Caitlin Whyte (Host): Pregnancy is beautiful and amazing, but it can also be stressful, even causing symptoms of depression and anxiety. Dr. Neha Hudepohl, Director of the Women's Mental Health Program and the Department of Psychiatry, joins us today to explain why this happens and how it's treated.

Host: This is Flourish, a podcast brought to you by PRISMA Health. I'm Caitlin Whyte. Well, doctor, very excited to talk about this topic today. To start off our conversation, can you tell me, is it common for a woman's mental health to change during and after pregnancy? And why would that be?

Dr. Neha Hudepohl: So, it is really common for mental health to be impacted around the time of pregnancy. Some studies show actually that postpartum depression is actually one of the most common complications of pregnancy, which not a lot of people realize. It is actually more common than things like gestational diabetes or high blood pressure, other things that we tend to hear a lot more about when it comes to pregnancy-related health. And we know that women who are pregnant or postpartum can be at an increased risk for depression and anxiety, other mood disorders and some pretty significant health outcomes either during pregnancy or after pregnancy within the first 12 months of their child's life.

There's a lot of reasons why this might be. There are biologic reasons. A lot of people feel that the hormone changes that happen during and after pregnancy are really big risk factors for women to develop these symptoms. There's probably genetic underpinnings as well, and then there's obviously all of the psychological and social stressors that come along with pregnancy and childbirth and parenting, things like the transition to parenthood, as well as other social support structures that may or may not be in the right place for women during this time period.

Host: Wonderful. So, what are some of the signs of depression and anxiety during pregnancy that we can kind of look out for?

Dr. Neha Hudepohl: So, women who have depression or anxiety during pregnancy present very similarly to depression and anxiety at other times in a woman's life cycle. So, that can often present with sadness or loss of interest or pleasure in things that are normally pleasurable. It can present as, you know, detachment or disengagement from loved ones or other interests in a woman's life. She could have changes, energy changes, appetite changes, changes in concentration or focus. And significantly, in severe symptoms, you can have women who start to think about whether or not they, you know, want to be living anymore, so they can have thoughts of suicide or even just feeling like life isn't worth living anymore and feeling very hopeless and worthless, and often very guilty.

What's unique about perinatal depression in particular is that women tend to have a lot of anxiety symptoms that go along with their depression symptoms. So, they tend to have a lot of worry, a lot of racing thoughts and what we call ruminating thoughts, where they're worrying about different topics kind of over and over again. Some women can even have really intrusive or obsessive thoughts of something bad happening to someone they care about, and particularly something bad happening to their infant or their pregnancy. And those can sometimes get so severe that women spend a lot of time during the day thinking about them. They find these thoughts really, really distressing, and they have to go to some extreme lengths to try to help manage or control those thoughts.

And so, I think one of the most unique things about depression in pregnancy is that it actually presents with a lot of anxiety. It's really common for new mothers to worry about their pregnancies or about their babies, especially when it's a first pregnancy, that experience can be really new and scary and different for people. However, this anxiety goes beyond the normal worries of pregnancy and the postpartum period. So, these women are really spending a lot of time worrying, the worrying is really interfering with their ability to function on a day-to-day basis. And so, those are the symptoms that I would encourage women to really be watching out for.

And perhaps one of the most concerning kind of outcomes of having depression or anxiety during pregnancy or in the postpartum period is when women start to feel a different relationship with their infants. So, they start to feel like they have to detach a little bit from their babies, because they feel so overwhelmed by sadness or anxiety, or they have to feel like they have a hard time separating from their babies, that they can't let anyone watch their baby or hold their baby because they're so fearful. And those are some of the outcomes that we really try to prevent when it comes to identifying and treating these conditions in pregnancy.

Host: Well, thank you for those signs. Definitely something that we can all watch out for. So, is there anything that puts you at a higher risk for experiencing depression during pregnancy, something we can think about beforehand maybe?

Dr. Neha Hudepohl: One of the most common and identifiable risk factors for depression in pregnancy are, first and foremost, if you've ever had depression in a previous pregnancy. Any woman who's had depression previously, either in pregnancy, or also around the time of their periods or around the time when they first started getting their periods when they were teenagers are often at higher risk of developing depression during pregnancy or the postpartum period. And we think, again, that that's tied back to some of those hormonal changes that might make some women susceptible to these types of symptoms. But anyone who's ever had depression or anxiety at another time in their life could also be at risk for depression during pregnancy. And anyone who's had a family member who's had perinatal or postpartum depression can also be at higher risk for having depression in pregnancy. So, those are some of the biologic or genetic risk factors that we know about.

In addition, women who have a lot of stress or trauma in their lives, either recently or even in childhood, can be at an elevated risk for depression during pregnancy, as well as women who are adolescent mothers actually are at extreme risk of depression during pregnancy.

Other factors include things like support from a partner, financial and housing stability and things of that nature, that put most people at risk for depression when they're unstable in general. But those are the most commonly identified risk factors for perinatal depression.

Host: And on that note, how does depression during pregnancy affect the baby?

Dr. Neha Hudepohl: So, this is a great question. And what I want to emphasize first is that while there's a lot of research looking at how depression and anxiety in pregnancy affect the growth of the pregnancy or the fetus or the baby after delivery, that a lot of those risks can go away when a woman is adequately treated.

So, I want to start by saying that because what I don't want to do is to scare people into thinking that this is such a horrible thing. But we know that when these symptoms go untreated, that when women have really severe symptoms that are not addressed during pregnancy, that those pregnancies are at risk for a variety of negative outcomes, including preterm delivery, so babies that are born too early; including low birth weight at delivery, so babies that are born too small. We also think that untreated depression and anxiety can increase the risk of complications like miscarriage or preeclampsia or other things. And these are obviously all pregnancy outcomes that we want to prevent as much as possible. We spend a lot of time and energy and effort in prenatal care preventing these outcomes.

In the postpartum period, the biggest risk of having depression in the postpartum period is really those relationship issues or those attachment issues that can happen between mom and baby and what that can mean long-term for a child's emotional and social and cognitive development. We want to make sure that we're preventing that. And what we do know is that when we treat these symptoms, that a lot of these risks disappear. And that's a really important point to kind of focus on.

Host: Well, let's talk about treatment now. How is depression treated during pregnancy? And is it safe to take antidepressants then?

Dr. Neha Hudepohl: I think the first part of the conversation about treatment has to start with how we identify it. So right now, all of our prenatal care providers like our OB-GYNs and our midwives are all screening regularly for depression and anxiety during pregnancy. And this is based largely on the recommendations of a lot of different organizations that have recommended that all women be screened for depression and anxiety during pregnancy.

So, I think that first and foremost thing to talk about is that if you are experiencing symptoms while you're pregnant, you've got to talk to your provider about what's going on. You've got to let them know how you're feeling and they might administer some surveys or some tests for you to complete to really help understand kind of your symptoms and how severe they are.

Once you're identified as having, you know, potential depression or anxiety during pregnancy, your doctor or your provider are going to talk to you about your treatment options. And if you have relatively mild symptoms that are not very impairing for you, the primary treatment is usually referring to a therapist or doing some adjunctive treatment where you're really focusing on your wellness and your health.

But anyone who has more of a moderate to severe picture of symptoms, we're really going to recommend taking medication in addition to those other adjunctive treatments, because we know that when we combine those treatments together that they tend to be more effective. And our goal in pregnancy is always to decrease the amount of symptoms of depression and anxiety a woman has, so that those risks that we know about when a woman goes untreated can disappear.

So in terms of taking medications to treat depression and anxiety during pregnancy, there is no yes or no answer to that question. But the one thing that we do know is that these medications are incredibly well studied. There are lots and lots of papers that have been published looking at their safety. And what we know in general is when you're looking at the risks of taking these medications versus the risks of not treating your symptoms, that almost always the risks are lower when we look at the medication as compared to untreated symptoms. And so, we're really looking at one set of against another set of risks, and identifying that treating those symptoms of depression and anxiety with my medication are almost always safer for a pregnancy than not treating it.

Host: Well, if you're being treated for depression already and then want to become pregnant, what is the recommendation for that course?

Dr. Neha Hudepohl: One of the best done studies that I've ever read has looked at women who have a preexisting history of depression. And when they stop their treatment to get pregnant, their symptoms almost always invariably get worse. And so, one thing that I would encourage women who have a preexisting history of any mental health condition, whether it's depression or anxiety or something else, that they talk to their doctor who's treating them for that condition before they start trying to get pregnant. So, ideally looking at what it is that we're treating, what it is that you're taking in terms of treatment and really thinking about having some information about how to go into a future pregnancy with those medications or having a great treatment plan in place, knowing that if you stop your medications, you're likely going to get worse. And pregnancy itself puts women at risk for worsening symptoms as it is.

So ultimately, what we want women to do is to have that conversation before they come off of whatever type of contraception or birth control they're using so that we can have a plan in place before they get pregnant. It does not mean that women should stop taking their medications when they find out they're pregnant. That's actually probably the one thing we would ask women not to do. We should continue to treat symptoms, just like we would any other underlying medical condition when you find out that you're pregnant.

So, one thing I would ask women to do is talk to their OB or their midwife or their nurse practitioner or whoever it is that they may be seeing for their prenatal care or for their general primary care. And if needed, get a referral to a psychiatrist or, if you have access to one, to a reproductive psychiatrist, someone like me who specializes in the care of women who are pregnant and postpartum to do a consultation about your illness and your treatment before you get pregnant.

Host: Those are some great points. Thank you. Now, if you've had postpartum depression before, does that mean that you'll have it with another pregnancy? Or is there anything you can do to prevent it from returning if you've experienced it already?

Dr. Neha Hudepohl: Statistically speaking, if you've had postpartum depression in a previous pregnancy, you are at an elevated risk to develop it again. And that's likely due to a number of factors, particularly the hormone changes that occur with pregnancy that likely made that person susceptible to having it before. But that doesn't mean that it has to happen. So when you know you've had this before, again, it would be very useful to talk with your doctor, talk with your prenatal care provider about your past experience with postpartum depression to try to make a plan to prevent it from happening. And so, a lot of times we use medications to prevent those symptoms from recurring or we use other types of non-pharmacologic support, whether it's psychotherapy or other interventions to really prevent those symptoms from recurring, and the awareness alone can be really helpful. So, you know, when a woman has had postpartum depression before, she knows what to look for. And so, looking for those symptoms again and identifying them when they happen early and treating them then can also be a very useful strategy.

Host: Well, how long does postpartum depression generally last?

Dr. Neha Hudepohl: So, that really varies based on the person. For some women, it can last months and others it can even be longer than that. But the one thing that we know is that there are some very effective treatments out there to help interrupt or prevent those symptoms from persisting for long periods. And that's really our goal. We want to get our mothers back to a functional state so that they can enjoy their pregnancy or their time with their infants at home. That's really an important thing. And so, it is really our goal to get women as functional as possible, as quickly as possible. And so, with treatment, I think we can really shorten the cycle of depression. But if left untreated, those symptoms really can persist for months, if not longer.

Host: Well, as we wrap up here, doctor, a few more questions for you. Can men or other folks get postpartum depression?

Dr. Neha Hudepohl: The answer to that question is yes. So, there has actually been some emerging information and research over the past couple of years looking at paternal postpartum depression or partner postpartum depression for the non-birthing parent. And likely, the etiology is a little bit different for the development of those symptoms as the non-birthing partner usually doesn't have the hormone changes in the same way that the birthing partner does. But a lot of the psychological risk factors and changes that come along with parenting happen for all of the people involved in the parenting process, not just for the birthing partner or the mother.

And so, I think it is important for partners to really consider how they're experiencing this transition to parenthood and whether they're having any of their own symptoms of anxiety or depression. Some of the symptoms can present very similarly to the way postpartum depression in the birthing parent presents. There can be a lot of anxiety that's predominant. And so, I do think it's important for all of the partners involved to really be cognizant of their mental health. This is a stressful time. Having a child is very stressful and it's not easy. It can be very joyful and very, very rewarding, but it's also a very hard transition. And so, I think it's really important for people to understand that anyone can be susceptible to worsening mental health symptoms at this really stressful time.

Host: Absolutely. So on that note, our last question here, how can you best support a partner with postpartum depression?

Dr. Neha Hudepohl: So, I think this is a wonderful question. When I talk with my patients, I love to bring family members into the conversation because I really think that this is an illness that affects everybody in the home, not just the person that I may be treating in that moment. One of the most important criteria or one of the most important interventions for helping support people is actually support for healthy sleep.

So, as you may know, sleep is really hard to come by when you have a newborn at home or when you're pregnant. Allowing a woman who's suffering from postpartum depression to have longer periods of uninterrupted sleep can actually be really restorative and can serve a therapeutic benefit. Helping to kind of think about sleep shifts or sharing the overnight burden is one really practical way that a partner or even another family member could support a person with postpartum depression.

Other really maybe more intuitive things are just support and understanding and some grace. I think recognizing that this transition is hard and that postpartum depression makes it so much harder. And that really understanding and being supportive and allowing women to pursue the treatment that they need to get better without judgment or without feeling like they need to sort of do it on their own or that they should be happy is something that's really important for family members and partners to be able to do for their loved ones who have postpartum depression.

Host: Well, some great information here today for, like you mentioned, both mothers, birthing parents and the partners and people around them. Thank you for being on the show and for sharing. For more information, head on over to prismahealth.org/flourish. This is Flourish, a podcast brought to you by PRISMA Health. I'm Caitlin Whyte.