By Cassie Shortsleeve | May 20, 2022
"Ask any new birthing person about the realities of postpartum life or anyone post-menopausal about menopause and they'll usually say something along the lines of, "No one told me it was going to be like this."
There's a lot no one tells you about the way reproductive transitions impact mental health, say reproductive psychiatrists—doctors who specialize in the historically siloed field of mental health throughout the reproductive cycle, from adolescence through menopause.
People have long experienced reproductive transitions and the symptoms and conditions that come with those shifts—like postpartum depression (PPD), for example—but the medical community has not known much about them until recently. While the American Psychiatric Association (APA) has dozens of textbooks on all kinds of psychiatric topics, there has been no comprehensive textbook in reproductive psychiatry—until now.
In December, thanks to a volunteer effort by 80 authors from more than 30 different institutions around the country, the APA put forth a textbook: Textbook of Women's Reproductive Mental Health.
In the authors' words, it's "the first comprehensive text for understanding, diagnosing, and supporting the unique mental health needs of women and others who undergo female reproductive transitions during their entire reproductive life cycle."
Lucy Hutner, M.D., a reproductive psychiatrist in New York and one of the book's co-editors adds: "It's a flag-on-the-moon moment for women's mental health."
After all, when she was training to be a doctor, she was told that the field that she specializes in today didn't exist. As recently as the 1980s, doctors and research studies alike suggested falsehoods such as the idea that mood is protected in pregnancy or that "without exception" psychological changes after having a baby were positive.
It's ironic, Dr. Hutner says, considering that postpartum depression is the most common complication of childbirth. But when you have patients with symptoms of diseases that exist and a field that doesn't, it's more than just ironic; it's detrimental to the overall health and wellbeing of that population. A lack of legitimacy perpetuates shame, misinformation, silence, and stigma.
"This medical textbook is almost symbolically more important than anything else," says Dr. Hutner. "It sort of says, 'Hey, this is as important as any other aspect of medicine.' It validates people's voices. It says, 'We don't need to have this stigma anymore. We're done.'"
The Messy World of Reproductive Mental Health
There's nothing non-existent or niche about reproductive psychiatry. But today, if you find yourself with something like PPD or postpartum anxiety (PPA), one of your first touchpoints with the medical system is likely your six- or eight-week follow-up appointment with your OB-GYN or a few trips to the pediatrician.
If you're lucky, you might land in the office of someone like Dr. Hutner for specialized treatment. But too often new moms wind up in an OB-GYNs offices crying and reporting their symptoms with little to no guidance.
Just as this setup fails patients, it fails providers trying to care for those patients, too. The American College of Obstetrics and Gynecologists (ACOG), for example, recommends mental health screening at least once in the perinatal period. But as Dr. Hutner puts it, OBs may not always know what to do with positive screens, or may not know how to treat crying patients.
"The training, education, and dialogue around reproductive mental health have been ad hoc. There hasn't really been a standardized way of approaching it," says Dr. Hutner.
In short: Some physicians have training; some don't. Some are great at providing resources or spotting symptoms; some aren't. There are also big issues including systemic racism in medicine, as well as lack of awareness of queer health issues. This leads to a lot of patients who inadvertently wind up feeling invalidated and alone, without treatment.
Looking Ahead at Reproductive Mental Health
Most people recognize the importance of reproductive mental health, and doctors in training are eager to learn more about it. Lauren M. Osborne, M.D., one of the co-editors of the textbook and the director of the Johns Hopkins Center for Women's Reproductive Mental Health, has piloted a new curriculum designed to educate medical trainees in the field. She asked budding psychiatrists to rank six subspecialties of psychiatry—including reproductive psychiatry along with five officially recognized fields. Doctors ranked reproductive psychiatry in the top half, consistently outranking other specialties that are deemed essential knowledge for independent practice and board certification.
Yet because reproductive psychiatry isn't yet an official subspecialty of psychiatry, it currently lacks government funding for more post-graduate fellowship programs. And learning about widespread problems such as postpartum depression is elective, not a requirement. This contributes to a lack of faculty to teach reproductive mental health and a lack of providers to treat it."
By: Shahram Heshmat Ph.D. | January 18, 2022
"Many of our everyday choices require making tradeoffs between the present and the future. These choices tend to have delayed consequences. In general, we want things now rather than later. This tendency is known as present bias. Present bias occurs when individuals place extra weight on more immediate rewards than future rewards. The more we disregard our longer-term interests in favor of immediate gratification, the more likely we will have an overspending problem.
The present bias is partially attributed to judgments of connectedness between the present and future self (Hershfield, 2018). We tend to think about our future selves as if they are someone else, wholly different from who we are today. If we view our distant self as another person who is more of a stranger to us, then the future selves’ well-being is none of our concern.
Feeling psychologically close to one’s distant self motivates more farsighted decisions that could lead to better outcomes in the future, such as having more money, better health, and fewer regrets. So how do we learn to relate to our future selves?
1. Psychological continuity
Psychological continuity refers to the perceived connectedness between the current self and the future self. To feel connected to our future selves means the continuation of our core identities such as values, life goals between the present and future self. When individuals feel similar to their future self, they are more likely to delay present gratification and make plans for the long run. Research has shown that higher levels of self-continuity to be positively correlated with better academic performance and less procrastination.
The inability to imagine a realistic future self fully and vividly is another reason for poor choices over time. Having a vivid view of the future ahead is a sign of social maturity for young adults. Education is shown to enlighten the person about the value of deferred versus current consumption. We might also spend time with older generations (our parents or grandparents) to remind ourselves of what our lives might be like 20 years from now. Vivid examples are often processed more emotionally, and this can affect motivation. For example, people who viewed age-progressed images of themselves expressed increased intentions to save for retirement.
3. Small steps
Another strategy is to frame sacrifices felt by the present self as being less burdensome. The key to reaching long-term goals often starts with small acts. A study demonstrated higher response rates for an automatic savings program when contributions were framed in daily terms, which feel less painful to the current self. For example, $5 a day in savings versus $150 a month."
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Written by Sharon Martin, LCSW on March 19, 2020
"Stress is an inevitable part of life. We all feel overwhelmed, confused, and anxious at times. And there are many effective and healthy ways to cope with stress, including releasing physical tension (such as through exercise or a hot bath) and reducing obsessive worries and negative thoughts.
Using affirmations is one way to change our thoughts and feelings. They can help us focus on how we want to feel and on our ability to cope.
However, if affirmations are going to work, they need to be realistic and authentic. Some positive affirmations are really corny and unbelievable (like, I am full of peace and joy). Telling yourself that you're full of peace and joy when you're actually full of tension and worry, probably isnt going to feel true or helpful. Instead, try to acknowledge your situation and feelings (that you feel stressed and anxious) and focus on how you want to cope — what you want to think, feel, and do in response.
Below are some affirmations that you may find helpful during times of stress and uncertainty. What feels true and right and helpful, certainly varies from person to person. So, use these as ideas to create your own affirmations or mantras. For example, you can make them more specific by stating something in particular that you're grateful for or a particular coping strategy that you will use.
Affirmations for stress and anxiety
By: Pregnancy and Postpartum TV | August 12, 2021
By: Kaiser Permanente | 2021
"Time is valuable for any busy mom. There never seems to be enough of it. And when you think about your priorities, making time for self-care probably falls near the bottom of your list —below work, kids, home, and family.
But if you don’t take time for yourself, you could be doing more harm than good. Stress, exhaustion, burnout, and even illness can take more of a toll when you aren’t getting what you need. So whether you carve out a few minutes for yourself, or a whole day, here are some ideas to get you started:
1. Focus on the physical
2. Give your brain a boost
3. Pamper yourself
4. Find time for your friends
5. Take a leap
Do something big that you’ve never done before, like:
6. Hone your skills
7. Get silly
Source: WebMD Medical Reference | Reviewed by Dan Brennan, MD on March 05, 2021
"What Are Essential Oils?
Essential oils are plant abstracts made by steaming or pressing different parts of a plant to capture the compounds that produce fragrance. It can take several pounds of a plant to produce just one bottle of essential oils.
When evaluating essential oils' effectiveness, research is promising, but the human clinical trials are mixed. Some studies show an improvement for people, while others show no improvement at all.
The most common way essential oils are used during pregnancy is to help treat anxiety, aches, and lack of focus. There are many varieties of oils to choose from. Finding a high-grade quality variety is recommended. It’s also helpful to consult with your doctor before you start using essential oils while pregnant.
Is It Safe to Use Essential Oils While Pregnant?
Essential oils come in different scents and qualities. Certain varieties are safe to use while pregnant while others should be avoided.
Essential oils that are good to use while pregnant:
How to Use Essential Oils Safely
If a doctor or midwife recommends essential oils to help you during pregnancy, use them carefully. A few good tips to keep in mind include:
Safety Risks of Using Essential Oils While Pregnant
Some people may experience an allergic reaction or skin irritation after using essential oils. You're more likely to have a bad reaction if you have atopic dermatitis or a history of reactions to topical products.
Some essential oils that may carry a higher risk of causing an allergic or skin irritation include:
By Melissa Willets | Updated August 22, 2021
"The term rainbow baby may not be familiar to people who haven't experienced a loss. But to those of us who have, it has a very deep and even life-changing significance.
So what is a rainbow baby? It's "a baby born after a miscarriage, stillborn, or neonatal death," says Jennifer Kulp-Makarov, M.D., FACOG. "It's called a rainbow baby because it's like a rainbow after a storm: something beautiful after something scary and dark."
She adds, "It's an extremely emotional and devastating experience to lose a pregnancy [or baby]. To create a life or bring a baby into the world after such a loss is amazing like a miracle for these parents."
I'm currently seven months pregnant with a rainbow baby, and indeed, I feel like I'm walking around with a miracle in my belly. There was a time when I never thought I could feel hopeful again. Just last year, we lost our beloved baby Cara at 23 weeks of pregnancy. The days, weeks, and months after she became our angel baby were the darkest of my life. But soon a dim hope flickered inside my heart, and eventually ignited a flame, that became my desire to try again, in part to honor Cara, and to find meaning in her loss.
Rainbow Babies Can Honor an Angel Baby
Moline Prak Pandiyan, a previous ambassador for March for Babies, March of Dimes Eastern North Carolina, knows this feeling well. She lost her son Niko when he was five months old due to complications related to his premature birth. "Although Niko lost his fight, his spirit lives on, and he continues to inspire many," she explains. Not only is this mama involved in fighting prematurity, but she was also inspired to conceive a rainbow baby.
Not that she previously knew the meaning of the term "rainbow baby." "I remember the feeling that I had when I first heard [it]," says Pandiyan. "It was perfect. I so much wanted to make sure that Niko wasn't forgotten, and the term so eloquently acknowledges the babies who we've lost, while also celebrating the joy of our babies who do survive."
Prak Pandiyan is now a proud mom of a little girl, her rainbow, who truly informs her parenting philosophy. "My husband and I always wondered what life would have been like if our son could be discharged and come home with us," she says. "When we welcomed our rainbow baby into this world, our perspective as parents shifted. Whenever things get hard—feeding challenges, sleeping challenges, mild illnesses—we always make it a point to step back and remember that things could be so much worse."
Parenting a Rainbow Baby May Feel Different
Mama Stephanie Sherrill Huerta, who has one daughter, is also expecting a rainbow baby, via adoption, after several miscarriages and failed adoption attempts. She too acknowledges that parenting her rainbow baby will be different, telling Parents.com, "We will love him a little differently than our daughter because we went through so much grief and pain before meeting him. He will truly be the light at the end of the tunnel, the pot of gold under the rainbow, and the rainbow after our storm."
That same spirit has encouraged me to enjoy my current pregnancy more than before. Morning sickness and heartburn can't take away my gratitude for the chance to carry a healthy baby.
Elizabeth Lorde-Rollins, M.D., MSc, OB-GYN at CareMount Medical says this is normal. "For parents who have experienced the loss of a child, whether that loss occurs before or after birth, the life adjustments associated with pregnancy are accompanied with an acute sense of gratitude even when they are uncomfortable," she notes. "And although most of us have the great fortune of being wanted babies, parents tend to have a special, and in many cases incredibly sharp, sense of being blessed when they are expecting and then giving birth to a baby that follows loss."
By Paige Glidden | May 07, 2021
"During TheBlueDotProject's Maternal Mental Health Awareness Week, it's time to focus on the mental health of mothers—especially during a life-changing pandemic. The most recognized maternal mental health disorder is postpartum depression, but there are other common mental health concerns to look out for.
Juggling societal and familial expectations is a heavy burden for anyone. But when you add a new baby into the mix (during a pandemic!), it can become overwhelming. Sleepless nights, hormones, and new emotions all feed into overwhelm after the birth of a baby, not to mention that maternal anxiety and depression are the most common complications of childbirth, impacting up to 1 in 5 women.
The first week of May serves as Maternal Mental Health Awareness Week, bringing to light the challenges that moms face and the reality of postpartum depression and anxiety. Maternal Mental Health Disorders (MMHDs) include a range of disorders and symptoms, including depression, anxiety, and psychosis. Although often referred to more commonly as "postpartum depression," there are several different types of postpartum mental health disorders that affect new moms.
Symptoms can occur during pregnancy and/or the postpartum period (together often referred to as the perinatal period). These illnesses can affect anyone—and they are far more common than you'd think. Although an estimated one in five women have a maternal mental health disorder, most cases go undiagnosed, leading experts to believe that the number should be much higher. New parents also experience the baby blues, which is not formally considered an MMHD—up to 80 percent of women suffer from this in the initial two to three days postpartum, according to Bridget Frese Hutchens, Ph.D., CNM, RN, CNL, PHN.
What's worse is that only 30 percent of women who screen positive for depression or anxiety seek or receive treatment. When left untreated these disorders can cause devastating consequences for moms, babies, families and communities. The good news is that risk for both depression and anxiety can be reduced (and sometimes even prevented), and with treatment, women can recover.
It can be hard to identify some of the symptoms of postpartum mental health challenges, but it's worth paying attention to. Here are five types of maternal mental health conditions to look out for:
Common Maternal Mental Health Disorders
1. Postpartum Depression
Pregnancy and Postpartum Depression (PPD) is a mood disorder that can begin during pregnancy or in the first three weeks after having a baby, according to ACOG, the American College of Obstetricians and Gynecologists. Symptoms can range from mild sadness, trouble concentrating, or difficulty finding joy in once-loved activities to severe depression, and mothers with pre-existing depression prior to or during pregnancy are more likely to experience postpartum depression, according to The Blue Dot Project. While there is no single cause for PPD, experts attribute it to the drop in hormones estrogen and progesterone following childbirth and general stressors which increase during pregnancy and the postpartum period. With proper mental health care, PPD is treatable and the risk of severe depression can also be prevented.
2. Dysthymia, Persistent Depressive Disorder
Dysthymia is defined as a low mood occurring for at least two years, along with at least two other symptoms of depression. According to the Mayo Clinic, people with dysthymia may lose interest in normal daily activities, feel hopeless, or have overall feelings of inadequacy. Women with pre-existing dysthymia may be at a higher risk for severe symptoms/depression during the perinatal period, according to The Blue Dot Project.
3. Pregnancy and Postpartum General Anxiety
It might seem normal to worry before or after having a baby, but if your anxiety is more than just the baby blues and you can't get these worries out of your brain, you might be suffering from pregnancy or postpartum related generalized anxiety . Around 10 percent of women will develop anxiety during pregnancy or after childbirth, according to the American Pregnancy Association. Anxiety is treatable during pregnancy and postpartum.
Symptoms often include restlessness, racing heartbeat, inability to sleep, extreme worry about the "what if's"—questions like "what if my baby experiences SIDS" or "what if my baby has autism," and extreme worry about not being a good parent or being able to provide for her family, according to The Blue Dot Project."
By Sydney Daniello, Programs Intern at Mental Health America | June 01, 2020
"Routines have a bad reputation of being dull, boring ruts we fall into over time. But a lot of routines can actually be really helpful for maintaining both our physical and mental wellbeing. And now that many of our normal routines have been disrupted, it’s become more important than ever to establish routines to keep us healthy, happy and - well - sane.
I, for one have been having a tough time setting up and sticking to any routine other than waking up every morning and silently screaming into the void. So, I asked my coworkers here at MHA about what kinds of routines have been helpful to them for maintaining their wellbeing during these ~unprecedented times~
Here’s a list of what they said (summarized, not all direct quotes):
By: Lindsay Dolak | Editor at Aaptiv | August 6, 2020
"No matter how fit you were before and even during pregnancy, postpartum exercise presents a unique set of challenges. Your body is still healing from delivery, and with a newborn in the house, you might be feeling more tired than ever. But finding time to fit in fitness is amazing for both your body and mind—it can be just what you need to get back to feeling like your pre-pregnancy self. No, we’re not talking about “getting your body back.” We’re talking about a boost to your energy, self-confidence and physical strength. Plus, you’re bound to sleep better too. Do we have your attention now? Here, two trainers from Aaptiv—a fitness app offering trainer-led, music-driven audio workouts—break down why you should start a postnatal fitness routine, and how to do it.
Benefits of Postpartum Exercise
Postnatal exercise brings a host of positive benefits to your body, but also for your mood and stress levels. Fitness not only helps your body heal but also provides an outlet to recenter and focus on yourself—something that might feel a bit out of reach now that you’re caring for another tiny human. “Postpartum exercise gives moms back that feeling of being in control,” says Aaptiv trainer Candice Cunningham, an ACE-certified personal trainer and Fit For Birth pre- and post-natal corrective exercise specialist. “It’s a huge stress-reliever and also gives new moms something to really focus on for themselves.”
Aaptiv trainer and mom Jaime McFaden, an ACE-certified pre- and post-natal fitness specialist and health coach, agrees, adding that consistent exercise post-baby provides a huge boost in not only physical strength, but mental strength as well. “You just went through so many changes—things have shifted. Exercise helps you heal from the inside out,” she says.
In addition to the many mental and emotional benefits, postnatal fitness can lead to weight loss, improved strength (carrying around a baby all the time is no joke), better sleep and more balanced hormones—a must after nine months of ups and downs.
When to Start Postpartum Exercise
First things first: Don’t jump into a postpartum exercise routine without your doctor’s approval. Many doctors recommend waiting six to eight weeks after birth before starting trying any type of exercise, but it often varies. Some women may experience complications during pregnancy or labor that might set them back a few more weeks. For example, a mother who had a vaginal birth will likely have a different timeline than one who had a c-section. And others may even be able to work out sooner than six weeks.
According to McFaden, working out during pregnancy may help when it comes time to start exercising again. “Your body’s muscle memory will kick in and you’ll have an easier time getting back into it after birth,” she says. “You still want to give your body time to recover, though. Never push yourself too hard post-baby. Patience is key.”
No matter what, it’s crucial to work with your doctor to find out exactly when is right for you and your body. “Every mom is different and it’s important to pay attention to stresses the body may undergo post-pregnancy,” Cunningham says. “A doctor will be able to check for an indication of diastasis recti (the separation of the abdominals) and be able to recommend the appropriate physical work to heal that or any other side effects of childbirth.”
There’s no real reason to rush back into exercising early anyways. In fact, it can cause you more harm than good down the line. It might be hard for women used to high intensity workouts or long runs, but taking it slow is key.
When you’re ready, start by adding walking and low-impact bodyweight exercises at first. Aaptiv’s fourth trimester program meets new moms where they are and focuses on building back up to regular workouts. It covers core, strength training, outdoor walking and elliptical, and places special emphasis on healing the pelvic floor muscles and not aggravating a diastasis recti—both of which are crucial for new moms with recovering bodies. Don’t worry, you’ll gradually work your way back to sprints and burpees in no time.
Best Postpartum Workouts
Before you starting working out again, it’s important to temper your expectations. Your body is different now and you won’t immediately be as strong as you once were. Start with simple, functional exercises you can ultimately build on. To get you started, we asked McFaden and Cunningham to share some of their favorite postpartum exercises to work your entire body."
"Infertility is difficult to live with. That said, sometimes, we make things harder on ourselves. Not intentionally or consciously, of course. We may not know it can be any other way. Or we just don't realize we're self-sabotaging ourselves.
Here are some things you should stop doing if you are fertility challenged, so you can start living a better, fuller life.
1. Stop Blaming Yourself
Maybe you waited "too long" to start a family. Maybe something foolish you did as a college student has wreaked havoc with your fertility. Maybe you wonder if that year you decided to live on only fast food wasn't the brightest idea.
Or, perhaps you have no idea what could possibly have led to your current fertility woes. But you're sure it's something you could have stopped had you only known better.
You need to stop blaming yourself. Even if you can find a way to somehow make it "your fault," you should still stop blaming yourself. It doesn't help. It just depresses you.
Plus, most cases of infertility are either not preventable or not predictable. You really can't know if you had done something different whether you'd be a Fertile Myrtle or not. Drop the blame, and focus on what's most important now--moving forward and tackling the problem.
2. Stop Waiting for a Miracle
If you have been trying to conceive for more than a year (or more than six months, if you're over 35), and you have not succeeded, it's time to see a doctor. Some couples decide this advice isn't really for them, though. It's for those other people. You know, the infertile ones. They decide to keep trying on their own and pray for a miracle.
Here's the problem with that thinking: There are some causes of infertility that worsen with time. While you pray for your miracle, your chances may be quickly disappearing.
There's nothing wrong with deciding to keep trying and wait on treatment, or even deciding not to pursue fertility treatment in the end. But you shouldn't avoid fertility testing. At least find out what is wrong and what your options may be.
Get checked out, both you and your partner, and confirm that whatever is wrong can wait. Then, if you want, set a "miracle waiting" period. Speak to your doctor about how long they think you can try without losing valuable time.
3. Stop Feeling Hopeless
A diagnosis of infertility can hit a person hard. Sometimes, it's difficult to see past the next couple of days or weeks. You may feel hopeless, certain that you will never conceive or that your life will never be happy.
If you can't conceive a biological child, maybe you can use an embryo donor, egg donor, or sperm donor. If you can't use donor gametes, maybe you can adopt. If you can't adopt, remember that people can live childfree and have happy, normal lives.
To be clear, these other possibilities don't magically make the pain go away. You will need time for grieving and healing from the trauma of infertility.
However, when you start to wonder if you will never have a child, or when you start to think your life is ruined, try as best as you can to hold onto at least a sliver of hope. There is life after infertility. Please remember that.
While it's possible you won't conceive, you'll feel better if you can keep your thoughts focused on the positive possibilities. Low-tech treatments work for many couples. Your chances for success may be better than you think. Speak to your doctor about your particular prognosis.
4. Stop Acting Helpless
Most couples are extremely pro-active in their care. But not everyone realizes they are the decision makers.
To the couples whose doctors tell them they are "too young," despite trying for over a year...
To the couples whose fertility clinics refused to try IVF with their own eggs because their chances aren't great, not realizing that the clinic probably doesn't want to "ruin" their track record with a risk...
To the women whose doctors won't test or treat them until they lose weight, but leave it to them to figure out how exactly to do so...
You are not as helpless as it seems. If the doctor you're seeing refuses to run an evaluation, go find a new doctor. If a clinic turns you down because your chances are "too low," seek out a second opinion.
If your doctor tells you to lose weight, be sure they evaluate and treat any hormonal imbalances that may make losing weight difficult, and ask for a referral to a nutritionist.
Maybe go get a second opinion on whether you really need to lose weight first.
You have so much more power than you realize. Don't be afraid to stand up for yourself.
4. Stop Living in Two-Week Increments
This is a basic one but so common it deserves special mention. When you're trying to conceive, your life can easily fall into two-week increments: the two weeks you wait for ovulation, followed by the two weeks you wait to take a pregnancy test.
The worst part about this is there are no breaks; there's no anxiety-free time when you're anxious about ovulating or anxious about feeling pregnant.
While it's unrealistic to think you'd be able to just drop all the fretting, you should at least try to live beyond the two-week wait craziness. You may need the support of friends, a support group, or a counselor to learn how. But it's possible.
4. Stop Basing Self-Worth on Fertility
Infertility can make you feel worthless. Broken. Ashamed. These are all very common feelings, experienced by men and women who live with infertility.
Before you started trying to conceive, before you ever realized you faced infertility, you probably felt different about yourself—hopefully more positive. You need to remember that the old you is still there. You don't become someone else when you're diagnosed with infertility.
If you were awesome and lovable before infertility, then you're just as awesome and lovable after. If you doubt this, think about what you'd say to a friend who told you they felt ashamed and worthless because of their infertility. You probably wouldn't say to them, "Yep, you're right. You're worthless!" No way.
You know it's not true of a friend, and you need to understand it's also not true of yourself. You are so much more than your fertility."
"What Is Prenatal Depression?
Prenatal depression, also called perinatal depression, is depression experienced by women during pregnancy. Like postpartum depression, prenatal (or perinatal) depression isn’t just a feeling of sadness—mothers who experience this mental health disorder may also feel anxious and angry.
You've likely heard of postpartum depression—and that's a good thing. The more that postpartum depression is talked about and understood, the more mothers will seek the help they need so that they can feel better and live full and healthy lives as new moms.
But prenatal depression is a maternal mood disorder that hasn’t gotten nearly as much attention as it should. While prenatal depression can be treated, many expecting mothers don’t even know that it’s a “thing” and therefore don’t seek treatment for it.
Many feel ashamed to even share how they are feeling. After all, you are supposed to be overjoyed and excited when you are expecting a baby, right? It’s easy to feel guilt and shame when you are feeling the exact opposite.
Here’s what you should know about prenatal depression, including how common it is, what to look for in terms of symptoms, and most importantly, how to get help.
How Common Is Prenatal Depression?
Like postpartum depression, which impacts as many as 1 in 7 new moms, prenatal depression is actually quite common.
According to a journal article by Maria Muzik, MD, and Stefana Borovska, published in Mental Health in Family Medicine, 13% of pregnant moms experience depression.
As the authors note, perinatal depression (both prenatal and postpartum) is even more common among mothers facing adverse experiences, such as a history of depression or economic hardship.
“The prevalence of perinatal depression is even higher in vulnerable groups with certain risk factors,” the authors explain. “Young, single mothers, experiencing complications, with a history of stress, loss or trauma are far more likely to succumb to depression. Furthermore, one study found that up to 51% of women who experience socioeconomic disadvantage also report depressive symptoms during pregnancy.”
It's important to note prenatal depression doesn’t discriminate: You can experience it whether or not you have pre-existing risk factors. Always remember there is no shame in experiencing a serious bout of depression during pregnancy, and you are not alone.
Similar to postpartum depression, experts can’t pinpoint one particular cause of prenatal depression, but have hypothesized that it’s likely caused by a confluence of factors—a “perfect storm” of triggers that come to a head for some mothers during their pregnancies.
Either way, it’s important to note that whatever caused your prenatal depression, it most certainly wasn’t your fault. There was nothing you did wrong, and you are not a bad mom (or going to be a bad mom).
“Depression and anxiety during pregnancy or after birth don't happen because of something you do or don't do—they are medical conditions,” notes the Academy of American Pediatrics (AAP).
“Although we don't fully understand the causes of these conditions, researchers think depression and anxiety during this time may result from a mix of physical, emotional, and environmental factors,” they add.
Prenatal depression manifests differently for every mom—you may even experience it differently from one pregnancy to another. It’s important to understand that anytime you feel overwhelmed by your emotions, unable to function in your day-to-day life, or just “off,” you should reach out to discuss your feelings with a trusted loved one or medical provider.
Here are some of the most common symptoms of prenatal depression:
For more mental health resources, see our National Helpline Database."
Depression During Pregnancy Affect Infant’s Brain Anatomy, But No Change with Prenatal Exposure to SSRIs
By MGH Center for Women's Mental Health | June 22, 2021
"When a woman comes in for a consultation regarding the use of medications during pregnancy, we spend most of our time reviewing the potential risks of exposure to medications during pregnancy. However, we must also include a discussion of the effects of untreated psychiatric illness in the mother on the developing child, for there is a growing body of literature which demonstrates that what happens in utero, while the fetus is developing, may have effects on the child that persist into adulthood.
A number of recent studies have examined the brain anatomy of infants born to depressed mothers. Neuroimaging has revealed changes in connectivity between the amygdala and the prefrontal cortex (reviewed in Duan et al, 2019), and it is hypothesized that these alterations are responsible for the children’s increased vulnerability to anxiety and depression.
In a recent study Sethnaa and colleagues add to this literature, using MRI to compare regional brain volumes in 31 3-to-6-month-old infants born to women with a diagnosis of major depressive disorder (MDD, confirmed using the SCID) and 33 infants born to women without a current or past psychiatric diagnosis. The study recruited women during the second and third trimesters of pregnancy from antenatal clinics and perinatal psychiatric services in South London.
MRI assessments were conducted in infants between the ages of 3 and 6 months. Compared to infants born to non-depressed mothers, infants born to mothers with depression during pregnancy have larger subcortical grey matter volumes and smaller midbrain volumes. This finding persisted after adjusting for potential confounders, including medication use during pregnancy, postpartum depressive symptoms, and infant sex.
These findings are consistent with other studies looking at different types of insults, such as hypoxia and substance use, suggesting that these subcortical structures are particularly susceptible to changes in the in utero environment. The authors note that this finding of an association between maternal antenatal depression and midbrain development is not surprising given the midbrain’s role in stress regulation."
By: Robin Elise Weiss, PhD, MPH | June 14, 2021
"Affirmations are statements that you use intentionally to instill a sense of positivity and purpose in your mind about a particular subject. You can use these short phrases and sentences to help yourself focus on and accept a positive message that you wish to remember.Affirmations are an example of using positive thinking to set an intention and increase the likelihood of positive results. Even better, they are simple to do, free, and accessible to all.
Why They Work
While there is no guarantee that affirmations will actually change the outcome of your pregnancy, some studies suggest that affirmations can reduce stress and anxiety—which can make it easier to rest, eat, and avoid issues such as headaches and fatigue. Plus, positive thoughts tend to cultivate positive feelings, which may help to make your pregnancy experience more enjoyable and relaxed.
Studies show that using positive affirmations impacts brain pathways, increasing activity in the areas of the mind responsible for self-worth, self-regulation, and core values. Researchers believe that making a regular practice of saying affirming statements can effectively shift your focus from negative emotions or stressors to your own expansive capacity to cope, bolstering your confidence and bringing you new ideas, strategies, energy, and hope for the future.
Write Your Own
The beauty of positive affirmations is that you can write your own to use whenever you like. They can be said out loud or silently in your head, quietly whispered to yourself, or written down. In lieu of writing your own, you can also use one you have read or heard elsewhere. If it makes you feel strong, positive, and hopeful, then you're on the right track.
Remember, your affirmation should be in the present tense, as if what you wish to happen is already occurring. For example, someone who is worried about coping with childbirth might say, "I am strong." A person who is trying to get pregnant and having difficulty might say, "I am a good parent to my child."
This person might decide to repeat the affirmation every morning as a reminder of their goal and to foster their hope for this desired outcome. During infertility treatments, they might visualize this affirmation while undergoing procedures and tests, as well. During pregnancy, daily pregnancy affirmations may serve to enhance the mother's bond to their growing baby while also alleviating the worry that something might go wrong.
How to Do It
Anything that speaks to you can work as an affirmation. If you're unsure, brainstorm statements that connect to the feelings, values, and intentions you want to affirm. If you have a specific worry or negative thought that keeps coming to mind, try flipping it around to a positive one.
If you catch yourself thinking, "I can't do this," counter that with, "I can do this." "Childbirth is scary" becomes "childbirth is beautiful." Simple is good. Setting your positive intention can literally change your mind.
To help you get started writing your own affirmations, consider beginning with phrases like the following:
By MGH Center for Women's Mental Health | June 10th, 2021
"When we meet with women for perinatal psychiatry consultations, we now ask about vaccinations. It’s not something we typically do, but after the last year, we are now getting involved in their decisions regarding vaccination against COVID-19. Just as we counsel women to avoid alcohol and to consistently take their prenatal vitamins, providing information on the COVID-19 vaccine is an important aspect of promoting the health of pregnant and postpartum women.
Considering a growing body of evidence indicating that pregnant women are more likely to have certain manifestations of severe COVID-19 illness, including admission to the ICU and mechanical ventilation, the American College of Obstetricians and Gynecologists (ACOG) has urged the CDC’s Advisory Committee on Immunization Practices to include pregnant and lactating women in the high-priority populations for COVID-19 vaccine allocation. ACOG clearly states that all pregnant and lactating people should be allowed to receive the vaccine, and that their decision to do so should be based on a careful discussion of risks and benefits with their healthcare provider.
From our vantage point, there are other benefits to the COVID-19 vaccine. During the past year, before the vaccination was available, we watched as pregnant and postpartum patients undertook the most extreme forms of lockdown. Many of these women were literally housebound: never leaving the house and cutting off contact with friends and family, while at the same time taking on more childcare responsibilities as outside care providers and day care centers were no longer available. And all the while wondering what would happen if they or a member of their family felt ill?
We are yet to fully appreciate the impact of the COVID-19 pandemic on perinatal women, but preliminary studies indicate that during the lockdown, pregnant and postpartum women reported higher levels of stress, loneliness, depression, and anxiety. And this is not really a surprise. So many of the things we typically recommend to reduce stress and social isolation, such as exercising regularly or spending time with friends and family, vanished.
While it might seem like the pandemic is fading into the distance, the resurgence of the pandemic in places like India and Brazil where immunization rates are low, we cannot be so sure about this. So far the most successful way to avoid becoming seriously ill with COVID-19 is to get vaccinated.
A recent article in Medscape, however, suggests that mothers appear to be less likely to get vaccinated than others in the general population. According to a recent poll from Morning Consult, about two-thirds of adults in the US have either already been vaccinated against COVID-19 or plan to do so. In contrast, mothers are the most likely to be hesitant about the vaccine. In this study, 51% of the mothers reported that they are unwilling to get vaccinated or are uncertain about getting vaccinated, at 51% (compared to 32% of other women and 29% of fathers)."
By familydoctor.org editorial staff.
"The amount of sleep you get while you’re pregnant not only affects you and your baby, but could impact your labor and delivery as well. Lack of sleep during pregnancy has been tied to a number of complications, including preeclampsia (a serious condition that affects your blood pressure and kidneys). This condition could result in pre-mature birth. Now is the time to take sleep seriously.When you become pregnant, one of the first symptoms you may notice is being overwhelmingly tired, even exhausted. Sleep will be irresistible to you. You can most likely blame your changing hormones for this, especially the extra progesterone that comes with being pregnant. In the beginning, pregnancy also lowers your blood pressure and blood sugar, which can make you feel tired.
Shortly after the first trimester, your energy should return. Sometime during the third trimester, you’ll begin to feel tired again. Some of this feeling can be blamed on the sheer physical exhaustion that comes from growing a baby and the stress that it puts on your body. However, your weariness during this time is in direct relation to your inability to get a good night’s sleep.
Even if you’ve never had trouble sleeping before, you may find it much more difficult while you’re pregnant.
Path to improved health
Sleep should never be seen as a luxury. It’s a necessity — especially when you’re pregnant.
In fact, women who are pregnant need a few more hours of sleep each night or should supplement nighttime sleep with naps during the day, according to the National Institutes of Health.
For many pregnant women, getting 8 to 10 hours of sleep each night becomes more difficult the farther along they are in their pregnancy. There are many physical and emotional obstacles to sleep in this stage. Anxiety about being a mom or about adding to your family can keep you awake. Fear of the unknown or about the delivery can cause insomnia. Plus, there is the getting up every few hours to go to the bathroom. It also can be difficult to find a comfortable position in bed, especially if you are a former stomach sleeper.
If any of the following is keeping you awake at night, try these strategies for getting a good night’s sleep.
At some point in their pregnancy, most pregnant women suffer from heartburn, which is a form of indigestion that feels like burning in your chest and throat. Heartburn can wake you up in the middle of the night and ruin a good sleep. Minimize the chance for this by avoiding spicy foods. Also, cut down on rich foods for dinner.
Restless leg syndrome
Few things are more distracting than restless legs syndrome (RLS), especially when you are trying to go to sleep. While you can’t take traditional RLS medicines when you are pregnant, you can try to reduce the feelings of RLS with a good prenatal vitamin that includes folate and iron.
Morning sickness — at bedtime
Despite the name, morning sickness can occur any time and is often worse later in the day. Try eating a few crackers at bedtime and keep a stash in your nightstand in case a wave of nausea hits as you are trying to go to sleep.
There are many ways insomnia can creep in and compromise your sleep time. Often, it’s just about being able to shut down your brain. Most medicines for insomnia should not be taken while you are pregnant. Instead, try journaling some of the things you are anxious about. Write down what is stressing you and try to let it go as you go to sleep. Also, stop drinking caffeine by early afternoon. Try not to take long naps during the day. Doing any — or all — of these things can help ease you back into sleep at a reasonable bedtime.
Not many things can wake you as quickly and painfully as a leg cramp. Sometimes called a charley horse, these cramps are usually a contraction of your calf muscle. Less frequently, they can occur in your thigh or your foot. These can plague you in pregnancy because of a lack of minerals, especially calcium and magnesium. They also are more common if you are dehydrated. To guard against leg cramps, make sure that you continue to take your prenatal vitamin and drink plenty of water and other fluids during the day.
Finding a comfortable position
As your body grows, sleep becomes a little harder to come by, especially in the third trimester. It’s difficult to get comfortable. It’s harder to move around and shift positions in bed. If you’ve been a stomach or back sleeper, it can be hard to adjust to sleeping on your side. The best position to sleep in when you’re pregnant is on your left side. This improves blood flow and, therefore, nutrient flow to your baby. Try lying on your left side, knees bent with a pillow between your knees. It also helps to tuck a pillow under your stomach, as well, for extra support.
Frequent bathroom breaks
With the baby pushing down on your bladder, you likely can’t make it all night without waking at least once to go to the bathroom. You can help minimize nighttime bathroom trips by cutting down on how much you drink in the evenings. Just be sure to get adequate hydration during the day. Bright lights can make it harder for you to fall back asleep, so use nightlights so that you will not need to turn on the lights when you get up to go to the bathroom.
In addition to minimizing the common obstacles to getting a good night’s sleep, there are also ways to encourage good sleep habits. This is called good sleep hygiene.
Things to consider
Sleep is essential to health. Lack of sleep is associated with many chronic diseases, including type 2 diabetes, obesity, depression, and even heart disease. If you’re pregnant, not getting an adequate amount of sleep can put you at risk for some serious conditions. Lack of sleep can also complicate your delivery.
In one research study, pregnant women who slept less than six hours at night late in pregnancy had longer labors and were more likely to have cesarean deliveries.
Another study reports that the sleep you get in your first trimester can affect your health in the third trimester. Women who don’t get enough sleep (less than five hours per night) in the first trimester are nearly 10 times more likely to develop preeclampsia late in pregnancy. Preeclampsia is a condition associated with pregnancy-related high blood pressure, swelling of hands and feet, and protein in urine.
If you’ve ever had a sleep disorder, it could be made worse by pregnancy. If you’ve had sleep apnea in the past, your snoring may get worse during pregnancy. This is especially true if you were already overweight when you became pregnant. Expect that RLS will worsen during this time. Heartburn will intensify, too."
"For a new mom-to-be, experiencing sleep deprivation after the baby is born is a given. But you probably didn’t realize that it could also occur during the first trimester of pregnancy.
Most women experience sleep problems during pregnancy. Pregnant women tend to get more sleep during their first trimesters (hello, early bedtime) but experience a big drop in the quality of their sleep. It turns out that pregnancy can make you feel exhausted all day long. It can also cause insomnia at night.
Here are some of the most common culprits for insomnia during early pregnancy, plus a few tips to help you get a better night’s sleep.
What is insomnia?
Insomnia means you have difficulty falling asleep, staying asleep, or both. Women can experience insomnia during all stages of pregnancy, but it tends to be more common in the first and third trimesters. Between midnight bathroom breaks, out-of-control hormones, and pregnancy woes such as congestion and heartburn, you might be spending more time out of your bed than in it. The good news: While insomnia might be miserable, it’s not harmful to your baby.
Sheer logistics play a role as well. By the end of a pregnancy, many women have a hard time just getting comfortable enough to sleep well. During the first trimester, you might not have much of a baby belly to accommodate, but there are other issues that can prevent a good night’s sleep.
What causes insomnia during pregnancy?
Expecting? There are many reasons you might be wide awake in the wee hours. These can include:
It can be difficult to distract yourself from these thoughts, but try to remember that worrying isn’t productive. Instead, try writing down all of your concerns on paper. This will give you a chance to consider possible solutions. If there are no solutions, or there is nothing you can do, turn the page in your journal and focus on another worry. This can help empty your mind so you can rest.
Being up front with your partner about your feelings and worries can also help you feel better.
Develop a bedtime routine
One of the best things you can do to manage insomnia while you’re pregnant is to set up good sleep habits.
Begin by trying to go to bed at the same time every night. Start your routine with something relaxing to help you unwind.
Avoid screen time at least an hour before bed. Blue light from the TV, your mobile phone, or tablet can have an impact on your body’s circadian rhythm. Try reading a book instead.
Taking a soothing bath might also make you sleepy. Just be careful that the temperature isn’t too hot — that can be dangerous for your developing baby. This is especially true during early pregnancy.
To be safe, avoid hot tubs.
Diet and exercise
Diet and exercise can have an impact on your sleep.
Drink plenty of water throughout the day, but minimize drinking after 7 p.m. Try to avoid caffeine starting in the late afternoon.
Eat to sleep
Eat a healthy dinner, but try to enjoy it slowly to reduce your chances of heartburn. Eating an early dinner can also help, but don’t go to bed hungry. Eat a light snack if you need to eat something late in the evening. Something high in protein can keep your blood sugar levels steady through the night. A warm glass of milk can help you feel sleepy, too."
"Seaneen Molloy was excited to discover she was expecting her second baby during lockdown. With a history of mental illness, she carefully planned the pregnancy, but when her baby arrived she experienced the "terrifyingly rapid" onset of a crisis which left her unable to hold baby Jack."
"Having a baby is supposed to be a joyful experience, and for lots of women it is. However, up to 20% experience mental ill health during pregnancy and the year after birth. Tragically, suicide is the leading cause of death in new mothers.
Women who already have a mental illness are at a high risk of relapse during pregnancy - that's women like me.
I have a diagnosis of bipolar disorder and an anxiety disorder. This meant that pretty much from the moment I became pregnant, the perinatal mental health team were involved.
This includes specialist midwives, psychiatrists, nurses and social workers whose goal is to support women to stay well, and intervene quickly if they don't.
Normally, I manage my mental health by being careful with my sleep and leading a pretty boring life away from overwork and alcohol, but pregnancy chucks in a host of factors you have no control over.
Hormones rage through your body, wreaking havoc upon your mood, your energy levels and your ability to keep your lunch down. You either can't stay awake or are awake for hours - peeing a thousand times and being hoofed by tiny feet.
I had managed to stay well, and off medication, for years, but in the run-up to birth antipsychotic medication was introduced to prevent postpartum psychosis. This can cause women to develop delusions and lose touch with reality.
It's the one I was most at risk of developing due to my history of bipolar disorder, but in the end, I experienced postnatal anxiety.
My mental health had been largely OK during my pregnancy and my labour and after-care were carefully planned.
I had a calm elective Caesarean section due to a traumatic first birth, a room of my own and the baby was whisked away on his inaugural night so that I could get some all-important sleep (this bit was hard - it went against every natural instinct). A procession of midwives, doctors and social workers visited to see how I was doing.
Although I found it intrusive, it helped me feel safe. When I was discharged from hospital with my baby, Jack, I felt swaddled in care and confident everything would be OK.
It was a complete shock that I did get ill.
In the chaos of newborn-life I forgot a dose of my anti-clotting medication which is given to mothers after C-sections.
And this one tiny event broke my brain.
I went from mildly chiding the home treatment team for their postnatal visits, because I was fine, to a full-blown mental health crisis within about 12 hours. It was terrifyingly rapid - which is why perinatal mental illness can be so deadly.
My mild anxiety exploded into an all-consuming panic that I was going to die imminently from a blood clot in my lung. I couldn't think of anything else but the black terror of certain death that was coming for me - how I was going to leave my children, how I'd brought a new child into the world never to know me.
I called out-of-hours GPs describing symptoms I was convinced I had, sobbed, screamed and couldn't breathe. I terrified my husband and myself.
Then we hit the emergency button.
The psychiatrist came over with the home treatment team. They took my fears seriously, which I appreciated, and gave me a physical examination and the missed dose of medication. My antipsychotic medication was increased to the maximum dose and benzodiazepines - a type of sedative - prescribed, to try and calm me down.
I wasn't allowed to be left alone and the mental health team were to visit me every day where I tried to articulate my terror to their masked faces.
At first I resented their visits, but they became a 30-minute space where I could let down the exhausting facade and share how I was really feeling.
My anxiety then transformed into an obsession that Jack was going to die. I was afraid to leave the room and rested my hand on his chest all night.
If my husband took him out to the shops with his brother, I cried and paced about, imagining they had all been hit by a car. I texted him incessantly.
Everyone was saying I needed "rest", so he tried to give me space. But after the second or third breakdown, he agreed to keep his phone on loud and to answer quickly. The home treatment team also advised he give me clear timescales so I knew when to expect them home.
But the medication also caused intense restlessness. I couldn't sit still. I couldn't get comfortable enough to hold my baby for more than a minute."
By MGH Center for Women's Mental Health | May 19th, 2021
"This is a question we often hear. One of the challenges in answering this question is the interpretation of the word “best”. On one hand, the best antidepressant is the one that is the most likely to be effective. On the other hand, the best antidepressant is the one that carries the least risk when used during pregnancy. What this means is that there is no single answer. Each situation is different, and our recommendations are based on a careful assessment of the patient’s course of illness, treatment history, past medication trials, and the most up-to-date information on reproductive safety. Added to this calculation is the understanding that untreated depression also carries some risk in terms of maternal well-being and has been associated with worse pregnancy outcomes.
Stay with the Same Treatment or Switch?
We often meet with women who have switched to a different antidepressant medication in preparation for pregnancy. Other women make a switch when they discover they are pregnant. These switches are motivated by the belief that there is a “safer” medication to be used during pregnancy. The reality is that most of the antidepressants taken by women today are relatively safe and carry a very low risk to the developing fetus. What separates one antidepressant from another is that some medications have more data to support their reproductive safety than others. But even this distinction is disappearing; we have data to support the use of most SSRIs (with less data on fluvoxamine or Luvox), the SNRIs duloxetine (Cymbalta) and venlafaxine (Effexor), and bupropion (Wellbutrin). Tricyclic antidepressants, although not commonly used today, also have data to support their reproductive safety.
We have very little data on the reproductive safety of the MAO inhibitors. In addition, MAO inhibitors may have serious interactions with other medications frequency used during pregnancy and labor and delivery, specifically medications used to manage pain, such as nalbuphine (Nubain) and meperidine (Demerol). In women taking these medications, we are likely to suggest switching to another antidepressant with a better reproductive safety profile.
At this point, we have less data on the use of the newer antidepressants. There is some data on mirtazapine, with the most recent study including 334 cases of neonates with prenatal exposure to mirtazapine. While these data are reassuring and there is no indication that mirtazapine carries significant teratogenic risk, the number of mirtazapine exposures remains small. Ideally we would like to have data from 600-700 exposures to get a better estimate of risk. Making decisions regarding safety on studies with small sample sizes can lead to miscalculations of risk in either direction.
The data is even more limited with regard to the use of vortioxetine (Trintellix), vilazodone (Viibryd), levomilnacipran (Fetzima). If there are effective alternatives, we typically recommend switching to another antidepressant.
In settings where we have limited data regarding the reproductive safety of a particular antidepressant, we may consider switching to an antidepressant with a better characterized reproductive safety profile. It is important, however, to carefully consider the benefits and risks of making this switch. With any switch, there is the risk of relapse when making a change in the maintenance treatment. Thus, there are situations where we recommend continuing an antidepressant with limited reproductive safety information because there are no effective alternatives and the risk of relapse is significant.
What About Zoloft? Isn’t Zoloft the Safest?
At some point in the early 2000s, there emerged the belief that sertraline (Zoloft) was the safest antidepressant to use during pregnancy, and many women taking other antidepressants were encouraged to switch to sertraline during pregnancy. It is somewhat unclear where this opinion came from — maybe one paper suggesting lower placental passage of sertraline compared to other antidepressants; however, there is and never was any solid data to support the assertion that sertraline is safer or the safest antidepressant. Reflexively switching women to sertraline puts women at risk for recurrent illness.
While sertraline is effective for the treatment of depression and anxiety and is a reasonable choice for many women, one problem with sertraline is that it tends to be under-dosed. The typical starting dose is 50 mg; however, many individuals will need 150 mg to 200 mg to effectively manage their symptoms. Especially when sertraline treatment is initiated in the primary care setting, we often see women whose dose is too low to effectively manage their symptoms.
What About Paxil? Doesn’t It Cause Heart Defects?
The most current data regarding the use of paroxetine (Paxil) during pregnancy does not indicate an association between the use of paroxetine during pregnancy and risk for cardiovascular malformations. However, in 2006, GlaxoSmithKline (GSK) elected to change product label warnings for the antidepressant paroxetine (Paxil), advising against the use of this drug by women who are pregnant. This decision was based on two preliminary studies which suggested a small increase in the risk of cardiovascular malformations among infants exposed to paroxetine in utero. For many years, this concern regarding risk of heart defects resulted in recommendations that women taking paroxetine should either stop paroxetine or to switch to a different antidepressant during pregnancy.
However, in 2008, a study from the Motherisk Program in Toronto reported on the outcomes of over 3000 paroxetine-exposed infants and found no association between the use of paroxetine during pregnancy and increased risk of cardiovascular malformations. Nonetheless, some women and their treaters continue to feel uncomfortable with the use of paroxetine during pregnancy. Furthermore, many websites (including reputable sites like the Mayo Clinic) continue to urge women to avoid paroxetine during pregnancy because of the risk of malformations.
At this point, we typically do not recommend switching from paroxetine to another antidepressant for pregnancy. Although paroxetine is an SSRI, there are definitely situations where an individual may respond better to paroxetine than to other SSRIs. Thus, switching to a different antidepressant may increase risk for relapse.
What About Lexapro? And Pristiq?
There are some newer antidepressants that are derived from older parent antidepressants. For example, citalopram (Celexa) is a racemic mixture, composed of R- and S-enantiomers (or mirror images) of citalopram. While the S-enantiomer is clinically active, the R-enantiomer is not. Escitalopram or Lexapro contains only the active S-enantiomer. Because the S-enantiomer is contained in the original citalopram formulation, we can infer that the reproductive safety of escitalopram (Lexapro) is the same as that of citalopram (Celexa).
Another example is desvenlafaxine or Pristiq. For venlafaxine to be effective as an antidepressant, it must first be metabolized by the body to desvenlafaxine. Pristiq contains only the active metabolite desvenlafaxine. Because desvenlafaxine is a metabolic byproduct of the original venlafaxine formulation, we can infer that the reproductive safety of desvenlafaxine (Pristiq) is the same as that of venlafaxine (Effexor).
The Bottom Line
No two situations are identical; thus, we must carefully consider each woman’s clinical history and preferences in order to select a treatment plan that makes sense. Ideally this discussion should occur long before a woman is pregnant, so that there is ample time to consider the various options and to make changes, if necessary.
When we meet with women to discuss the use of antidepressant medications during pregnancy, we typically consider a number of issues:
The perinatal psychiatry consultation should be viewed as a collaborative venture, where provider and patient decide together what is the best option for treatment during pregnancy."
-Ruta Nonacs, MD PhD
By: Love Amy Michelle | October 28, 2017
"Love Amy Michelle is a space for you to reconnect with yourself + to find some peace amidst the chaos."
Depression During the COVID-19 Lockdown Highlights the Importance of Social Connections for New Moms
By MGH Center for Women's Mental Health | May 18th, 2021
"Because pregnant and postpartum women face unique challenges in the context of the COVID-19 pandemic, they may be at increased risk for mental health problems in this setting. In a recent study, researchers from the University College of London surveyed 162 new mothers in London between May and June 2020 using a social network survey designed to assess the impact of the COVID-19 lockdown.
Almost half (47.5 percent) of women with babies less than six months of age had depressive symptoms suggestive of postpartum depression assessed using the Edinburgh Postnatal Depression Scale. This is a huge increase in the expected prevalence of postpartum depression; studies carried out prior to the pandemic have shown that about 10% to 15% of women report depressive symptoms during the postpartum period.
The researchers also observed that the more contact new mothers had with other people — whether remotely or face-to-face — the less likely they were to report depressive symptoms. While this finding suggests that social isolation incurred as a result of the COVID-19 lockdown may have increased risk for depression, another interpretation is that women with greater social networks are less vulnerable to depression (whether or not there is a lockdown). However you interpret the data, multiple studies have demonstrated that social isolation is a risk factor for depression, in general, and having adequate social support reduces the risk for postpartum depression.
We often encourage new mothers to bolster their support networks and often recommend new moms groups. While this is a reasonable approach to managing the social isolation of new parenthood, many new mothers struggle to get out of the house and are unable to establish new social networks. One of the silver linings of the pandemic has been increased access to support groups on virtual platforms. For example, Postpartum Support International or PSI now offers a wide array of online group meetings for women who are pregnant or postpartum. Whether or not a lockdown is in effect, these social networks are so important to a new mother’s emotional well-being and may potentially decrease risk for psotatum illness."
-Ruta Nonacs, MD PhD
By MGH Center for Women's Mental Health | May 6th, 2021
"While we have relatively limited information regarding the prevalence of obsessive-compulsive disorder (OC) during pregnancy and the postpartum period. Previous studies have indicated that women may be more vulnerable to the onset of OCD during the postpartum period. Other studies indicate that women with OCD may experience worsening of OCD symptoms during pregnancy and the postpartum period.
A recent study published in the Journal of Clinical Psychiatry looks at the prevalence of OCD symptoms during pregnancy and the postpartum period. They speculate that using standardized instruments for the diagnosis of OCD may fail to capture perinatal OCD, and their study incorporates a detailed assessment of obsessions of infant-related harm and corresponding compulsions.
In this study, 763 English-speaking women living in the Canadian province of British Columbia were recruited into this longitudinal study following women from the third trimester of pregnancy until 9 months postpartum. The Structured Clinical Interview for DSM-5 (SCID-5) was used to confirm DSM-5 diagnoses of OCD.
The weighted prevalence of OCD during pregnancy was 7.8%, and the weighted prevalence increased to 16.9% across the postpartum period. The estimated point prevalence of OCD diagnosis was 2.6% during pregnancy (6 weeks prior to delivery) and increased to 8.7% at 8 weeks postpartum. The point prevalence of OCD remained high (6.1%) at 20 weeks postpartum.
The incidence of new OCD cases was estimated to be 4.7 new cases per 1000 women each week during the postpartum period. By six months postpartum, the cumulative incidence of new cases of OCD was 9.0%. Most cases emerged during the first 10 weeks postpartum.
In total, the researchers observed that 100 women reported symptoms consistent with a diagnosis of OCD at some point during pregnancy or the postpartum period. In this group, 60 of the women reported onset of OCD symptoms during pregnancy or the postpartum period. The remaining 40 women reported that their OCD symptoms preceded the pregnancy.
High Prevalence of OCD During Pregnancy and the Postpartum Period
The lifetime prevalence rate of obsessive-compulsive disorder (OCD) has been consistently estimated to be 2%-3% in the general adult population in the United States. The current study indicates that the weighted prevalence of OCD during pregnancy was 7.8% and increased to 16.9% across the postpartum period. Consistent with previous studies, Fairbrother and colleagues conclude that pregnancy and the postpartum period is a time of increased vulnerability to OCD. In addition, new onset of OCD is relatively common during pregnancy and the postpartum period, with 9% of women reporting postpartum onset of OCD in this study.
These estimates of prevalence are higher than those reported in previous studies, a finding that the researchers attribute to using a more comprehensive evaluation of perinatal-specific OC symptoms, including intrusive thoughts of infant-related harm. However, the authors note that some women joined the study after childbirth and may have been attracted to the study because of their experience of postpartum intrusive thoughts. Nonetheless, this is one of the largest studies we have regarding the incidence of OCD during pregnancy and the postpartum period and is noteworthy in that it used the SCID to confirm OCD diagnoses.
Current guidelines for screening perinatal women do not specifically recommend screening for OCD. This study indicates that perinatal OCD is relatively common and the authors recommend more careful screening for perinatal-specific OC symptoms. They note that standardized assessments for OCD include questions about obsessions involving dirt, germs, arranging and ordering; however, perinatal OCD is more often characterized by intrusive thoughts related to harming the infant (e.g., unwanted thoughts or images of harming the infant on purpose, harm to the infant stemming from parental distraction or neglect, being sexually inappropriate with the infant). Furthermore, given the shameful and horrifying nature of these thoughts, many women are hesitant to share these thoughts with others."
-Ruta Nonacs, MD PhD
By MGH Center for Women's Mental Health | May 5, 2021
"At this point, nine states and Washington, DC have legalized the use of recreational marijuana. Another 30 states have legalized medical marijuana. The downstream effect of these changes has been a significant uptick in the use of cannabis among women of childbearing age. According to data collected from the National Survey on Drug Use and Health, the use of cannabis in pregnant women rose from 2.37% in 2002 to 3.85% in 2014 in the United States, noting that 21.1% of pregnant women who used cannabis reported doing so on a daily basis.
While we have data to indicate that the use of cannabis during pregnancy may negatively affect fetal growth and brain development, we have less information on how the cannabis and its byproducts, which are secreted into the breast milk, may affect the nursing infant. Here are some important things we do know:
Can cannabis be found in the breast milk?
No matter how marijuana/cannabis is consumed (smoking, vaping, or ingesting), its byproducts can be found in the breast milk. Figuring out how much is passed into the breast milk is complicated because how women use cannabis varies considerably. For example, the kinetics of smoking vary considerably from ingesting. Both cannabidiol (CBD) and the psychoactive component, delta-9-tetrahydrocannabinol or THC, have been detected in breast milk.
In the largest study to date, which included eight breastfeeding women, the amount of THC detected in pumped breast milk ranged from 0.4%-8.7% of the maternal dose, with an estimated mean of 2.5%. Using these data, the average absolute infant dose was estimated to be 8 micrograms per kilogram per day.
If cannabis is consumed, how long does it persist in the breast milk?
Cannabis concentrations in the breast milk are variable and are related to maternal dose and the frequency of dosing. However, there are some things that make cannabis a little different than alcohol or other recreational drugs. Cannabis and its byproducts are very fat-soluble or lipophilic. Because in women the percentage of body fat is 25-30%, there is a large reservoir for the storage of cannabis. What this means is that it takes much longer for cannabis to leave one’s system, compared to substances like alcohol. Furthermore, there is an especially long washout period in those who have been daily users. Long after the psychoactive effects have faded, THC and its metabolites can be detected in blood, urine, and breast milk.
Studies focusing on the detection of THC in milk have yielded variable results, with duration of detection ranging from 6 days to greater than 6 weeks in various studies. The most recent study from Wymore and colleagues In a recent study, Wymore and colleagues collected data on self-reported marijuana usage and measured levels of THC in maternal plasma and breast milk samples several times a week. In all 25 participants, THC was detectable in breast milk throughout the six week duration of the study.
The researchers estimated the mean half-life of THC in breast milk to be 17 days (SD 3.3). Based on this estimate, they calculated that it would be possible to detect THC in breast milk for longer than 6 weeks. In addition, the researchers were able to calculate a milk:plasma partition coefficient for THC which was approximately 6:1 (IQR, 3.8:1 – 8.1:1). Milk:plasma ratios give us a sense of how easily a compound passes from the mother’s bloodstream into the breast milk and can be used to estimate the amount of exposure through breast milk. Most M:P ratios for drugs commonly used in breastfeeding women are around 1 or less than 1; thus, an M:P ratio for THC of 6 is high and suggests that levels of THC in the breast milk may be higher than in the mother’s bloodstream.
The findings of the Wymore study are consistent with previous studies measuring THC in breast milk which observed a duration of detection ranging from 6 days to greater than 6 weeks after using cannabis. The longevity of THC in the breast milk may be related, in part, to the extremely high fat content of breast milk and the lipophilic nature of THC, so that the breast milk “traps” the THC, in a sense acting like a reservoir for THC storage.
What are the effects of exposure to cannabis in the nursing infant?
The bioavailability of cannabis and its metabolites ingested by neonates in the breast milk has not been well-characterized. There are conflicting data regarding the outcomes of infants exposed to cannabis during breastfeeding and very few studies assessing outcomes in this population. These studies are not easy to conduct. First of all, recreational use of cannabis continues to be illegal in many states. Furthermore, it is difficult to disentangle the direct effects of cannabis delivered in the breast milk from the indirect effects of cannabis on the quality of childcare and parenting, especially in heavy, chronic users or when cannabis is combined with other substances.
In one study, 136 breastfeeding infants were assessed at one year of age. In the 68 infants exposed to cannabis during the first month of life, there was evidence of decreased motor development at one year, when compared with matched infants who were not exposed to cannabis. Specifically, there was a 1465-point decrease in the Bayley index of infant motor development. However, the authors of this study cannot conclude that these findings were entirely due to exposure via breastfeeding, as many of the women also used marijuana during pregnancy.
In another study, 27 breastfed infants exposed to cannabis were compared to 35 unexposed breastfed infants. At one year, no differences were noted for motor and mental development using the Bayley Scales of Infant Development. However, the small size of this study limited statistical analysis.
So the jury is still out regarding the effects of cannabis on the nursing infant.
All women should be screened for drug use as a component of standard prenatal care. Screening for substance use should occur during the course of pregnancy with the goal of providing information regarding the potential adverse effects of cannabis and to ensure referral to appropriate resources for treatment as needed. Because many women are able to abstain from substances during pregnancy but resume use after delivery, screening must be repeated during the postpartum period.
Both the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics recommend that women refrain from using cannabis during pregnancy and while breastfeeding. Because of the persistence of cannabis and its byproducts in the breast milk for days to weeks, using cannabis and waiting for it to clear out of the breast milk is not a viable option. For women who use cannabis for medical indications, alternative therapies with more safety data during breastfeeding should be considered."
-Ruta Nonacs, MD PhD
By: Becky Vieira
"Dear Husband-I see you. Then and now. You might not think I did.
I try to imagine what you endured. The pain, fear. While the primary focus was on me, my health and recovery, I know you were suffering also. Silently. Never saying a word of complaint.
I recognize all you did to get me where I am today. To get us here.
We thought we’d just be tired. That exhaustion would be the biggest of our problems once our son was born. Neither of us expected that I’d be gripped – no, controlled – by my postpartum depression. It was supposed to be the happiest time of our lives, not the living nightmare it soon became.
It started slowly, do you remember? We thought I was tired. That my hormones were adjusting yet again. But before we knew it I was underwater. The progression from healthy to dangerous transpired within days once that beast took hold of me.
How did you do it? We had a newborn. No idea what to do with him. You carried that aspirator in your back pocket at all times “just in case.” And while we watched him sleep for fear something would happen if one of us closed our eyes, I began losing my fight.
Yet you continued on.
I started to slip away. I wanted to leave, convinced you both would be better off without me. You held me when I needed it. Let me run into the street to scream, then greeted me at the door with a warm blanket and tea when I returned. Researched treatment. Medications. Called my doctor and hid my car keys when things got dark.
You also got up every morning and went to work. Held things together for us financially. All while receiving frantic calls from me. Coming home between meetings, at lunch. To check on us.
There was no guidebook for you. No one you could call to ask questions on how to handle the situation. I was wrapped in the support I found online from other mom’s with postpartum depression. But what did you have? No men on social media were presenting themselves as the husbands of women with PPD. You had nowhere to turn.
There are resources for PPD. Help. But no one can really tell you how to live through it. It felt as if we were thrust into a new universe, one that spoke an entirely different language. My mind started lying to me and my will to live was faltering. Our coping skills were stripped away and we had to find a way to survive. I needed to be healthy again.
You kept going, for all of us. Trusted your instincts and did the best you could. Yes, there were moments when I was angry over the things you said or did. But today I see that it was in my best interest. You always tried to help.
Even when I screamed at you and said horrible things. Threatened to walk out of your life because I was convinced you deserved better than a sick wife. You never gave up.
You should be proud of yourself and recognize all you did. I’m proud of you. And grateful you stayed by my side. I’ll never forget sitting on the kitchen floor, crying to you as I said, “I’m crazy.” You kissed me and said, “then I guess I’m crazy, too.” Our tears turned to laughter and I knew I’d never be alone.
We survived and our marriage is actually stronger today because of all we endured. You held it together so that I could fall apart safely. And then build myself back up again.
Yes, I spoke up. Got help. Worked on myself, started taking medication. But it would have been much harder without you by my side.
I know you suffered. Were scared. And probably angry, frustrated and hopeless at times. But I never saw that. I only felt loved and supported.
Thank you for everything. I see you and what you did for me and our family. And I’ll never forget."
"If you think you may be suffering from postpartum depression, don’t wonder. Speak up. Talk to you doctor, partner, family and friends. If you are scared or worried about the stigma (I get it… we shouldn’t be concerned about that but of course we often are) and would rather talk to someone outside of your circle, you can call Postpartum Support International at 1.800.944.4773. If you just need a fellow mom to validate you and listen to your fears, find me on Instagram and reach out.
Anxious, overwhelmed, unhappy, or scared by how you feel? If you’re struggling emotionally, you could be depressed. Take this 10-question quiz to find out."