A Bump in the Road

Pregnancy is not always a blissful time, especially for women who suffer from emotional illnesses such as depression, anxiety or an eating disorder. Untreated, these conditions can have serious consequences for both mom and baby. Here, experts—as well as mothers who've been there—share their solutions.


Blissful. Joyful. Glowing. These are words that typically describe moms-to-be. But what about the other possibilities: blue, anxious, pregorexic? Pregnant women’s struggles may slowly be coming out of the closet, but many moms-to-be still suffer in silence with emotional issues, and the majority are never diagnosed or treated. The result can be problematic for their babies as well as themselves.

Many OBs don’t screen for mental health issues, and a lot of expectant women don’t reveal their problems to their doctors, says Heather Flynn, Ph.D., an associate professor and director of the women’s mental health program at the University of Michigan Medical School’s department of psychiatry. “Women attribute what they’re feeling to hormonal shifts, and many fear they’ll be judged,” she says. Those who are diagnosed often don’t seek treatment because they’re afraid to take medication, think their symptoms are normal or lack the time and money for care.

Experts blame the emotional extremes on wildly shifting pregnancy hormones combined with the physical, social and even existential challenges that come with pregnancy—a changing body shape, a new identity as a mom and fears of being responsible for a child. Some women are blindsided by a sudden onset, but in many cases, pregnancy triggers an exacerbation of a condition they were already dealing with. (See “When Problems Are Pre-Existing,” to learn how pregnancy affects bipolar, panic, obsessive-compulsive and post-traumatic stress disorders.)

Left untreated, psychological ills during pregnancy are linked to an increased risk of prenatal and delivery complications, a greatly increased risk of postpartum depression, and possible cognitive and behavioral issues in children down the road. So whether you have borderline symptoms or a full-blown problem, don’t suffer in silence: Help is available. Here’s how some mothers coped with their emotional issues during pregnancy and what the experts recommend.


Depression “I felt really sad, had no energy and fell into this strange state where I thought, ‘What’s the point of anything?’ ’’ Kelly Judge, 32, an orchestra teacher in Kirkwood, Mo., describes herself as an extremely happy, positive person. About two weeks after she found out she was pregnant with her second child, Judge felt her good mood disappear. “I had a fabulous marriage, a wonderful 3-year-old, no financial stress, the pregnancy was planned, so life should have been great,” she recalls. “But I felt really sad, had no energy and fell into this strange state where I thought, ‘What’s the point of anything?’ ”

At the same time, Judge began to feel very anxious, but not about anything in particular. Caring for her child or keeping the house in order became difficult. After several weeks, she called her OB. “I knew that this was not me and that something was wrong,” she says. Her OB referred her to a psychologist, whom she began to see regularly. Judge also started taking the antidepressant Lexapro. Within weeks, her mood lifted.

Judge gave birth to a healthy baby girl in January. Her daughter shows none of the possible side effects of the antidepressant, and Judge is staying on the drug until she’s out of the postpartum woods, albeit reluctantly. “I was fortunate that I was able to recognize that something was wrong and was not afraid to ask for help,” she says.

Why it happens} An estimated 14 percent to 23 percent of moms-to-be experience serious (clinical) depression, and about 40 percent have some symptoms. It may be set off by the steep rise in pregnancy hormones, worries about the life changes a new baby will bring, or both.

The signs} Feeling sad for several weeks; loss of interest in activities you normally enjoy; feelings of guilt or hopelessness; difficulty concentrating. You can take a self-test called the Edinburgh Postnatal Depression Scale, aap.org/ practicingsafety/toolkit_resources/module2/epds.pdf, which is used to screen for prenatal depression as well; you should also talk to your doctor or midwife.

Who’s most at risk} Women who have suffered from depression or anxiety in the past, especially during pregnancy, or had postpartum depression (PPD) or a family history of depression (the mother, in particular); women with a low income or poor social support.

Risks of not treating} Increased risk of preeclampsia, preterm delivery, having a low birth-weight baby or one with low Apgar scores, and PPD; poor cognitive, neurologic and motor skill development and long-term behavioral effects in children.

What works} Many expectant women are reluctant to take antidepressants because of concerns that the drugs may harm their babies (see “Are Antidepressants Safe During Pregnancy?”), but drugs aren’t your only option: Depression-specific psychotherapies, such as cognitive behavioral therapy, have been shown to be just as effective in treating mild to moderate cases.

The American College of Obstetricians and Gynecologists (ACOG) states that pregnant women with mild to moderate depression should seek therapy and support first, especially in the first trimester. Then, if that’s not effective, discuss adding an antidepressant, says Diane Sanford, Ph.D, author of Life Will Never Be the Same: The Real Mom’s Postpartum Survival Guide (Real Moms Ink).

The current advice for the many women with major symptoms who are already on antidepressants when they become pregnant is to stay on their medication. “We do not recommend that women with severe depression go off their medication—unless it is known to be hazardous to their babies, as certain bipolar medications are,” says Sanford. Studies show that almost all such women who discontinued their medication relapsed by their third trimester, putting them at an increased risk for PPD.

To help keep depression at bay, exercise regularly and get enough sleep, which is crucial in how well you respond to any treatment, says Flynn. You can also undergo acupuncture: A recent study found that 63 percent of women who had major depression during pregnancy experienced a 50 percent or greater reduction in symptoms after acupuncture treatments, compared with 44 percent of women who received sham acupuncture or got massages. Several studies have also shown that omega-3 fish oils can be effective in easing depression.


Eating disorders “I automatically went back to the one thing I could control—food and my body. All those old obsessive-compulsive voices came back strongly.” Ann Marie Hopwood, 34, had struggled with anorexia on and off for 20 years, and the worst of it—carrying a mere 63 pounds on her 5-foot-6-inch frame—was behind her. She was up to 113 pounds, newly married and had just gotten her master’s degree in counseling so she could help others with eating disorders. And then, despite her thinness and many months of missed periods due to her anorexia, she got pregnant.

“I was a new wife and starting a new career and [being pregnant] was going to change my whole perception of who I was,” says Hopwood, who lives in Omaha, Neb. “So I automatically went back to the one thing I could control—food and my body. All those old obsessive-compulsive voices came back strongly.”

In her first trimester, between morning sickness and her anorexia, Hopwood lost 5 pounds. “It was a daily struggle to eat enough,” she says. She kept her eating disorder secret from friends, but her husband supported her through the pregnancy and made her promise to gain weight. “He checked in every day to make sure I was eating,” she says. She also self-treated with reiki, an energy healing technique, and turned to prayer for strength.

In the second trimester, with much effort, Hopwood managed to eat about 1,200 calories a day, still far below the 2,300 calories recommended for the average pregnant woman. Making matters worse, she over-exercised to burn calories. But by the end of her pregnancy, she had gained 17 pounds. Her son was born two weeks early, but healthy. Immediately after his birth, though, Hopwood lost 25 pounds and developed postpartum depression. She reluctantly started taking an antidepressant, which she says helped immensely.

Hopwood is currently breastfeeding and is worried about the possible weight gain when she stops. But she’s trying not to obsess about it. “It helps being a role model, knowing that I have this little boy to take care of, and I have to be alive and healthy for him,” she says.

Why it happens} Pregnancy taps directly into the very issues that contribute to eating disorders—concerns about weight gain, changes in body shape and a loss of control over what’s happening to your body and your life. But these disorders, which include anorexia (extreme weight loss, often achieved by starving yourself), bulimia (binging and purging) and binge eating often go undiagnosed during pregnancy.

While up to 4.5 percent of pregnant women have diagnosed eating disorders, the actual numbers are probably much higher because so many cases are undiagnosed or unreported. The good news is that between one-quarter and three-quarters of women who have a pre-existing eating disorder “get better” during their pregnancy; the bad news is that up to half relapse after delivering.

The signs} An increased focus on body shape and weight or a seriously negative body image and negative self-talk; inability to admit that you’re hungry or your eating habits have changed (including binge eating or extreme dieting); using laxatives, purging or exercising more than an hour a day specifically to burn calories. You can find self-tests like this one online: psychcentral.com/quizzes/eat.htm.

Who’s most at risk} Women who’ve had any of the symptoms described above, even if they were never officially diagnosed or treated for an eating disorder; those who are anxious about how their body will change during pregnancy; pathological dieters (about one-quarter of such women develop an eating disorder).

Risks of not treating} Increased risk of miscarriage, preterm labor, Cesarean section, intrauterine growth restriction, postpartum eating disorders and depression; having a low-birth-weight baby or one with low APGAR scores, respiratory problems, delayed development and disturbed feeding behaviors.

What works} Cognitive behavioral therapy (CBT), which helps you work through negative thoughts and destructive behaviors, offers the quickest response for eating disorders. Dealing with long-term issues, such as poor self-esteem or chronic perfectionism, will take more time to address, says clinical psychologist Sari Shepphird, Ph.D., an expert on eating disorders and author of 100 Questions and Answers about Anorexia Nervosa (Jones & Bartlett Learning). Experts recommend tackling the most harmful symptoms first. “For example, addressing such extreme behaviors as purging and laxative abuse is key,” says Shepphird.

Taking medication to treat eating disorders is not typically recommended during pregnancy because CBT is so often effective. It’s also helpful to practice relaxation techniques like deep breathing and yoga, and to join a support group, as women with eating disorders tend to isolate themselves because of shame and embarrassment.


Anxiety disorders “I was always looking for subtle cues, like when the doctor said, ‘Everything’s OK right now,’ I’d think, ‘But what about tomorrow?’ ’’ A few weeks after she found out she was pregnant, Rebecca Thomas, 29, of Detroit started to feel paralyzing fear. “I was afraid to move the wrong way, change the sheets, to exercise,” she says. Before the pregnancy, she’d worry from time to time, but she had never had anxiety grip her like this. “I remember one evening I didn’t move at all because I thought if I didn’t move, I could keep something from going wrong,” Thomas says.

There was nothing high risk about her pregnancy to trigger the anxiety, and no amount of reassurance from her doctor made her feel any better. “I was always looking for subtle cues, like when the doctor said, ‘Everything’s OK right now,’ I’d think, ‘Right now it’s OK, but what about tomorrow?’ ” Thomas never sought help because she thought these were normal pregnancy fears, so she just suffered through her pregnancy, unable to enjoy any of it.

After Thomas gave birth to her daughter, the anxiety remained; even worse, she developed postpartum depression on top of it. “I had fears I would do something wrong with the baby, and then I began to feel that I didn’t fit in anymore socially or that people were talking about me behind my back,” she recalls. When her daughter was about 4 months old, Thomas finally reached out to a therapist for help.

Thomas became pregnant again about a year later, and recognized feelings of depression at about 16 weeks. She waited another month to talk to her doctor, who gave her a prescription for the antidepressant Lexapro. It still took her a few more weeks before she used it.

“At some point I decided that I didn’t want to not enjoy another pregnancy, so I filled the prescription,” she says. Thomas began to feel much better and sailed through the rest of her pregnancy. “I wish I had taken it even sooner,” she says.

Why it happens} Almost every pregnant woman has moments of worry about her developing baby, especially when it’s time for prenatal testing. But for some women, the fears are constant and affect their ability to function normally. The stress hormone cortisol and other hormones that increase during pregnancy may be associated with the surge in both anxiety and depression. Experts believe that anxiety disorders are at least as common during pregnancy and postpartum as depression, possibly even more so, and the two often go hand in hand.

The signs} Anxiety that is persistent, intrusive or out of proportion; irritability; inability to sleep because of fears; waking up with a racing heart; difficulty concentrating.

Who’s most at risk} Women who have experienced anxiety or depression in the past.

Risks of not treating} The elevated cortisol is thought to affect a baby’s developing nervous system, says Tom O’Connor, Ph.D., a professor of psychiatry and psychology at the University of Rochester Medical Center in New York. Children whose mothers experienced higher levels of stress during pregnancy tend to have poorer cognitive functioning, are more reactive or more fearful, or have more behavioral problems like attention deficit or hyperactivity than children of mothers who were less stressed while expecting.

What works} Cognitive behavioral therapy can be very effective in reducing anxiety, especially when the therapy focuses on teaching relaxation and coping skills.

Some of the same SSRI medications that are prescribed for depression are also used to treat general anxiety disorder, but women should talk to their doctors about their risks and benefits. Calming drugs like benzodiazapenes are typically avoided during pregnancy because of known risks to the fetus.


Studies on babies’ risks from commonly used SSRI antidepressants, such as Prozac, Lexapro and Celexa, are conflicting, as are the opinions of experts. “The majority of patients who have been studied have had no clinically significant effects or measurable risks during pregnancy,” says Heather Flynn, Ph.D., director of the women’s mental health program at the University of Michigan Medical School’s department of psychiatry. The decision to take antidepressants should be made based on history and severity of illness, previous response to treatment and discussion with your heath care provider, she advises.

While a recent Canadian study found that women who took antidepressants during pregnancy had a higher chance of miscarriage, researchers reported that some of the increased risk could be ascribed to the depression itself. And some studies have showed a link between SSRI use and heart defects in babies, though the actual risk is still very low—0.9 percent in women who took an SSRI, compared with 0.5 percent in the control group, according to one study.

It’s also been documented that newborns who were exposed to SSRIs in utero may experience temporary withdrawal-like effects, including hypoglycemia, unstable body temperature, irritability and a weak cry. “I’m concerned about the risks of antidepressants, especially when, for many women, there’s a perfectly reasonable option, which is cognitive behavioral therapy,” says Tom O’Connor, Ph.D., a professor of psychiatry and psychology at the University of Rochester Medical Center in New York.


If you already have a psychiatric problem, major life changes, transitions and stresses—such as preg- nancy—can increase the intensity of your symptoms or the likelihood of relapse, says Heather Flynn, Ph.D. Here’s how some common mental health issues may be affected by pregnancy:

BIPOLAR DISORDER Pregnant women and new mothers with this disorder have an increased risk of hospitalization and of having a recurrent episode. (Note: Lithium, Depakote and a few other drugs fre- quently prescribed for this and other conditions are off limits because of the risk of birth defects.)

OBSESSIVE-COMPULSIVE DISORDER (OCD) A Yale University study found that among women with preexisting OCD, symptoms worsened one-third of the time during pregnancy. It also found that 32 percent of the women who had ever been pregnant had their first OCD symptoms during or soon after pregnancy.

PANIC DISORDER According to Flynn, an estimated 9 percent of women experience this condition during pregnancy, though some expectant women report improvement in their symptoms.

POST-TRAUMATIC STRESS DISORDER (PTSD) This can result from rape or other abuse, an accident or other traumatic experience in a woman’s life. The prevalence in pregnancy may be 1.5 percent to 6 percent, Flynn says. Symptoms often worsen during pregnancy, and new cases can arise as a result of a previous traumatic childbirth or loss of a baby. While these and other conditions can be safely treated during pregnancy, locating a qualified care provider can be difficult. You can find referrals to well-trained specialists at Postpartum Support International (postpartum.net.).