Not Always 'the Happiest Time'

Let's just say that you are among the millions of women for whom pregnancy was not bliss. You may have felt cranky or anxious, exhausted or fat, moody, stressed, nauseated, overwhelmed, isolated or lonely. You may even have felt bad about feeling bad. Now let's say that you, like Marlo Johnson, are a veteran of depression, someone who has battled the illness on and off for years. Then pregnancy can feel like the worst thing that ever happened to you. Johnson, 35 years old and from Brentwood, Calif., felt her mood plummet almost as soon as she conceived. But she put a brave face on it at work, with her family--even with her own therapist. The only time she cried was when she visited her obstetrician. Every time. Johnson's doctor encouraged her to look on the bright side. " 'Just think, at the end you're going to have this beautiful baby, the most beautiful gift'," Johnson recalls her saying, "and I said, 'I don't care. I don't want it. It doesn't matter to me'."

Contrary to conventional wisdom and medical lore, pregnancy does not necessarily equal happiness, and its hormones are not protective against depression. Doctors estimate that up to 20 percent of women experience symptoms of depression at some point during their pregnancy--about the same as women who are not pregnant. Even as postpartum depression has become morning-television fodder, the problem of depression during pregnancy has remained hidden--largely because most people still assume that pregnancy is or should be the realization of every woman's dream. When she was training as a psychiatric resident in the 1980s, Katherine Wisner, now a professor of psychiatry and Ob-Gyn at the University of Pittsburgh, remembers being told not to worry about pregnant patients who were, in her view, "very ill." Pregnant women, her teachers said, are "psychologically fulfilled."

Finally, pregnancy-linked depression is coming into the open. A series of studies, published this year in medical journals, is looking at all aspects of the problem--with special focus on the effects of anti-depressants on the health of pregnant women and newborn babies. These studies have launched, for the first time, a serious debate among doctors on the risks and benefits of treating pregnant women with medication. "There are still unanswered questions" about SSRIs and pregnancy, says Lee Cohen, a psychiatrist at Mass General Hospital in Boston and author of one of the recent studies. "But the doctors--the psychiatrists, the OBs--can't be cavalier, and can't presume that [without treatment] things are going to be fine."

Pregnancy probably doesn't cause depression, per se, but just like a divorce or a death in the family, it can trigger it in women who may already be genetically predisposed. And the hormones don't help. The relationship between estrogen, progesterone and mood is not well understood, but scientists believe it is the changes in hormonal levels, rather than the levels themselves, that affect people's moods. In a series of experiments published in The New England Journal of Medicine in 1998, psychiatrists Peter Schmidt and David Rubinow found that women who were prone to mild depression associated with premenstrual syndrome felt better only when their hormonal cycles were artificially shut down. They guess that the same is probably true with pregnancy: massive hormonal changes affect mood, but only in susceptible women. "In some women it may be the dramatic drop in hormones at childbirth that is the trigger," says Rubinow. "In others, it may be the elevated levels at the end of pregnancy."

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It's difficult to detect depression in a pregnant woman, doctors say, because so few of them admit they're depressed--and because so many of the symptoms, such as sluggishness and sleeplessness, look alike. But Linda Worley, a psychiatrist at the University of Arkansas, who has a $250,000 federal grant to raise awareness about pregnancy and depression, says too many doctors don't ask pregnant patients about their mood or administer routine screening tests; some are too busy, some assume it isn't a problem and a few--not knowing where to refer such a patient--are afraid to hear the answer. According to preliminary results of a survey Worley received from 145 obstetrical providers, more than 80 percent rely on patients to self-report depression.

Treating a pregnant woman for depression is a delicate balancing act, a constant weighing of risks and benefits to the mother and to the fetus. But intervention is critical: a recent study by Columbia's Myrna Weissman shows that a mother's mental health directly affects the mental health of her children. Without aggressive treatment, "the whole family will suffer," Weissman says. Cohen's study, in The Journal of the American Medical Association, showed without a doubt that depressed mothers-to-be do better on SSRIs. Women who continued taking medication while pregnant were five times less likely to have a relapse of their illness than women who didn't. This is important--and not only because it improves the mother's health. Depressed women are far likelier to smoke, drink and miss doctors' appointments; depressed mothers give birth more often to under-weight babies. Faced with these facts, Claudia Crain of Newburyport, Mass., decided to continue taking her antidepressants: "The more research I did, the better I felt about what, in the end, was my personal decision." Her twins are due this month.

At the same time, no one would argue that antidepressants are good for growing fetuses. Two new studies help people assess the risks for themselves. In one, published in The New England Journal of Medicine, researchers found that newborns whose mothers took Prozac, Paxil or Zoloft in the third trimester had six times the risk of persistent pulmonary hypertension, a rare blood-pressure condition that is potentially fatal. In another, smaller study, 30 percent of infants whose mothers took SSRIs showed symptoms of neonatal abstinence syndrome, a kind of supercrankiness linked to withdrawal. Most got better within days.

Therapy is a good alternative, especially for women with mild or moderate symptoms. In today's world, where families live far apart and everyone works all the time, many pregnant women say they feel isolated. This can be alleviated by talking. Margaret Spinelli, a psychiatrist at Columbia University, was surprised to find in a 2003 study that depressed pregnant women had a 60 percent recovery rate with interpersonal psychotherapy, a short-term, focused treatment--about the same rate as with antidepressants. "We just don't have the networks of close-by girlfriends and sisters and neighbors and moms that provide support," adds Pittsburgh's Wisner.

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One of the reasons Marlo Johnson kept her depression hidden was that she didn't want to take antidepressants during her second pregnancy, as she had during her first. "I don't like being on medication; I kept telling myself I could handle it," she says. But finally Johnson's doctor took action. She ordered her to take a leave from work and to come clean with her therapist; Johnson's husband, who was working hundreds of miles away, came home. On March 20, Carter Patrick Johnson was born, weighing more than eight pounds. Mom says she loves the baby, "but I'm still depressed," and is back on medication. Sometimes even happy stories have bittersweet endings.

Not Always 'the Happiest Time' | News