Antenatal depression

Antenatal depression, also known as prenatal or perinatal depression, is a form of clinical depression that can affect a woman during pregnancy, and can be a precursor to postpartum depression if not properly treated. It is estimated that 7% to 20% of pregnant women are affected by this condition. Any form of prenatal stress felt by the mother can have negative effects on various aspects of fetal development, which can cause harm to the mother and child. Even after birth, a child born from a depressed or stressed mother feels the effects. The child is less active and can also experience emotional distress. Antenatal depression can be caused by the stress and worry that pregnancy can bring, but at a more severe level. Other triggers include unplanned pregnancy, difficulty becoming pregnant, history of abuse, and economic or family situations.
Commonly, symptoms involve how the patient views herself, how she feels about going through such a life changing event, the restrictions on the mother's lifestyle that motherhood will place, or how the partner or family feel about the baby. Pregnancy places significant strain on a woman's body, so stress, mood swings, sadness, irritability, pain, and memory changes are to be expected. Left untreated, antenatal depression can be extremely dangerous for the health of the mother and the baby. It is highly recommended that mothers who feel they are experiencing antenatal depression have a discussion about it with their health care provider. Mothers with a history of mental health issues should also talk to their doctor about it early in the pregnancy to help with possible depressive symptoms.

Signs and symptoms

Antenatal depression is classified based on a woman's symptoms. During pregnancy, a lot of changes to mood, memory, eating habits, and sleep are common. When these common traits become severe, and begin to alter one's day-to-day life, that is when it is considered to be antenatal depression. Symptoms of antenatal depression are:

Inability to concentrate
Overwhelming anxiety and fear
Difficulty remembering
Feeling emotionally numb
Extreme irritability
Sleeping too much or not enough, or restless sleep
Extreme or unending fatigue
Desire to over eat, or not eat at all
Weight loss/gain unrelated to pregnancy
Loss of interest in sex
A sense of dread about everything, including the pregnancy
Feelings of failure, or guilt
Persistent sadness
Thoughts of suicide or death

Other symptoms can include the inability to get excited about the pregnancy, and/or baby, a feeling of disconnection with the baby, and an inability to form/feel a bond with the developing baby. This can drastically affect the relationship between the mother and the baby, and can drastically affect the mother's capacity for self-care. Such inadequacies can lead to even greater risk factors for the mother. Antenatal depression can be triggered by various causes, including relationship problems, family or personal history of depression, infertility, previous pregnancy loss, complications in pregnancy, and a history of abuse or trauma.

Onset and duration of symptoms

Antenatal depression can be caused by many factors. Often it is associated with the fear and stress of the pregnancy. Other factors include unintended pregnancy, hyperemesis gravidarum, financial issues, living arrangements and relationships with the father and family. Typically, depression symptoms associated with pregnancy are categorized as postnatal depression, due to the onset of symptoms occurring after childbirth has occurred. The following is a breakdown of when a group of various women began to feel the onset of symptoms associated with depression:

11.8 percent at 18 weeks
13.5 percent at 32 weeks
9.1 percent 8 weeks after the birth
8.1 percent 8 months after the birth

In a recent article posted by The BabyCenter, the authors stated that "For years, experts mistakenly believed that pregnancy hormones protected against depression, leaving women more vulnerable to the illness only after the baby was born and their hormone levels plunged." This is a possible explanation as to why antenatal depression has just recently been identified.

Prevalence and causes

The prevalence of antenatal depression differs slightly by region of world. In the United States, antenatal depression is experienced in as many as 16% of pregnant women, while in South Asia it is experienced in as many as 24% of pregnant women. It's becoming more prevalent as more medical studies are being done. Antenatal depression was once thought to simply be the normal stress associated with any pregnancy, and was waved off as a common ailment. It can be caused by many factors, usually though involving aspects of the mothers personal life, such as family, economic standing, relationship status, etc. It can also be caused by hormonal and physical changes that are associated with pregnancy. Additional risk factors include lack of social support, marital dissatisfaction, discriminatory work environments, history of domestic abuse, and unplanned or unwanted pregnancy. Studies have determined that there may be a connection between antenatal and postpartum depression in women with lower vitamin D levels. There is a higher risk of antenatal depression in woman living in low-income countries who deal with less access to quality healthcare, have economic issues, and don't have a good support system.
Antenatal depression is also experienced by parents who identify as part of the LGBTQ+ community. Literature on the experiences of pregnancy amongst transgender men reveals that sources of antenatal depression amongst pregnant transgender men arise from gender dysphoria. Where feelings of isolation and loneliness are already reported high amongst this particular group, the experiences they commonly face during their pregnancy exacerbate those feelings.

Screening

Perinatal mental health screenings are important in detecting and diagnosing antenatal and postpartum depression early. The American College of Obstetricians and Gynecologists is one of the many maternal health organizations that strongly encourage universal screening for expectant and postpartum women for depression as part of routine obstetric care. In fact, many states, including California have already legislated laws that require providers to screen patients during visits because they recognize that early screenings can expedite the process in receiving effective treatment. The Patient Health Questionnaire 9 is a screening tool typically used to detect depression. Another tool, the Edinburgh Postnatal Depression Scale, was developed for the postnatal period, but has also been validated for use during pregnancy.
PHQ-9 is a reliable depression severity scale that was formulated in accordance with DSM-IV criteria for depression, consisting of 9 items correlating to the 9 criteria listed in DSM-IV. It is a shortened version of the PHQ and has been assessed for comparable sensitivity and specificity. The screening test is self-administered to patients and are usually performed at the primary care clinic.
However, it is not enough to just provide mental health screenings to at risk patients. Interventions such as referrals to treatment and mental health monitoring should be implemented in health care systems in order to ensure these women are helped consistently throughout their recovery journey.
Studies suggest that obese woman tend to develop mental health issues more frequently and should discuss any symptoms with their doctor at the first prenatal appointment.

Treatment

Treatment for antenatal depression poses many challenges because the baby is also affected by any treatment given to the mother. There are both non-pharmacological and pharmacological treatment options which can be considered by women with antenatal depression.

Non-pharmacological therapy

Psychotherapy

Psychotherapy is recommended for any woman with antenatal depression, as it is an effective way for the mother to express her feelings in her own words. Specifically, cognitive behavioral therapy effectively helps decrease symptoms of antenatal depression. In addition to psychotherapy, being seen by a psychiatrist is recommended as they can assess if medications will be beneficial and make specific medication recommendations, if warranted. Familial support may also play a role in helping with the emotional aspects of antenatal depression.
While mental health specialists are trained in providing counseling interventions, results from a recent systematic review and meta-analysis of the literature found that nonspecialist providers, such as lay counselors, nurses, midwives, and teachers with no formal training in counseling interventions, often fill a gap in providing effective services related to depression and anxiety treatments.

Exercise therapy

Studies suggest that forms of exercise can help with depressive symptoms both before and after birth, but not prevent it entirely.
Exercise options that have been studied to help reduce symptoms:

Yoga
Walking
Stretching
Aerobic exercise
Medications

When discussing medication options for antenatal depression, it is important to ask the prescribing healthcare provider to share more details about all the risks and benefits of the available medications. During pregnancy, there are two main kinds of antidepressants used during pregnancy; tricyclic antidepressants and selective serotonin reuptake inhibitors. Once prescribed, anti-depressant medication has been found to be extremely effective in treating antenatal depression. Patients can expect to feel an improvement in mood in roughly 2 to 3 weeks on average, and can begin to feel themselves truly connect with their baby. Reported benefits of medication include returned appetite, increased mood, increased energy, and better concentration. Side effects are minor, though they are reported in some cases. Currently, no abnormalities of the baby have been associated with the use of antidepressants during pregnancy. It may be true that maternal SSRI use during pregnancy can lead to difficulty for their newborn adjusting to conditions outside of the womb immediately following birth. Some studies indicate that infants with exposure to SSRIs in the second and third trimester were more likely to be admitted to intensive care following their birth for respiratory, cardiac, low weight and other reasons, and that infants with prenatal SSRI exposure exhibited less motor control upon delivery than infants who were not exposed to SSRIs. Newborns who were exposed to SSRIs for five months or more prior to birth were at a greater risk for lower Apgar scores 1 and 5 minutes after delivery, indicating they were of lesser health than newborns who were not exposed to SSRIs before birth. However, prenatal SSRI exposure was not found to have a significant impact the long-term mental and physical health of the children. These results are not independent of any effects of prenatal depression on infants.