UIC PERINATAL MENTAL HEALTH PROJECT

Welcome to the University of Illinois at Chicago Perinatal Mental Health Project website! “Perinatal” means anything pertaining to pregnancy or postpartum (up to a year after giving birth). Pregnancy and the postpartum period are times of higher risk for clinical depression and anxiety disorders. Untreated symptoms of these disorders can affect the health of the mother and the baby, and often indirectly affect the whole family. Some of the treatments for these disorders, such as medications, can also cause risks to mother and baby. Understanding and weighing these risks to come up with the best treatment plan for each woman is a specialized skill. The health professionals with the expertise to do this are known as women’s mental health psychiatrists or reproductive psychiatrists. Other health professionals, such as advanced practice nurses, psychologists and social workers, may also have specialized knowledge and skills to diagnose and treat perinatal psychiatric problems.

Our project’s purpose is to increase the ability of health care providers, such as doctors and nurses, to recognize, diagnose and treat perinatal depression and anxiety disorders. We do this by conducting training workshops and consulting directly to health care providers.

Here is a summary of some key facts about common disorders during pregnancy and postpartum:

Perinatal depression
About 9 – 12 of women develop major depression while pregnant. “Major depression” is a term for a medical diagnosis, not to be confused with the colloquial use of the word “depressed” to mean sad or down. Women with clinically diagnosed major depression do indeed feel sad, empty, and/or unable to experience pleasure, but this is a sustained, nearly constant mood and out of proportion to events in their lives. Women with major depression also have other symptoms, which can include feeling hopeless, helpless, guilty and/or very negative about their self-worth. They may have difficulty sleeping even when they are exhausted and the baby is fast asleep, or they may have difficulty ever getting out of bed. They may eat excessively for comfort, or may lose their appetite. They may have difficulty concentrating or making everyday decisions, like what clothes to wear. Their energy levels and motivation to socialize or do anything else may be very low. They may wish they were dead, think others would be better off without them, and consider suicide.

Untreated depression major during pregnancy appears to increase the risk that babies will be born premature or not weighing as much as they should. Also, babies born to mothers with untreated depression seem to be fussier and more difficult to soothe. Some studies have also found that untreated depression during pregnancy leads to higher risks of miscarriage, bleeding, high blood pressure, and a condition called pre-eclampsia that can lead to seizures, but these findings are less certain. Also unclear, but found in some studies, is a link between depression during pregnancy and low Apgar scores in babies (a score indicating the baby’s health at the time of birth) and need for the baby to be admitted to an intensive care unit.

Why does depression lead to these problems for babies? Some of the increased risks to babies may be because as a group, mothers with untreated depression get less prenatal care, drink more alcohol, and smoke more cigarettes. Clinical depression also causes hormonal abnormalities, especially to the stress hormone, cortisol, and this affects the child’s stress responses and temperament later in life.

Over 20% of women develop major depression sometime during the first year after giving birth. While many depressed new mothers heroically provide excellent care for their babies, postpartum depression can interfere with mother-infant bonding and increase the risk of emotional and intellectual problems in the child. An especially distressing symptom of postpartum depression is thoughts of harming the baby. It is very rare that a depressed mother will act on these thoughts.

It’s important to note that about half of women develop a normal mood change called “postpartum blues” within the first few days to weeks after giving birth. This is not the same as clinical depression. A woman with the “blues” usually finds that she is more emotional than usual, crying very easily or flying off the handle more quickly than usual. But the key difference between normal “blues” and clinical depression is that women with normal “blues” don’t feel sad or empty most of the time. If a woman can’t tell whether what she is experiencing is “blues” or clinical depression, it is important to see a doctor to help sort this out.

Perinatal bipolar disorder
In some cases, women who have episodes of depression also have episodes of “mania” or “hypomania”. Symptoms can include excessively happy or irritable moods, thoughts that race very fast, talking rapidly, reduced need for sleep, excessive activity, excessive spending of money, and impulsive behaviors. It is very important to figure out whether a woman with depression has bipolar disorder or not, since some treatments for depression can make bipolar disorder worse.

Bipolar disorder is a frequent cause of the most severe and dangerous postpartum psychiatric condition: postpartum psychosis. This is a condition in which a woman loses touch with reality – for example, she may hear or see things that are not really there (hallucinations), and may have irrational beliefs (delusions). Some of these hallucinations or delusions may be about her baby – for example, she may believe that her baby is the Devil, or she may hear a voice commanding her to drop her baby. In some tragic cases, these symptoms can lead a woman to kill her baby. If psychotic symptoms are going to happen, they usually start within the first three weeks of birth – in about half the cases, they start within the first three days. The symptoms can come and go – a woman can seem like her usual self for several hours or even days, but still have psychotic symptoms on and off until treated.

Anxiety disorders
Nearly all pregnant women have anxieties – worries about what labor and delivery will be like, whether the baby will be healthy, how they will fare as mothers, etc. Some women’s anxieties go far beyond these normal worries and become anxiety disorders – medical conditions that require treatment. Severe, untreated anxiety during pregnancy can affect the fetus. It can change the fetus’ blood flow pattern and contribute to premature birth, low birth weight and lower Apgar scores (a score that measures a baby’s health at the time of birth). Sometimes severe anxiety during pregnancy causes long-term changes in the way children react to stress.

Here is a description of specific anxiety disorders that are common during pregnancy and postpartum.

Panic disorder
Women with panic disorder have frequent panic attacks. Panic attacks are brief (about 10 – 15 minute) episodes of intense panicky feelings, along with physical sensations that can include difficulty breathing, heart pounding, sweating, trembling, stomach churning and light-headed or dizzy sensations. During a panic attack, a woman may feel like she is having a heart attack or dying. Panic attacks can get started in anxious situations, but they can also happen “out of the blue” when a woman is relaxing. They can sometimes even wake people from a sound sleep.

Pregnancy can affect the course and expression of panic disorder. While most women experience no change in symptoms, a small group of women experience marked improvement while pregnant – fewer panic attacks and less severe ones. However, women who continue to have severe, frequent panic attacks while pregnant can risk complications, including babies who are smaller at birth than they should be, and babies with cleft lip and cleft palate. For some pregnant women, panic attacks are brought on by fearing that normal bodily changes in pregnancy might be danger signs – for example, thinking that gas pains might be uterine contractions. Some pregnant women with panic disorder become more anxious due to feeling out of control as pregnancy unfolds, fearing labor and delivery, and fearing that something will be wrong with the baby.

Postpartum, it is more common for women with panic disorder to experience a worsening of symptoms. Breastfeeding, if it works smoothly and does not feel like a burden, can reduce panic attacks in some women.

Obsessive compulsive disorder (OCD)
Pregnancy and the postpartum period appear to be times of heightened risk for getting symptoms of OCD. People with OCD experience at least one of two types of symptoms - obsessional thoughts (thoughts that repeatedly come into their minds, even irrational thoughts), and compulsive behaviors (things they feel they have to do, even if they know they don’t make sense). Nearly everyone has obsessional thoughts and compulsive behaviors sometimes – for example, having a piece of music “stuck in one’s head”, or checking two or three times to make sure one has turned off the stove. If that’s all there is to it, it’s not OCD. People with OCD have obsessions and compulsions that are so frequent and/or severe that they are highly distressing and interfere with daily activities. For example, a pregnant woman with OCD might a continual thought that there could be dangerous additives in foods, to the point of being unable to eat anything, even though she knows rationally that eating nothing is much riskier than the chance of exposure to harmful food additives. Another example: a postpartum woman with OCD could feel so compelled to wash and rewash her baby’s bottles that she spends hours every day doing this, leaving little time to interact with her baby, even though rationally she is aware the bottles need only one good cleaning and the baby needs attention.

For new mothers with OCD, a particularly distressing but common symptom is an obsessional thought of harming her baby. Even though she would not actually act on the thought, it can cause her to be afraid to spend time with the baby, especially without other people around. Many women with these thoughts are afraid to mention them to anyone, fearing they will be viewed as horrible mothers. This leads to agonizing emotional isolation and prevents the woman from getting the treatment she needs.

Post-traumatic stress disorder (PTSD)
PTSD is a condition that happens to some people after they have experienced a very frightening, often life-threatening event, such as a rape, a car crash, or a beating. Symptoms can include nightmares, flashbacks (vivid memories of the trauma during the daytime), excessive startle response, difficulty sleeping, and avoiding places or things that trigger memories of the trauma. While peripartum PTSD can result from any type of trauma occurring during pregnancy or postpartum, four types of trauma are especially likely to produce peripartum PTSD symptoms: (1) difficult labor and delivery; (2) pregnancy-linked triggers of memories of childhood sexual abuse; (3) rape resulting in pregnancy; (4) serious health problems in the newborn.

Labor and delivery are always painful and there is always some anxiety about giving birth. Despite this, most women do not experience normal labor and delivery as so traumatic that they develop PTSD. Yet some labor experiences can be especially difficult – for example, ones in which something went wrong and the mother felt she or her baby might die. About 3 – 5% of women who give birth develop PTSD as a result of very difficult labor. Women are more at risk if they don’t have supportive family members, friends and obstetric staff helping them through the process. Women with birth-related PTSD sometimes avoid reminders of the trauma. These reminders can include the postpartum checkup, sexual relations, or even the baby. Some women are afraid to get pregnant again, and some who do get pregnant request Cesarean sections because they are afraid to go through labor again. Most women with postpartum PTSD end up thoroughly exhausted, afraid to sleep because of nightmares, and sometimes a need to constantly check on the baby. If the baby was temporarily affected by the difficult labor – for example, the baby may have been limp and blue for a few minutes but healthy ever since – a mother with PTSD might have repeated flashbacks of the limp, blue baby.

For women with a history of childhood sexual abuse, experiences during prenatal care, labor, delivery and/or breastfeeding may trigger memories, flashbacks and emotions associated with the abuse. Women experiencing this type of PTSD may recoil when touched during obstetric examinations, or avoid prenatal care altogether. During labor, some women with sexual abuse histories begin acting childlike, having difficulty separating the past from the present. Some women become so anxious that they tense up their muscles and slow down the labor process without meaning to.

Untreated PTSD during pregnancy may increase the risk of complications in offspring. For example, pregnant women who developed PTSD during the September 11th terrorist attack had smaller babies than similarly-exposed women who did not develop PTSD; both the mothers with PTSD and their babies had abnormal cortisol levels.

What causes peripartum depression and anxiety disorders?
Scientists do not yet fully understand why some women develop clinical depression or anxiety disorders during pregnancy and postpartum, but research has uncovered factors that make some women more vulnerable than others. One of these is heredity. If a woman’s biological relatives have had depression and/or anxiety disorders, especially peripartum, she is at higher risk. Another factor is that some women are vulnerable to mood symptoms at times when sex hormone levels change rapidly. This is because sex hormones like estrogen and progesterone affect neurotransmitters, chemicals that brain cells use to communicate with one another. Women with premenstrual mood changes are at higher risk for developing postpartum mood changes.

Another major risk factor for perinatal depression and anxiety disorders is stress. The most difficult kind of stress during pregnancy and new motherhood is not having enough support from others. Single mothers and teen mothers are at greater risk for postpartum depression, especially if they don’t have strong emotional support from family members and close friends. Other kinds of stress that often lead to perinatal depression include the death of a loved one or a major life change, such as moving to a new home or changing jobs.

How are perinatal depression and anxiety disorders recognized and diagnosed?
Many prenatal care clinics and pediatricians’ offices give women a brief questionnaire asking about symptoms of depression and/or anxiety. Much like checking blood pressure, weight and blood sugar, these depression and anxiety questionnaires are screening tools to help you and your health care provider notice early symptoms of problems so treatment can begin promptly before the condition becomes risky.

A screening tool does not diagnose major depression or anxiety disorder. But if the screening questionnaire shows that a woman might be at high risk for depression or anxiety disorder, she will be offered a clinical assessment to see whether she has those diagnoses. The assessment consists of a detailed interview, observations and sometimes blood tests.

If a woman has not received a screening questionnaire, but she or a loved one suspect she may have clinical depression or an anxiety disorder, it is important for her to see a doctor or advanced nurse practitioner for an assessment.

Treatments for perinatal depression and anxiety disorders
There are three types of treatment that are well established to be effective for treating depression and anxiety disorders during pregnancy and postpartum: interpersonal psychotherapy, cognitive behavioral therapy, and medication. There are other treatments that look promising in early studies, but are not yet proven to be effective. There are also things that women can do for themselves that will help them recover more quickly and fully, along with professional treatment. Parenting coaching can help in situations where perinatal depression and/or anxiety have interfered with the mother-baby relationship.

Interpersonal psychotherapy
When a woman becomes a mother, her relationships with others may substantially change. Not only does she need to adjust to motherhood, but she may need to negotiate a new relationship with her partner, her other children, her parents, her in-laws, her boss and her co-workers. Sometimes this goes relatively smoothly. When it doesn’t, and when the woman is dissatisfied with her roles and lacks enough support from others, this can be a major cause of postpartum depression.

Interpersonal psychotherapy helps a woman examine each of her key social roles and figure out what works and doesn’t work for her in each of them. In therapy, she clarifies what specific types of support she needs from others. Then she learns effective ways of negotiating with others to get what she needs. Often this type of therapy includes role playing to practice the skills.

Cognitive-behavioral therapy
Women with peripartum depression may have certain habits of thinking and behaving that contribute to depressed moods. For example, a depressed woman may overly focus on negative interpretations of events. If her baby cries and she has difficulty soothing the baby, she may interpret that to mean she is a bad or ineffective mother. Her depression may make her feel like staying in bed all day, refusing phone calls and visitors, and not eating healthy foods. Cognitive-behavioral therapy helps a woman identify these thoughts and behaviors and develop health-promoting thoughts and behaviors.

Certain types of cognitive-behavioral therapy are highly effective for treating perinatal anxiety disorders. A cognitive-behavioral therapist can teach a woman effective relaxation techniques, and can help her design a systematic way of gradually exposing herself to anxiety-provoking situations while using techniques to conquer the anxiety.

Medication
Certain types of medication are highly effective for treating clinical depression and anxiety. Any medication can have side effects, including effects on a fetus or newborn. Some antidepressant and anti-anxiety medications have been systematically studied for their effects in human pregnancies, and some have not.

When a woman has major depression or an anxiety disorder during pregnancy or postpartum, it is important to consult with a physician or advanced practice nurse who can figure out whether medication is needed, can weigh the risks of the symptoms against the risks of the medication, and is familiar with the research about different medications during pregnancy and breast-feeding. Some women can be fully restored to health with psychotherapy alone, but some require medication (often along with psychotherapy) in order to recover. In many cases, the risks of the symptoms are worse than the risks of carefully chosen medication. Choosing the safest medication at the safest dose for different stages of pregnancy can reduce risks of the medication.

Experimental treatments
Small studies have used innovative treatments for postpartum depression. Estrogen has helped women with depression in some small studies, but it is not yet known what the risks of estrogen use are, or how long women need to take estrogen to prevent the symptoms from coming back. Light therapy, also known as phototherapy, may help a woman restore her natural hormonal body rhythms after birth and that may reduce symptoms of depression. This is especially worth considering for women who notice that they feel much more depressed in the fall and winter, when there is less light.

Many women wonder whether herbal products would be effective and safer than prescription antidepressants. Unfortunately, there is no evidence from studies so far that any herbal product is effective for treating perinatal major depression. Some commonly used herbal remedies can interfere with fertility and can make the uterus contract, so it’s not true that herbal products can be assumed to be safe just because they are “natural”.