Treating mental illness during pregnancy

In the U.S., the prevailing attitude about pregnancy is baby first. Unfortunately, for women with mental illness, this often means feeling pressure from family and friends, from themselves, and even from physicians to avoid using medication to treat their depression, anxiety or other mental health issues.

Rachel Shmuts, DO, a perinatal psychiatrist at Rowan University School of Osteopathic Medicine, understands the concern for the developing baby but believes treating mental illness during pregnancy is also critical—and all options should be considered.

For women who want to avoid medications, Dr. Shmuts recommends gently tapering off their medications over a couple of months before getting pregnant to see how they respond. She also suggests adding in talk therapy and activities, like yoga and meditation. Of course, this all comes with a caveat:

“Pregnancy is a time of vulnerability for mental health issues, due to all the stress and upheaval,” says Dr. Shmuts. “Even if women stay on their meds, there’s a 30% chance of relapse because their metabolism spins up and they need a higher dose for it to be effective.”

She adds that SSRIs, which are common for treating depression and anxiety and considered a first-line treatment during pregnancy, have been shown to have very mild and passing effects on babies.

Pregnancy is a time of vulnerability for mental health issues, due to all the stress and upheaval. Even if women stay on their meds, there’s a 30% chance of relapse because their metabolism spins up and they need a higher dose for it to be effective.

Potential side effects

Dr. Shmuts says symptoms in newborns usually fall under neonatal abstinence syndrome or poor adaptation syndrome, which can include lower APGAR scores, fussiness, and trouble with sleeping and feeding. However, she says these symptoms typically go away quickly and do not cause any long-term issues.

While any side effects for the baby can be concerning, Dr. Shmuts cautions against half measures in treatment. She says some primary care and OB/GYN physicians will reluctantly prescribe a very low dosage of medication that ultimately is not effective.

“The problem with that approach is you assume the same risks without the benefit of effective treatment. The critical guidance is to prescribe the lowest effective dosage,” says Dr. Shmuts. “But if that means a high dose, then that’s what it has to be.”

Weighing risks

Untreated mental illness during pregnancy is also associated with significant risks to the mother and baby, Dr. Shmuts explains. These include less attendance to self-care, less compliance with perinatal care, and increased risks of substance abuse, gestational diabetes, preeclampsia, preterm birth and other obstetrical complications.

“People worry about the effects of medication on the baby as if there are no risks from not treating the mother’s mental illness,” says Dr. Shmuts. “I tell moms, ‘If there’s no you, there’s no baby.’ ”

Perinatal vs. postpartum

While mental illness remains stigmatized, especially for pregnant mothers, awareness of postpartum depression has increased in recent years. However, many do not realize that postpartum depression symptoms usually begin during pregnancy. The condition also highly correlates to preexisting mental illness

“We are trying to shift the common language from postpartum depression to perinatal mood disorders,” says Dr. Shmuts. “It’s important for people to understand there is a wide range of experiences that we need to recognize if we’re going to treat patients appropriately.”

Dr. Shmuts says it is believed that postpartum depression may be triggered by the sudden and dramatic hormone fluctuation that takes place after delivery. For women who are likely to be more sensitive to that change, there is now an FDA-approved drug specifically designed to treat postpartum depression.

The drug, brexanolone, is IV-infused over 60 hours after delivery to mitigate the severity of the drop in hormone levels. It also has a calming effect, and patients who receive treatment have shown to do well 30 days later.

“Since the drug is new, it is very expensive,” says Dr. Shmuts. “And, like any medication, it’s not for everyone, but it is a very good tool for some and generally an exciting development in this field.”

Knowing when to worry

Dr. Shmuts says perinatal mood disorders are very common, occurring in one in five mothers. She adds that being able to recognize the symptoms is important, especially for women with no diagnosed mental health issues. These can include experiencing low mood for several weeks, or feeling anxious or irritable.

She adds, “When I see a mom who’s not future thinking about naming the baby or figuring out the childcare situation, I tend to get a little concerned.”

On the other hand, she believes it is important that the public collectively begins to better manage expectations around pregnancy and parenthood, understanding there is a wide range of feelings, behaviors and experiences that do not need to be pathologized.

Dr. Shmuts gives an example of mothers who do not feel immediately attached to their child and feel guilty because of that. She says that experience is especially common for those who had infertility issues and took months or years to get pregnant.

She says this largely stems from the U.S. culture that tends to idealize motherhood and avoids discussing its negative aspects. Becoming more open and honest about the range of feelings and experiences would help mothers feel less stigmatized and isolated.

“Whether a new mom just isn’t as glowingly happy as she is expected to be, or if she’s actually clinically depressed, it’s important for her to know two things: This is not her fault or something she has done to herself—and there is help and treatment available.”