Identifying women at risk could protect them and their infants.
Perhaps not everyone knows that depression during pregnancy is as common as, or possibly more common, than postnatal depression.
Contrary to what is commonly thought, women are not “hormonally protected” from mental health difficulties during pregnancy. Indeed, up to 20% of women will experience depression or anxiety at some point while they are pregnant.
The whole perinatal period, i.e., pregnancy, birth and the first postnatal year, is associated with an increased vulnerability for the woman’s mental health. This increased vulnerability is because of the many changes and challenges, as well as the high levels of stress, associated with this particular time in a woman’s life.
Whilst depression during pregnancy is common, many women are not currently identified as depressed by their doctors and midwives, thus they do not receive adequate treatment.
Why is this important?
There is extensive literature showing that an untreated episode of depression during pregnancy can be associated with negative long-term effects on the offspring’s development, not only in infancy but also through adolescence and young adulthood, even when taking the mother’s mental health outside of this period into account.
We also know that antenatal depression is one of the strongest risk factors for developing postnatal depression, and that postnatal depression is itself often associated with difficulties in the mother-infant relationship, high levels of parenting stress (that is, the stress associated with the role of being a parent) and less optimal child development (for example, infants who have difficulties in speaking and in learning, or infants who show behavioural or emotional problems).
The good news is that we can identify women who are at risk of suffering from depression and anxiety early on, when symptoms are only starting to emerge or even when they are not present yet.
Understanding the risk factors can help more women to remain well.
Indeed, the perinatal period represents a unique window of opportunity for intervention, as most women will have contact with health professionals, and they are usually highly motivated to engage in order to promote their own, as well as their infants’ wellbeing.
Of course, it is important to highlight that feeling sad, tired and stressed during pregnancy does not necessarily mean that a woman is depressed. It can be completely normal to feel this way at times during pregnancy.
What we are talking about is clinical depression — a pervasive and prolonged sadness that severely affects the woman’s ability to function everyday, to enjoy things in her life and to interact with people as she normally would.
So, which women are at risk of developing depression and anxiety in pregnancy?
In what is still one of the most read papers from our research group, published in Journal of Affective Disorders, I have discussed which factors increase the risk of depression and anxiety in pregnancy, ranging from the psycho-social aspects to the presence of obstetric and pregnancy-related difficulties.
Perhaps not surprisingly, a previous history of mental disorders, and particularly a previous history of depression and anxiety, is one of the strongest risk factors.
However, it is less known that high levels of stress also increase the risk of depression and anxiety in pregnancy. This includes stress during pregnancy (adverse experiences, such as the death of a relative or close friend, losing a job or experiencing a serious illness) but also, interestingly, stress early in life (for example, having been exposed to a difficult childhood because of violence or emotional neglect).
Domestic violence, both current and previous, is another important risk factor, and women should be supported by health professionals in seeking help and refuge in such situations.
There are also factors related to pregnancy, such as an unwanted pregnancy, as well as current or previous pregnancy complications or pregnancy loss.
Some factors relate to social and economic circumstances: for example, experiencing economic difficulties, or a lack of social and partner support; not having a partner or experiencing problems in the marital relationship. Indeed, the experience of lack of support, particularly from the partner but also from family and friends, increases the woman’s vulnerability to depression and anxiety during pregnancy.
On the other hand, protective factors have also been shown by research: being satisfied with the marital relationship; perceiving the partner and the social network as supportive and having a positive and active coping style. These protective factors are very important and can limit any potential negative impact of the risk factors.
It is important to highlight that these are just “risk factors”, and do not cause these problems for every woman. Indeed, many women who have these risk factors will not develop depression and anxiety in pregnancy.
Mental health during pregnancy depends on many different circumstances interacting and combining together in different ways, eventually increasing the risk that some women will become unwell while others remain well. Therefore, these are not causal and non-modifiable journeys, and they are not identical for all women.
It is also important to say that not all episodes of depression during this period will be associated with negative consequences for the child. Once again, there are multiple factors that combine and interact together in different ways. For example, there are many factors that can protect the infant’s wellbeing when the mother is unwell, such as the presence of a supportive and caring partner.
Nevertheless, correctly identifying the women most at risk of suffering from these disorders would offer the opportunity to provide preventative and supportive interventions and to monitor these women during pregnancy so that early symptoms could be recognised, and therapeutic interventions implemented in a timely manner.
This is likely to have a long-term positive impact on both mother and infant.