Postpartum Depression: Signaled During Pregnancy?

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Heide Benser / Corbis

Six years ago, Jamie Nesi, a case manager for special-ed children in Bellport, N.Y., received a diagnosis of mild depression. Her doctor prescribed a low dose of Prozac, which eased her symptoms. In 2005, Nesi, then 33, got pregnant, and at her gynecologist's recommendation, she discontinued the medication. For the first two trimesters, things went smoothly. "It was my first child, and everyone said I was having a perfect pregnancy," said Nesi in a phone interview.

But at about the sixth month, Nesi began experiencing panic attacks. Soon her intermittent anxiety evolved into full-blown depression. "I didn't want to get out of bed all day. I avoided people, kept crying a lot, didn't eat properly and even had second thoughts about having a baby," Nesi says. At Nesi's prodding, her obstetrician referred her to a psychiatrist, who suggested that she get back on a low dose of antidepressants. "It was a very difficult decision," says Nesi. "I spoke to my husband, and we finally decided that [taking antidepressants] was the right thing to do."

Nesi's depression abated, but she continued to feel periodic pangs of sadness throughout the course of her pregnancy. On Oct. 27, 2006, when her first son was born, Nesi was overjoyed. But two weeks later, a powerful shift in mood overtook her, ballooning into an episode of postpartum depression that lasted four months. "My mother had to come down and take care of my baby," says Nesi.

Nesi's case is not unique. Psychologists say that many women who experience postpartum depression have had depressive symptoms during pregnancy or even earlier. A 2007 study by the Centers for Disease Control and Prevention found that of 4,400 pregnant women, 457 were depressed postpartum, and nearly half of those women had developed depression previously, either during pregnancy or in the nine months before they got pregnant.

Over the past decade, researchers have increasingly focused on so-called antenatal depression (depression during pregnancy) and its effect not only on mothers but also on the development of the baby. In a new study published in the Feb. 5 issue of the journal Child Development, researchers found that children born to women who were depressed during pregnancy were four times as likely to be arrested for violent crimes by age 16 as children of nondepressed mothers. The study involved 120 randomly chosen women from South London, who were interviewed when they were pregnant and after they gave birth. Researchers also interviewed the participants' children when they were 4, 11 and 16 years old. Further, the authors accounted for other stresses in the mother's life that could contribute to a child's antisocial or violent behavior — such as smoking, alcohol use, relationship problems and poverty. "It's depression during pregnancy that seems to set the child on taking a violent path," says Dale Hay, a professor of psychology at Cardiff University in the U.K. and the lead author of the paper.

Hay's is not the first study to observe an association between negative behavior in children and mothers' antenatal depression. In 2003 a large Finnish study found that sons of women who were depressed during pregnancy had an increased likelihood of being arrested for criminal acts before they turned 30. The new British study went a step further, however, because Hay and her colleagues were able to interview the families and factor in the effects of environmental and socioeconomic circumstances, as well as the mother's psychological health.

Other small studies have found that compared with their healthy counterparts, depressed women have a slightly higher likelihood of miscarrying and giving birth preterm. And a 2006 study published in Infant Behavioral Development found that babies born to clinically depressed mothers were more irritable, less attentive and exhibited fewer facial expressions than infants born to mothers without depression.

The exact mechanisms by which antenatal depression may affect a child's future behavior are hazy, but researchers think they could have to do with the environment inside the womb and its long-lasting impact on the growing fetus — a process known as "fetal programming." Maternal influences such as alcohol or drug use, poor nutrition and stress are known to affect the level of hormones in the mother's body. It is thought that biochemical changes in the uterus have an impact on the baby's development, affecting its birth weight and even its future risk of disease, among other things.

From 14% to 23% of women giving birth in the U.S. each year experience a depressive disorder during pregnancy, according to a joint report published in September 2009 by the American College of Obstetricians and Gynecologists (ACOG) and the American Psychiatric Association. On Jan. 21, the ACOG made an urgent call for depression screening as early as possible during pregnancy. "Studies have shown that untreated maternal depression negatively affects an infant's cognitive, neurologic and motor skill development," read an ACOG communiqué issued to its members. The document went on to "strongly encourage" obstetricians to screen patients for depression as part of their routine practice.

Public-health experts, psychiatrists, obstetricians and social workers agree that many cases of depression during pregnancy are going undiagnosed or untreated. This is partly because American women tend to prefer a watch-and-wait approach to illness during pregnancy, says Dr. Shari Lusskin, director of reproductive psychiatry at the New York University (NYU) Langone Medical Center. Women's "hands-off method" — which may stem from an unwillingness to undergo treatment that could harm the fetus — combined with a general societal stigma that is still associated with depression, makes for a "'Don't ask, don't tell' sort of environment when it comes to depression during pregnancy," says Lusskin.

What's more, there is a shortage of experts who are qualified to deal with the diagnosis and treatment of antenatal depression. At NYU, Lusskin runs a program designed to educate ob-gyns about the symptoms of prenatal mood disorders so they can identify the problem early. Lusskin says even though depression-screening tests are helpful, asking the patient simple questions about her mood can go a long way. "There is no substitute for asking the patient how she feels," she says.

But once antenatal depression is diagnosed, the question of whether to treat it with drugs is a difficult one. There is very little safety data on the use of the vast majority of federally approved drugs, including antidepressants, during pregnancy. Of the dozen or so prescription medications specifically approved for expectant women by the U.S. Food and Drug Administration, all are pregnancy-related: drugs for inducing labor, for instance, or epidural anesthesia. That means that each year, thousands of pregnant women with common illnesses — from depression to flu or cancer — must decide whether the benefit of medications outweighs the unknown risks to their fetus.

As for Lusskin, she says that for depressed women who fall in the high-risk category — those with a history of chronic mood disorders, for example, like Jamie Nesi — antidepressant medications may be necessary. She thinks the "risks of untreated ailments are known and may be worse than the potential harmful effects of taking the drug."

Yet many women with less severe cases of depression may opt to forgo medications. Ariela Frieder, a psychiatrist at Montefiore Medical Center in the Bronx, N.Y., says treatment for these women should be geared toward the particular stress factors and contributors to their mood disorder. "We tend to think of depression as having multiple origins. It could be due to the circumstances in her life, there could be a genetic factor, or the woman could have a history of depression," says Frieder, who patient-tailors treatments that involve a combination of psychotherapy, support groups, yoga, exercise, peer counseling and, if needed, prescription drugs.

At the Touch Institute in Miami, massage therapist and psychologist Tiffany Field has been helping pregnant women by training their husbands and significant others to give them restorative massages. In a 2008 study involving 200 depressed pregnant women, Field found that women who received a 20-minute back massage twice a week had lower levels of stress hormones and depressive thoughts than women who did not get the massages. The incidence of premature birth and low birth weight in infants was also lower in the massage group than in the control group.

As with many other conditions, an individual's health may depend significantly on support from family and loved ones. Montefiore's Frieder says one of the first things she does after diagnosing a case of antenatal depression is talk with the woman's partner. "It's important to educate them and let them know what's happening. Because a lot of times, [they] just don't know how they can help," she says.