The Darker Side of Pregnancy

After discovering she was pregnant with her first child in the fall of 2011, Mariah Warren was excited, though somewhat nervous about becoming a mother. Around the six-month mark, her mild jitters turned into full-fledged anxiety, complete with insomnia, racing thoughts, physical and emotional agitation, distractedness, decreased appetite and other unpleasant symptoms. "I had depressed moods but the anxiety really stands out because it felt so much more urgent -- like being trapped in a horror movie, knowing something or someone was chasing me and having no thought other than to escape at all costs," explains Warren, now 42, of Holmes, New York.

Because she had experienced anxiety and depression previously, she recognized the signs and turned to her psychiatrist for help. "But he refused to prescribe medications to a pregnant woman," she recalls. Her obstetrician was in favor of medication for the sake of Warren's well-being and her developing baby's. But Warren didn't want to risk damaging her relationship with her psychiatrist -- "he was the person I credited with getting me to the point where I felt ready to have a child," she explains -- so she stayed medication-free. Instead, she relied on psychotherapy and daily dance sessions to get her through the emotional rough spots. Within a few weeks, her anxiety passed, and she went on to deliver a healthy baby boy.

These days, a considerable amount of attention is paid to postpartum depression, but depression and anxiety during pregnancy remain fairly well-kept secrets. (So does the fact that the two often go hand in hand.) After all, having a baby is supposed to be one of the most joyful events in a woman's life, so people often have a hard time imagining that she would feel anything but ecstatic. "It used to be thought that pregnancy was this special, protected, happy time against depression and anxiety but research now shows that's not always the case," notes Dr. Elizabeth Fitelson, an assistant professor of psychiatry and director of The Women's Program at Columbia University in New York City. "Some women struggle quite a bit during pregnancy, and one-third of postpartum depression actually starts during pregnancy."

[See: Apps to Mind Your Mental Health.]

As it happens, depression is nearly as prevalent during pregnancy as it is during the postpartum period, with up to 23 percent of pregnant women experiencing it, according to the American Congress of Obstetricians and Gynecologists, or ACOG. Meanwhile, a 2014 study from Sweden found that 16 percent of women experience anxiety in early pregnancy, while other research suggests that up to 30 percent of pregnant women may have anxiety at some point during the nine-month stretch.

Who's at Risk and Why?

Having a prior history of depression or anxiety is the biggest risk factor for experiencing a mood disorder during pregnancy; having a family history of a mood disorder is close behind. Other risk factors include marital instability, lack of social support, domestic abuse or having suffered a previous miscarriage or stillbirth. If the pregnancy is unintended, that's a risk factor. And if a woman has a chronic medical condition that's exhausting such as rheumatoid arthritis or poorly controlled diabetes, "these are biological factors that increase the probability of depressive illness during pregnancy," says Dr. Shaila Misri, a clinical professor of psychiatry and obstetrics and gynecology at the University of British Columbia in Vancouver.

In addition, "there may be a subset of women who are exquisitely sensitive to the hormonal changes of pregnancy -- the dramatic hormonal shifts may set off a chain reaction with the chemicals that regulate mood," explains Margaret Howard, a professor of psychiatry and human behavior at Brown University and division director of Women's Behavioral Health at Women & Infants Hospital in Providence, Rhode Island. "These are the same women who have PMS [premenstrual syndrome] or PMDD [premenstrual dysphoric disorder, a more severe form of PMS] and who are likely to have a rough time with menopause in the future."

[See: 11 Changes Women Go Through in Menopause.]

The concern isn't just that an expectant mother may feel emotionally lousy throughout pregnancy. A growing body of research suggests that untreated depression and anxiety during pregnancy can have negative effects on the mother's health and the developing fetus, increasing the risk for preterm birth and low birth weight. Left untreated, "depression and anxiety [during pregnancy] may increase the risk for miscarriage, possibly due to the increase in stress hormones such as cortisol, and they're associated with a three-fold increase in the risk of pre-eclampsia," Howard notes. Meanwhile, a 2016 study from East Tennessee State University found that women who are depressed during the first trimester have a higher risk of developing gestational diabetes.

An expectant mother who's suffering from depression or anxiety also may be less likely to eat or sleep well, take prenatal vitamins, attend prenatal appointments regularly or exercise consistently; on the other hand, she may be more likely to self-medicate with alcohol or other substances that are detrimental to her developing baby, Howard notes. If her depression and anxiety aren't treated, there's also an increased risk of a mother experiencing postpartum mood disorders and trouble bonding with her baby. "Depression can become chronic and you can develop cognitive deficits where you cannot concentrate," says Misri, author of "Pregnancy Blues." Warren went on to have severe postpartum depression and anxiety and continues to take antidepressants to this day.

Addressing Mood Changes

Obstetricians are getting better at screening for mood disorders during pregnancy, using tools such as the Edinburgh Postnatal Depression Scale or the Postpartum Depression Screening Scale (ACOG recommends that OB-GYNs screen women for these disorders at least once during pregnancy). But "without screening, we're not very good at picking them up," Fitelson says. This may be partly because some of the symptoms of depression -- fatigue, sleep, appetite disturbances or concentration problems -- often occur naturally during pregnancy. The key, experts say, is to focus on emotional changes such as increased sadness, irritability or weepiness; feeling lonely, inadequate, helpless or hopeless; agitation or free-floating anxiety; an inability to enjoy normally pleasurable activities; intense worries about the baby's well-being or your ability to function as a mother; and thoughts of death or suicide.

[See: 9 Things to Do or Say When a Loved One Talks About Ending Their Life.]

Some mothers-to-be with depression or anxiety may try to tough it out and hope their symptoms lift once the baby is born. But experts say that's a bad idea. "It's important to pay attention to how much pain these disorders can cause," Fitelson says. "Just like you wouldn't ignore a broken leg during pregnancy, depression and anxiety shouldn't be ignored -- they should be treated."

If your obstetrician doesn't ask about your mood, the onus is on you to broach the subject if you're feeling depressed or anxious. And if you're considered at high risk for one of these conditions because of your current circumstances or your family or medical history, "stay in close touch with your physician," Misri advises.

Psychotherapy -- in the form of cognitive behavioral therapy, nicknamed CBT, or interpersonal psychotherapy -- is usually recommended as a first-line treatment. Moderate exercise can help; so can bright light therapy, which is often used to treat seasonal affective disorder. Participating in group mindfulness-based cognitive therapy also can lead to significant improvements in anxiety, worry and depression, as well as substantial increases in self-compassion, among pregnant women, according to a 2014 study from the MGH Institute of Health Professions in Boston.

If these measures don't help sufficiently or if a woman has severe depression or a prior history of severe depression, medications may be warranted in combination with psychotherapy, Fitelson says. While using any antidepressant during pregnancy isn't 100 percent risk-free, experts say there is more reassuring information about many of these drugs, particularly the selective serotonin reuptake inhibitors, or SSRIs, than a decade ago. "There are risks but they're fairly safe depending on when they're taken during pregnancy," Fitelson says. If they're taken during the first trimester, there's no risk of major birth defects or deformities. If they're taken during the second or third trimester, there may be transient symptoms after birth -- such as tremor, decreased muscle tone or difficulty latching on during breast-feeding, Fitelson notes, but these typically last less than a week.

As in Warren's case, "general psychiatrists are often reluctant to medicate pregnant women," Howard says, so it's wise to seek one who's well-versed in the nuances of treating women's mental health during pregnancy. Ultimately, there's no good reason for a mother or her developing baby to suffer through a pregnancy that's marked by uncontrolled anxiety or depression.

"Untreated maternal depression affects kids' emotional and cognitive development," Fitelson notes, "and a mother's physical and emotional well-being is essential for the family system to function, especially if other kids are present." In other words, an expectant mother's health and well-being can have a substantial ripple effect on her family.

Stacey Colino is a freelance Health + Wellness reporter at U.S. News. You can connect with her on LinkedIn or email her at staceycolino@gmail.com.