Perinatal Depression: Who, What, Why?
This blog post is written by Dr Amanda Goldstein, a board certified psychiatrist, and Dr. Madeline Kaye, an obstetrician/gynecologist from the ThreeMDs, a blog that provides easily digestible, evidence-based, and integrative medical information.
You’ve most likely heard of postpartum depression from friends or a few courageous celebs who have shared their stories (oh hey Chrissy Teigen and Serena Williams). But did you know this is not just a postpartum issue? We now use the term “perinatal depression” to reflect the fact that it is a problem during pregnancy in addition to the period after delivery (most experts say within one year). During this time period, there are many unique changes hormonally, physically, psychologically, socially, and financially that cause you to be particularly vulnerable. Perinatal depression is characterized by intense feelings of sadness, anxiety, and hopelessness that often prevent new moms from being able to do their daily tasks.
You may have also heard of postpartum blues. This is a very common and temporary period of mild mood symptoms, occurring in up to 85% of women, and resolving within two weeks of delivery. It’s normal to get a bit teary and feel worried about your brand-new baby for a few weeks. It’s not normal when these emotions and thoughts start interfering with your daily life and your ability to care for your family.
Let’s Talk Numbers
Approximately 1 in 7 women experience postpartum depression, and for half of those women, this is their first episode of depression. Furthermore, about half of the women diagnosed with postpartum depression likely started experiencing symptoms during pregnancy (aka perinatal depression). Shockingly, when these numbers are broken down by race, approximately 1 in 3 black women experience postpartum depression. If changes in mood and anxiety were identified early, they could be treated with behavioral modifications and therapy, preventing a full-blown episode of depression.
Risk of Perinatal Depression
If you have experienced depression in the past, then you have a higher risk of developing perinatal depression. Relationship stress (especially domestic abuse), low socioeconomic status, first pregnancy, unplanned pregnancy, and previous miscarriage all increase your risk significantly.
Untreated depression has devastating consequences. Depression is a leading cause of disease-related disability in women, and suicide is a leading cause of maternal perinatal mortality. Perinatal depression increases mom’s risk of obstetrical complications, such as pre-eclampsia and substance abuse, and baby’s risk of neonatal complications, such as impaired brain development.
Depressive symptoms prior to delivery are as common and severe as postpartum, and if left untreated, they are likely to continue and worsen. Clearly, we need to do a better job at identifying and treating perinatal depression! But…
Depression is Under-Diagnosed
Depression is under-diagnosed in the general population, but to a greater extent in the pregnant population, despite the higher frequency of interaction with healthcare providers during this period. Approximately 60% of pregnant women with depression go undiagnosed, and only half of those diagnosed are treated. Black pregnant women are half as likely as white pregnant women to receive mental health treatment.
Why is depression under-diagnosed?
Pregnancy itself causes changes in sleep, appetite, and behavioral patterns, making it more difficult to distinguish normal from abnormal.
When a physician asks you how you’re doing, it’s easy to say “fine.” It’s much harder to say “not fine.” If your partner is in the room, you may not want him/her to know you’ve been struggling. You may be afraid of making the visit awkward or embarrassing yourself by crying (trust us, everyone cries, it’s totally normal). Furthermore, some physicians feel uncomfortable talking about mental health and may not ask any follow-up questions after you say you’re fine.
It takes time to open up and describe your feelings. OBGYNs typically have patients booked every 10-15 minutes, and they have a lot of territory to cover in that short amount of time.
These are not excuses, but an attempt at identifying barriers to better care, so we can begin to find solutions.
Why are there such big racial disparities?
Lack of access to healthcare. This could be physical lack of access, or more commonly, financial lack of access. Transportation issues and difficulty finding flexible provider schedules contribute.
Higher rates of history of trauma and violence.
Black women are more likely to be the sole head of household (72% of black mothers are single). This adds a ton of physical, emotional, and financial stress.
Cultural stigma. The stigma around mental illness is even greater in black communities.
Structural racism. Black women may fear being viewed as a “bad parent” or afraid of losing their job if diagnosed with depression.
The “strong black woman syndrome.” Society has forced black women to show strength and calmness in the face of adversity. This expectation of strength can result in denying or ignoring symptoms of depression.
So, what can we do?
If you are pregnant, your doctor should be screening you for perinatal depression (if your doctor is not, then you may need to advocate for yourself and your baby). There are many short screening questionnaires that help identify patients who are at risk. If you take the same survey several times throughout your pregnancy and postpartum, we can more easily identify who we need to have longer conversations with.
If you are worried about symptoms you are having, please, please speak up!! Do not ignore what you are feeling. As physicians, we care about your physical AND mental health, and need to know if something doesn’t feel right. We are not here to judge, but to do our best to get you the care you need.
Love from Team OBGynechiatry,
Dr. K and Dr. G
