Pregnancy blues

You've taken the pregnancy test and shared the good news with those closest to you. Everyone congratulates you and says how happy you must be. But although you're excited by the atmosphere, inside you may be feeling far from ecstatic. In fact, you may be downright unhappy sometimes.

To make matters worse, you may feel guilty about being unhappy. But if you think you're the only one to have these feelings, be reassured that you're not.

How can I tell if I'm depressed?

Pregnancy can be a positive time, but not always, and not for every woman. About one woman in 10 suffers from depression during pregnancy (Borton 2010, Dennis et al 2007, NCCWCH 2008: 118).

You may think you should gloss over your feelings if you've been led to believe that pregnancy is a time of joy. Perhaps you assume that your sadness is just a form of moodiness that's part of pregnancy. But depression is more than feeling sad or miserable and can become a serious problem if you don't get the help you need.

There isn't a simple set of symptoms which add up to depression, as it varies from person to person (NCCMH 2010:17-18). Some people have a low mood all the time, others feel irritable and tearful, or feel useless and want to withdraw from life.

Depression can affect you emotionally and physically and it can alter your behaviour (NCCMH 2010:17-18). You may find it very hard to talk about how you feel with others, including your doctor (NCCMH 2010: 99).

If you are suffering from depression, it's likely that you:

• have trouble concentrating
• feel anxious a lot of the time
• are short-tempered and restless
• have problems with sleeping
• feel constant, extreme fatigue
• are preoccupied with constant, negative thoughts
• want to eat all the time, or not at all
• feel that nothing feels enjoyable or fun anymore
• are low-spirited for most of the day
• feel weepy and helpless (NCCMH 2010: 18)

What has caused my depression?

It used to be thought that pregnancy hormones provided a protective effect from depression. That's because many women have a feeling of emotional well-being during pregnancy (Dennis et al 2007). But it's now thought that hormone changes in pregnancy may actually contribute to the development of depression (Borton 2010).

The stresses and strains of pregnancy, especially if you're already caring for young children, can leave you particularly vulnerable to depression (Borton 2010, Borthwick et al 2004, NCCMH 2007).

If things aren't going well, when you're perhaps experiencing relationship difficulties or money worries, then you may become even more prone to depression (Borton 2010).

Other, more specific causes of depression are:

Stressful life events

Major life changes such as moving house, or events such as divorce or job loss can cause depression (Dennis et al 2007).

Low income

Unemployment and lack of qualifications both play their part (NCCWCH 2008: 119, Borthwick et al 2004) but low income itself has a strong link with prenatal depression (Borton 2010, Dennis et al 2007). If you're struggling on a low income and looking after children already, then being pregnant again may add to your concerns (Borton 2010).

Problems with your pregnancy

A troubled pregnancy, such as one that's marred by severe morning sickness, can take its emotional toll (PRODIGY 2008b). If you didn't plan to become pregnant at this particular point in your life then this could also contribute to your feelings (Borton 2010).

Complications in a previous pregnancy or birth

Your experience of pregnancy and childbirth in the past can affect how you feel about this pregnancy. Previous pregnancy complications or a difficult or traumatic birth can cause depression and anxiety (Dennis et al 2007, RCOG 2011).

Infertility or miscarriage

If you experienced problems while trying to get pregnant, or have had a miscarriage in the past (Blackmore et al 2011), it's only natural to worry about the safety of this pregnancy.

Physical or emotional abuse

Unfortunately, pregnancy can be a trigger for domestic violence to start or get worse (Borton 2010, NCCWCH 2008). If you're a victim of domestic abuse you're also more likely to experience depression during and after your pregnancy (Flach et al 2011).

Talk to your midwife or doctor if you are suffering from, or have suffered from, abuse. It can be hard to bring up the subject, but once you ask for help, you can start to get the support you need (NCCWCH 2008).

Personal history of depression

If you've experienced depression, anxiety or other mental health problems in the past, you may be more likely to become depressed during pregnancy. You may also be more likely to have depression in the year after your baby is born (NCCMH 2007: 92, PRODIGY 2008a, NHS 2011).

During your prenatal appointments, your midwife or doctor should ask you how you're feeling now and about whether you've experienced depression in the past. This is to make sure that help is there for you if and when you need it (NCCMH 2007, NCCWCH 2008, NHS 2011). Be open and honest, even though it may not be easy (NHS 2011).

How should I deal with depression?

You don't have to cope with your depression alone.

• Talk to your midwife or doctor during your prenatal appointment about your low mood. Explain how you've been feeling during the past month (NCCWCH 2008: 118). And if you become depressed later in pregnancy, go back and explain that you're feeling more than just a bit low (NHS 2011).
• Take it easy by resisting the urge to pack in as many chores as you can before your baby comes. Make yourself top priority. Read a book, have breakfast in bed, or meet up with a friend. Taking care of yourself is an essential part of taking care of your baby.
• Try to get some exercise, even if you don't feel like it. It's unwise to start a full-on fitness regime when you're pregnant, but exercise can help to lift your mood (Borton 2010, NCCMH 2010:202). Swimming, walking, pregnancy yoga and aquafit classes are all safe in pregnancy. 
  
  
• Talk about how you feel to your partner, family and friends, even if you're more inclined to withdraw from them. Their support is important and unless they know how you feel, they won't be able to help. Working through your fears and worries about the future can help to unburden you.
• If you've tried everything to bring yourself out of a low spell for two weeks but nothing has helped, try joining a support group (PRODIGY 2008a, NCCMH 2007). This group therapy may offer you strategies for coping with your depression or breaking the cycle of negative thinking. Sharing your feelings and experiences with other people who are going through the same thing can make you feel less isolated. It can also help you to learn how other people use coping strategies.
• If joining a support group doesn't help, a therapist or a counselor might. Your doctor, midwife, family or friends may recommend good therapists to you, who practice cognitive behavioural therapy (CBT), problem-solving therapy or counseling (PRODIGY 2008a).Seeing a therapist can be very helpful. It means that you're a good mom who is willing to take the steps necessary to keep your baby and yourself safe and healthy.
• If you are having thoughts or hurting yourself, committing suicide or if you are disoriented, go to the nearest emergency room right away. Don’t wait for a doctor or midwife appointment.

Will I need medication for my depression?

It depends on the depth of your depression. If you're feeling suicidal or disoriented, unable to handle everyday responsibilities, or if you're having panic attacks, go to the nearest emergency room.

If you are feeling depressed but not suicidal or disoriented, make an appointment to see your doctor or midwife. This is really important if you're struggling to take care of yourself and not eating well, as it could affect your growing baby (Dennis et al 2007, NCCWCH 2003:65).

If your depression is making life very hard for you, talk to your doctor about what treatment is best for you. Usually doctors will consider whether psychotherapy (especially a kind called cognitive behavioural therapy, or CBT) would be enough before they will advise starting an antidepressant medication while you are pregnant. Some antidepressants can be taken in pregnancy (and if you've been taking one before getting pregnant, you and your doctor will again need to weigh the pros and cons of continuing or stopping slowly), and generally the risk of your baby being affected by the medication is less than the health risk for both you and your baby in not getting proper treatment for depression. Still, your growing baby will receive a small amount of any antidepressant medication you take, so there is a small chance that you and your baby's health could be affected.

Your doctor will help you figure out the best antidepressant for you. This will depend on what kind of depression you are suffering from, the severity of your illness and your prior mental health history.

The main category of antidepressant that is prescribed in pregnancy is selective serotonin reuptake inhibitors (SSRI). Within these categories there are many different kinds, for example there are six types of SSRIs. nNw evidence (MacArthur et al, 2016) suggests that some are safer and more effective than others if you need to take one during your pregnancy. It is also known that psychotherapy plus medication is more effective than medication on its own.

Some antidepressants, particularly venlafaxine (Efexor) or paroxetine (Seroxat), slightly increase your chance of miscarriage (Nakhai-Pour et al 2010). They may also increase your risk of high blood pressure (NCCMH 2007). That's why they're not usually recommended in pregnancy.

The herbal remedy St John's Wort is not recommended in pregnancy.

It's important to talk to your doctor about what treatment is right for you.

What about when my baby is born?

It's thought there is a link between depression in pregnancy and postpartum depression (Dennis et al 2007: NCCWCH 2008: 1188). But this doesn't mean that if you are depressed in pregnancy you will automatically be depressed after your baby is born.

Building a support network of your partner, friends, family, doctor and therapist means help will already be in place when your baby's born.