Pregnancy Blues: Why Aren’t We Talking About Pre-Natal Depression?

Feministe friend Jessica Grose has an important series up at Slate on prenatal depression, its pervasiveness, and the stigma still attached to it (Part 1 is here; you can click through at the bottom of the piece to read parts two and three). After detailing her own experiences with depression during her pregnancy, Grose looks at the utter dearth of conversation (and certainly empathy) for women who are pregnant and clinically depressed. She writes:

When I began looking into prenatal depression, it appeared to be an underdiscussed yet potentially devastating part of pregnancy for millions of women. This hunch was hammered home by the results of the survey that I posted along with the first and second parts of this series. At the time of this writing, more than 1,200 of you were gracious and brave enough to answer the survey. The survey was for women who had experienced prenatal depression and their partners, and the vast majority of respondents—more than 85 percent—said they felt guilty about their prenatal blues, and less than a third of survey-takers said they were comfortable talking about their depression with family and friends. Over and over again women used the same words to describe why they kept their feelings to themselves: They were embarrassed, they felt no one could relate, they feared being judged or misunderstood.

Many women, like Grose, experienced bouts of depression prior to their pregnancies and were on SSRIs or other medications to manage their conditions, only to go off of them while pregnant. Why? Because, as Grose herself reported feeling, there’s a cultural emphasis in certain parts of the U.S. for pregnancy to be natural and chemical-free. That doesn’t necessarily mean no painkillers and a bathtub homebirth, but for many women it does mean a concerted effort to avoid things that may be bad for a developing fetus — cigarette smoke, toxins in cosmetics, and certainly many prescription drugs. While studies have generally shown that some mental health medications don’t pose large risks to a fetus, the desire to do pregnancy right — to sacrifice to make sure your baby is ok — is often enormous, and something that many women bow to. Grose writes:

But even though I knew lots of women who had healthy babies while on Prozac and Zoloft, and I knew that many, many studies showed only a minuscule chance of those drugs affecting my fetus, I didn’t want to go back on. I suppose on some primal level I wanted to be pure while pregnant. If anything went wrong with the baby, I would always wonder if my being on antidepressants was to blame. This was not a science-based decision. But when it comes to pregnancy, particularly your first pregnancy, it’s tough to ignore your emotional brain.

Grose eventually realizes that her depression is wreaking havoc on her life. She also points out the value in taking holistic health into account — while there is a very tiny chance that a medication like Prozac can cause problems in a developing fetus, depression can also physically stress a woman’s body and lead to fetal damage or even miscarriage. Depression can also mean the loss of a job (and the attendant loss of health care), a disintegrating or destroyed marriage, and a new mother who is unable or barely-able to cope with an infant. Those are health care issues as well, and they need to be taken into account when making decisions about pregnancy and mental health.

But what Grose realized as she and her health care providers gradually came to the decision that going back on antidepressants was the right course for her was just how little information is out there about prenatal depression. Doctors, she found, didn’t even believe prenatal depression existed until very recently — the consensus was that pregnancy released enough estrogen to protect women from mental distress. And even when doctors do recognize that prenatal depression exists, pregnancy is such a delicate and complicated time that they’re hesitant to prescribe medication, for fear that any issues with the fetus or child will be pinned on them.

Numerous studies have pegged the rates of prenatal depression at more than 10 percent of women, and yet the myth persists that pregnancy protects you from melancholy. And it’s a dangerous one. The lack of public conversation about prenatal depression and the fallacy of the happy, glowing mother-to-be can block women from recognizing the problem and seeking help. This is particularly true for poorer women who have less access to regular prenatal care, much less sympathetic, enlightened doctors.

“Part of [the myth] is a wish that pregnancy would be protective,” says Dr. Elizabeth Fitelson, director of the Women’s Program at Columbia University. Fitelson thinks that the continued taboo of prenatal depression in part stems from our increasing devotion to all things natural in pregnancy. From the constantly growing list of foods to avoid to the overwhelming pressure to breastfeed, there’s an unavoidable cultural push toward being natural and pure in the prenatal and postnatal periods, and that includes a fear of antidepressants. “No one wants to take medications during pregnancy of any kind,” Fitelson says. “And no one wants to prescribe medication.”

Part of it is also good old-fashioned “fetus first” prenatal medicine. The same biases that lead doctors to go to court to force women to have C-sections and leads hospitals to attempt to drug test pregnant patients and then report them to police are in play here: The fetus’s health and rights are primary, and the woman is simply a vessel to get that fetus into the world.

Of course during a pregnancy that is being carried to term, doctors should inform patients of any risks posed to the fetus by the patient’s medications, behaviors or other conditions. And I would even argue that doctors do have an ethical obligation to advocate for the developing fetus. But advocating for the healthiest pregnancy possible can’t come at the expense of the actual patient, and her health should be the priority, even while fetal health is taken into account.

This is also a class issue. Unsurprisingly, prenatal depression is far more common in low-income women, with one study putting prenatal depression in low-income Atlanta women as high as almost 50%. That makes sense. Having a baby is stressful and life-altering no matter who you are, but if you’re an hourly wage worker without health insurance or maternity leave or a stable source of income? If you can barely afford to care for yourself and your existing family? Not to mention that under-insured or uninsured women may be seeing an OB through their very basic insurance or a variety of governmental programs, but probably aren’t able to see anyone who specializes in mental health care. And the doctors that low-income women do tend to see are in turn over-worked and stretched thin, and may not be able to spend adequate time talking with patients. Compounding all that is the sexism and racism in our health care system. Reports of pain or medical distress are less likely to be taken seriously if the patient is a woman — this is true for everything from chronic pain to joint pain to reproductive heath problems to heart attacks. It’s no surprise that pregnant patients — who are mostly women — see their mental health concerns belittled or ignored. The same goes for people of color. Black patients (including children) are less likely to get pain medication than white patients. And when it comes to pregnant patients who receive punitive treatment from doctors — being hauled to court to force c-sections, being prosecuted for drug use while pregnant — we’re looking at women who are disproportionately black, Latino and/or poor.

So not only are low-income women (and I would guess women of color) more likely to experience prenatal depression, but I’d imagine they’re also significantly less likely to receive adequate mental health treatment.

In the third part of her series, Grose discusses the various responses from Slate readers. They’re illuminating. Some women received great care; many others were told some variant of “it’s hormones” and prescribed fish oil. Many reported feeling embarrassed and ashamed; pregnancy is supposed to be a happy glowing time, and depression doesn’t fit that narrative.

If you want confirmation of just how strong the prenatal depression stigma is, read the comments (or don’t). Jessica is repeatedly attacked for simply being a “depressed women” who happened to get pregnant, and therefore not really a woman with prenatal depression (as if the two things are severable, and as if depression is universally a condition that is ongoing and even-keeled rather than, in many people, a condition that culminates in episodes). She’s also branded “Whiny” and self-indulgent. And then there are the amateur doctors in the house who insist that no woman should ever be given antidepressants unless x, y or z reason, or that depression is REALLY caused by dehydration or a lack of Omega-3s or whatever else. Also depression is just people who are maladjusted or overly-privileged crying about anything hard in life. Also BIG PHARMA! (Also, for the record, I do think there’s something to the argument that doctors prescribe antidepressants because it’s cheaper and easier than utilizing other therapies that might be as effective and a patient might prefer, but it doesn’t follow that because the jacked-up American medical system incentives antidepressant prescriptions over other therapies that all or even most antidepressant prescriptions are suspect or lazy or bad). Point being, a well-researched and well-articulated article is immediately shouted down with the usual accusations: You’re just whiny and narcissistic. Pregnancy should be the happiest time in your life. Seeking help is a sign of weakness, not strength and self-care.

It’s a shame, but it’s also the internet. And I’d imagine there’s a much larger group of people who read the article, found it informative and relevant, and didn’t bother commenting (as is true for everything written on the internet ever). I’m heartened, at least, that women like Jessica are willing to write about their own experiences, and encourage others to discuss theirs as well. And it’s certainly an unmitigated good to have prenatal depression come out of the shadows.

15 comments for “Pregnancy Blues: Why Aren’t We Talking About Pre-Natal Depression?

  1. FashionablyEvil
    August 16, 2012 at 2:58 pm

    And even when doctors do recognize that prenatal depression exists, pregnancy is such a delicate and complicated time that they’re hesitant to prescribe medication, for fear that any issues with the fetus or child will be pinned on them.

    Getting treated for anything during pregnancy is an exercise in frustration. I had an abscessed tooth that was infecting the bone in my jaw and needed to be pulled at the end of my first trimester. The hoop jumping was endless, not to mention the repeated condescending refrains of “This is a very important time of development for your baby!” Which a) I know and b) I think I’m capable of deciding that the risk of needing jaw surgery and developing sepsis are worse than the possibility that novocaine or a painkiller could cause harm.

    I can only imagine how much worse it is for a condition like depression which often isn’t seen as real.

  2. August 16, 2012 at 3:07 pm

    Given that depression, like all emotional states, is associated with a particular biochemical consequences for the body, I’d wonder if the potential harm to the foetus of being depressed while pregnant wouldn’t potentially be comparable to the potential harm to the foetus of being on anti-depressants while pregnant. Obviously in the latter case there’s a greater sense of medical liability, but if the bottom line is “what’s best for baby” (NB: it shouldn’t be), then shouldn’t we want to know this as well? Taking anti-depressants might be the “lesser of two evils” in that respect (NB: not actually evil, though).

    In actuality, I feel like the human body is evolved enough to be better at dealing with this kind of stuff than so many people give it credit for and I’m not surprised that the actual risk level of anti-depressants is pretty low. Once again, probably the best thing we can do to support babies is to support their mums and other caregivers.

  3. Verity Khat
    August 16, 2012 at 4:05 pm

    Over the past few years I’ve come to suspect that any pregnancy of mine would be a mental health disaster. (Older women and health care professionals have been, well, downright dismissive of my concerns.) So as I was reading this series, my blood ran cold with a mixture of terror and relief. Here was a woman with a history similar to my own — clinical depression, bad reactions to hormonal contraception — laying out her personal experience with every last one of my fears.

    On the one hand, my brain is not dreaming up non-existent conditions and my fears are valid. On the other hand holy shit this is a real thing my brain is not dreaming up non-existent conditions my fears are valid. Add in the fact that I have a poor track-record with anti-depressants in general and I am now firmly in the No Kids From This Womb camp.

    And if I’m screaming in terror at the mere thought of losing my mind while pregnant, how shitty must it be for women experiencing it?! Especially the ones with little or no support system, or whose health care professionals don’t take them seriously.

    Screw standardized societal narratives. They are SO damaging.

  4. jillian
    August 16, 2012 at 5:22 pm

    I was hit with bad depression – hormonal, circumstantial, who knows – during the middle and after my first pregnancy (from about month 3 to 9months post-partum). a variety of circumstances kept it lurking on and off for another year, at which time i was frantic to, and not to, have another baby. i was vigilant about my mental health in that time when i got became pregnant with kiddo number 2. that time was much better, though not perfect. i had only one relapse that scared me, though all things concerned, it was minor.

    so yeah, it sucks.

  5. Breply
    August 16, 2012 at 5:36 pm

    I had prenatal depression during my second pregnancy. It was awful. I wrote a longer comment about it, but I just can’t bring myself to post it. Blah. :(

  6. Ceka
    August 16, 2012 at 6:26 pm

    The thing that really drives me nuts is the stigmatization of actually treating depression, anxiety, and mental illness in general. If you go to therapy, you’re navel gazing, if you’re taking meds, you’re ignoring the root source of the problems…People say such ignorant and hurtful things, especially when they don’t realize that they’re talking to someone who is treating her depression. It gets worse when they’re talking about a woman who is pregnant or nursing.

  7. Beauzeaux
    August 16, 2012 at 7:46 pm

    Most insurances now (begrudgingly) cover mental health visits. But the restrictions are severe. They’ll only cover a limited number of visits and/or pay a set amount per visit and/or cover only half the charge.
    Apparently, they think that visits to a psychiatrist are like a bacchanalia — too much fun to allow you to do very much of it.

  8. Ashley
    August 17, 2012 at 12:27 am

    I had prenatal depression for the 1st trimester of my second baby, and now at 4 months postpartum I’m seriously depressed again. I know I can’t have another kid, I can’t go through this again, and yet I’m getting pretty steadily encouraged to breed more and more (I know too many misogynistic fundies), and I’m trying really hard not to say “I spent the first part of T’s pregnancy cycling through thoughts of aborting my very wanted pregnancy because I was so fucking depressed” just to get them to leave me the hell alone. Not that it’s not true, but man, leave me the hell alone.

    It’s true no one talks about it. I barely told my husband I was depressed. Here I was having a very wanted and planned baby. Why couldn’t I be happy?

  9. August 17, 2012 at 7:09 am

    It’s definitely a thing. I had depression and occasional suicidal thoughts during both pregnancies. Surprisingly, I was pretty okay AFTER both births.

  10. August 17, 2012 at 9:08 am

    This piece makes me realize just how lucky I was during my pregnancy. I have clinical depression which was exacerbated 2 years before I got pregnant by a double death due to violence in my family. The year before we started trying for a baby, I was a shadow of myself. I went off Zoloft during that year, thinking that I needed to be med-free during pregnancy, so I wanted to wean myself from it before hand. Big mistake. I was in terrible distress.

    So, my psychologist and my OB/GYN together helped me to decide that I could and should be on the Zoloft. In particular, my OB helped me realize that the potential harm to my child by having a depressed mother was much greater than the infinitesimal possibility that Zoloft (which is a Class C drug for pregnancy) would harm him.

    Since I made that decision, I haven’t looked back and I have had no pushback whatsoever, even when I had to move during my 7th month and find a new OB. I’m realizing just how unusual that is.

    I would rage about the “must protect the fetus and ourselves from a lawsuit!” type of medical decisions like FashionblyEvil mentions above. (When hit with a UTI whose symptoms were masked by the pregnancy until I was suddenly doubled over in excruciating pain, I was told by a nurse practitioner in my doctor’s office that she could NOT recommend that I get an over the counter med like Uristat, only to have my OB prescribe the exact same medication when I made it in to the office.)

    But even with that frustrating hoop-jumping for pain relief, it never occurred to me that depression is treated by doctors with the same level of paranoia. I know many women who feel they must drop their meds, and I know that their decisions are not necessarily rational. I would hope that doctors could be as helpful and rational as mine were.

    And, if you’re depressed and pregnant in the Columbus, Ohio, area, I can recommend a fantastic OB.

  11. August 17, 2012 at 2:13 pm

    I’ve read a discussion just recently. Some woman has written that she feels scared and depressed during her pregnancy and many people reacted kind of: pregnancy was your choise so stop whining. :(

  12. mh
    August 18, 2012 at 9:10 am

    I’ve been depressed, sometimes dangerously so, for most of my life. The good news is that I went into pregnancy prepared – I knew that prior depression put me at higher risk, and expected depression during pregnancy and postpartum. I managed with a huge (and that word is not sufficient to describe his actual effort) amount of support from my husband, teeth-gritting and a lot of sleep. I don’t like taking meds for depression anyway, as I am hypersensitive to side effects, but in retrospect I should have been more open to it.

    However, during the time I was pregnant and postpartum, there were a series of suicides by postpartum women that made national news, several of them in my hometown. In some cases, the women took their childrens’ lives as well, in some they disappeared and died alone away from home. It is a very, very serious condition that can be life-threatening; I feel lucky that I was protected from those consequences. I think about these women often.

    I agree, although there is more attention to this problem in recent years, there is not enough scientific study to create a set of medical best practices, pharmaceutical and otherwise. When I mentioned my concerns about depression, I got “hormones” as well.

    You know, respite care for at-risk mothers would be one place to start: the sleep deprivation of early parenthood alone is a serious aggravation to dangerous depression.

  13. William
    August 18, 2012 at 8:08 pm

    Beauzeaux ,

    Apparently, they think that visits to a psychiatrist are like a bacchanalia — too much fun to allow you to do very much of it.

    Psychiatrists tend to be covered as well as any other specialist MD, its us psychologists who people have trouble getting the OK to see. After all, a lot of psychiatrists are only going to see you for fifteen minutes twice a year before prescribing you something from your insurance’s formulary. Its a bargain for the insurance company compared to long-term individual therapy. This is why mental health parity is so damned important.

  14. Stony
    August 19, 2012 at 9:41 pm

    SO glad this is finally coming to light. I was frightfully depressed during my 1st trimester and had no one to talk to. I felt that I was the only woman to have experienced this and there was something wrong with me since I was unhappy during what should have been a truly happy time. True to form, it seemed that everyone I met had a wonderful, magical, glowing pregnancy story to tell me about how they loved every minute of pregnancy and weren’t sick for even a minute. It exacerbated the whole mess. Thank goodness for a friend of mine who said she experienced depression during her pregnancies. That simple admission may have saved me!

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