatal Panic Disorder 11%
Rage, although not an official diagnosis, is common as well.
Did you know that fathers and non-birth partners can develop postpartum depression as well? We’ll cover that in a separate blog post.
Am I at risk for developing depression or anxiety in pregnancy?
These conditions can happen to any one. However, we do know that certain factors put people more at risk. They include:
- Poor social support
- Prior loss
- Past mental health issue
- Financial hardship
- Homelessness/housing insecurity
- Unplanned pregnancy
What are the risks of untreated anxiety and depression in pregnancy?
- Pre term birth
- Low birth weight
- Lowers attendance at midwife/doctor’s appointments
- Impaired fetal growth
- Higher rates of NICU admission
- Cognitive, behavioral, and emotional issues in the baby and possibly other children in the family
- Poorer health habits including nutrition, sleep, and substance use
- Relationship conflict
- Poorer job performance leading to financial stress
Why does my mental health affect my baby?
Research in understanding the mechanism is still developing. We believe that changes in the Hypothalamic-Pituitary-Adrenal Axis of the mom (which happens when stressed) affect the developing baby. These changes expose baby to fluctuating stress hormones and cause a decrease in placental blood flow. This means that baby gets less oxygen and nutrients than she needs.
What is the actual cause of the perinatal mood and anxiety disorders?
Current theories include four causes. However, like anything we experience, it is probably an interplay of factors, not one specific thing. Although some women find relief in having a definitive “how come”, it is really more helpful to focus on treatment. Some women are very sensitive to the hormonal fluctuations that occur during pregnancy and thereafter. Sleep deprivation is a known driver of mental health issues as well. Of course , environmental factors like strained relationships of financial insecurity are stresses. Lastly, some people have a genetic predisposition to mental health issues.
History of medication in pregnancy.
The number of women taking some type of prescription medication during pregnancy has dramatically increased over the last four decades. Currently, 9 out of 10 women will take some type of medication while pregnant. Of course, not all of theses are mental health medications but the use of antidepressants has increased through the years. This is in part somewhat to the advent of SSRIs in the 1980s
From 1979-2015, the FDA used specific categories (A-D and X) to group medications in terms of risk to a developing fetus. Unfortunately, this did not really paint a clear picture of what was “safe” and “not safe” in pregnancy. In fact, some of the data was downright misleading. In response to clinicians and patients wanting a better way to evaluate medication in pregnancy, the FDA now groups medication into three categories: Pregnancy, Lactation, and Females and Males of Reproductive Potential. These categories offer more specific information but still do not confer absolute safety in pregnancy.
Why do you as a potential pregnant person need to know all of this? Because, if your provider says, “No, you must stop you (blank ) medication because it’s category C,” then you will know they are not keeping up with the times.
Limitations of the research.
Many women want to know “What is the safest medicine in pregnancy for me?”. Unfortunately, we can’t answer that. In fact, no one can. Medication registries and mounting research shed light on medication safety. However, there are some limitations. For example, many studies clump all of the SSRIs (Zoloft, Prozac, Lexapro, etc.) together so it’s hard to know specific risks for any particular one. Furthermore, many women take more than one medication while pregnant so it can be challenging to know what causes what. Lastly, some studies don’t control for things we know are higher risk like smoking, alcohol and substance use.
That being said, we do know that, overall, it is much safer for the baby, mom, and her family to have mental health conditions well managed than not. Even if that means using medication.
Guiding factors for choosing medication in pregnancy.
Medication use in pregnancy is considered with caution. We must evaluate the risk of untreated psychiatric symptoms vs. the risk of the medication. We must also consider that treatment presents benefits for both mom and fetus whereas untreated mental health symptoms put mom, fetus, her other children, and partner at risk. The following principles guide us when considering medication in pregnant/lactating women.
1. Your baby is exposed to something. Whether it is your mental health symptoms or the medication. Risks of exposure to symptoms can be as bad, if not worse, than risk of exposure to medication.
2. We use the least number of medications at the lowest doses possible to control symptoms. When symptoms are not controlled, baby is being exposed to them and the medication. Therefore, don’t be afraid to take a higher dose if needed.
3. Generally speaking, it is best to continue on whatever medication you were taking prior to pregnancy.
4. No one medication is “safest” in pregnancy.
We also consider the baby’s gestational age (or how far along you are) as certain medication may affect certain periods of development.
Selective Serotonin Reuptake Inhibitors (SSRIs)in pregnancy.
Zoloft, Prozac, Zoloft, Lexapro, Luvox, Celexa, and Paxil are all SSRis used in pregnancy.
These are the first line for depression and anxiety. They are also the most studies group of psychiatric medication in pregnancy. Unfortunately, most of the studies clump them all together, however Zoloft (sertraline) has the most data.
Human and animal studies conclude there is no increase in birth defects in babies exposed to SSRIs in pregnancy. However, use of any SSRI is associated with up to a 30% risk of the infant having neonatal adaptation syndrome (NAS).
Symptoms of NAS include :
- Excessive crying or high-pitched crying
- Excessive sucking
- Hyperactive reflexes
- Increased muscle tone
- Poor feeding
- Rapid breathing
- Stuffy nose, sneezing
- Trembling (tremors)
Weaning from the SSRI in the third trimester does not reduce the risk of NAS and may result in the resurgence or mood or anxiety symptoms. Therefore, it is not recommend to do that. However, skin to skin contact after birth can help reduce theses symptoms.
Although theses symptoms sound scary and the list is long, they are transient and not life threatening. They don’t have any lasting negative effects. In fact, in infants that do exhibit them, it is usually mild.
Serotonin and Norepinephrine Reuptake inhibitors (SNRIs)
Effexor, Pristique, and Cymbalta are all used in pregnancy
This category of medication is also used for depression and anxiety. They are not as common but certainly effective. Most recent data indicates the risks in pregnancy are similar to that of SSRIs. However there is less overall data. Common SSNRis are Effexor, Pristique, and Cymbalta.
Second Generation Anti-psychotics, mood stabilizers, and stimulants are also sometimes used during pregnancy. We will discuss those in later posts.
Benefits of medications in pregnancy.
How are you feeling now about taking a medication in pregnancy? One thing to consider is that there can be sizeable benefits. As the old saying goes: “If mama ain’t well, then nobody is well”. The key is to have effective treatment. Even if that means a higher dose of the medication. Moms can take better care of themselves and their family with treatment. All moms have the right to enjoy their pregnancy.
Other treatment options.
Of course medication alone is not the answer. Mental health conditions respond best to a multi-pronged approach.
Therapy or Counseling
Talk therapy is proven beneficial for perinatal or postpartum depression or anxiety. It can be short or long term. In my practice, I’ve seen women feel better in as little as 8 sessions. Obviously, everyone has their own individual experience. Look for a provider with a background in maternal mental health and who uses evidence based techniques.
It’s no secret that one of the first things sacrificed when you have a new baby is sleep. The sleep deprivation during pregnancy is less talked about. However, it can be significant as well. Strategize with your partner about ways you can maximize your sleep. Can midnight feedings be shared? Be vigilant about your own sleep hygiene. This means reduce screen time, limit caffeine, and delegate tasks so you can go to bed.
A simple walk in the morning sunshine can actually have a big effect! Most people can exercise while pregnant, just be sure to check with your provider. After baby comes, you may need to modify your routine but you certianly can go for walks or do gentle movement. This not only helps you mood but may also promote sleep later on.
Acupuncture offers myriad benefits during pregnancy.
How do I decide about taking an antidepressant during pregnancy?
Get REAL information from a trusted mental health professional. Make sure they have special training in perinatal mental health and are up to date with the latest data. Talk with your partner about it. Sometimes, it can be helpful for your partner to accompany you to an appointment to get the full information with you. Lastly, there are groups like The Blue Dot Project and Postpartum Support International that can offer resources and support groups.
Anxiety and depression are tough to deal with normally. Pregnancy adds a whole other dimension to managing them. It is understandable to have concerns about taking medication in pregnancy. In fact, many women will talk about their “anxiety about anxiety medication”. Just know that taking care of yourself helps your baby.