While most people have heard of post-natal depression, there is very little awareness of depression during pregnancy (antenatal depression) which is just as common, but often goes undetected.
The findings of the first survey of antenatal depression in Ireland suggest that antenatal depression is at least as prevalent as, if not more than, comparable jurisdictions in the EU.
Although common, antenatal depression may evade detection by staff because of multiple cultural and health service issues including lack of awareness and pressure on resources.
Veronica O'Keane, Professor in Psychiatry, Trinity College Dublin and lead research investigator on the survey, points out that screening for antenatal depression is not routine in maternity hospitals in Ireland, and our perinatal mental health services are grossly under-resourced in relation to other comparable EU countries.
“The findings indicate that perinatal mental health services need to be prioritised in the National Maternity Strategy, and more funding sought to develop these services across the country. Women should be screened for depression early in their antenatal care plan and encouraged to seek help,” she says.
Depression during pregnancy has been shown to lead to increased risk of poorer obstetric outcomes, and, in the baby, may lead to neurodevelopmental and behavioural disadvantage during infancy and an increased risk of psychiatric disorder in childhood and later life.
Screening tool
Some 5,000 pregnant women during all stages of pregnancy from five maternity hospitals throughout the Republic of Ireland were surveyed using the Edinburgh Postnatal Depression Scale (EPDS) as a screening tool. The survey revealed a 16 per cent rate of antenatal depression, which is higher than the rates found in the UK and comparable EU countries.
Rates of depression were shown to increase as the pregnancy advanced. The survey included women affected by first-time and recurrent depression.
Despite having the second highest birth rate in Europe, there was no data available on prevalence rates of depression among women giving birth in Irish maternity hospitals prior to this study which was compiled by the REDEEM research group, based in the Trinity College Institute of Neurosciences (TCIN), TCD and the national maternity services around Ireland.
The prevalence survey is a pre-cursor to a longer-term research study being undertaken by the REDEEM group investigating the effects of depression on pregnant women, the foetus and the infant.
Prof O’Keane says women may be reluctant to seek help for depression during pregnancy either because they are unable to identify that they are unwell, or because of the guilt and shame that is experienced by those who suffer with mental illness because of societal stigma. This stigma is likely enhanced during pregnancy, a time that is conventionally associated with happy anticipation.
“Our maternity services are very stretched and although depression is as common during pregnancy as diabetes, there is not the same level of awareness or resources. The expectation of pregnancy to be a happy time is not challenged much and depression during pregnancy is not talked about.”
Big concern
Prof O’Keane explains that although standard Prozac-like antidepressants do not seem to infer risk on the foetus when taken by the mother during pregnancy, it is a big concern for many women.
“The fear of antidepressants needs to be counterbalanced with the risk of untreated depression during pregnancy, which is very well established. There is an increased risk of babies born prematurely, or smaller for dates and depression in the mother during pregnancy leads to disadvantaged development of the baby. Depression does not just evaporate after birth; it generally deteriorates as there are more stresses on the mother trying to care for a newborn.”
Prof O’Keane is keen to stress that she does not want to make mothers with depression feel guilty about having this common illness or about any potential impact on their babies, but says it is an issue that needs to be highlighted so that there is a higher radar for detection of depression during pregnancy.
“Hormones definitely contribute to the development of depression during pregnancy, there is no doubt about that. There was a greater focus on the sex hormones, but we are now looking at the stress hormones as the condition of pregnancy increases secretion of stress hormones gradually and incrementally as the pregnancy advances. We know that the stress hormones are high in people with depression. We do need some sort of heightened alert system during pregnancy to warn us of any danger to the foetus, but in some women, these hormones can lead to depression.”
While low mood and anxiety are actually quite normal during pregnancy due to the increase in stress hormones and the enormity of what is happening, Prof O’Keane advises women who are feeling depressed or very anxious to seek help from their midwife or doctor.
Anna (42), mother of two from Cork: "I just thought there was something wrong with me if I was feeling so sad and anxious during what should have been such a happy time in my life."
Pregnancy is supposed to be such a joyous time in a woman’s life and certainly, my first pregnancy was a mostly happy experience. When I discovered that I was pregnant again when my first child was only nine months old, I was initially thrilled and grateful that it had happened so easily as we were not even trying for a baby at the time.
However, once the initial excitement of the first few days died down, I became increasingly anxious and tearful. As I suffered badly with “morning” sickness that lasted all day and into the night, and extreme fatigue, I put my low mood down to this, but when the worst of the nausea and fatigue passed after about 12 weeks, my mood began to worsen.
Having suffered with clinical depression for many years, I was already on antidepressant medication which had been working well for me, but now seemed to have stopped working. I felt my depression had to be related to my hormones as I had always suffered from very low mood coming up to my period every month, and now my pregnancy hormones seemed to have triggered it again.
Along with the depression and fatigue, I began to experience intense anxiety. I struggled with being a first-time mum to my baby son while being pregnant, and working outside the home. I worried constantly about how I would cope with a toddler and a newborn and found it hard to motivate myself to do anything.
When my GP suggested increasing my medication, I refused as I was worried about whether this would affect my unborn child. I knew there was no evidence that the medication I was on had any negative impact on the foetus, but worried about what evidence might emerge in years to come.
As a first-time mum, I wondered if all new mums felt as despairing as I did and if it was normal to feel the way I felt. I know now that while it is perfectly normal to feel exhausted, overwhelmed at times and tearful during pregnancy, it was not normal to dread getting out of bed every morning, to cry constantly when I was alone and to spend all day, every day wishing for bedtime.
When my mood failed to improve following the birth of my second baby, I went back to my GP who diagnosed post-natal depression and again recommended increasing the dose, which I did for a while, until things improved. There is a lot of awareness about post-natal depression among public health nurses and midwives, but I had never heard about depression during pregnancy and was not aware that the stress hormones which are at a higher level in people who are depressed increase during pregnancy. I just thought there was something wrong with me if I was feeling so sad and anxious during what should have been such a happy time in my life.
