Undoing Depression and Anxiety in Pregnancy

For many women pregnancy is not a time of blissful navel-gazing. Almost 1 in 5 women will experience depression during or after pregnancy1. For some, a history of depression or anxiety and associated treatment has left them with questions and confusion when they are planning a pregnancy or find themselves in a fertile bind. Since we have shed so many of the mood-supporting aspects of our ancestral lifestyle – outdoor activity, food derived from it’s natural chain, community, sleep when it’s dark – it can take a lot of work to be well and avoid biochemical pitfalls. What are some of the options?

That depends a lot on whom you ask.  As a perinatal psychiatrist, my conventional medical training is in decision-making around the use of psychiatric medication in pregnancy and postpartum.  With over 20,000 cases of pregnancy-related antidepressant exposure in the medical literature, we have a good sense (better than for many other commonly recommended meds in pregnancy) of what the risks might be, and of what they are unlikely to be2.  We counsel women on potential “neonatal adaptation syndrome” (a self-limited newborn agitation) and discuss questions about miscarriage, preterm labor, and pulmonary hypertension of the newborn which may be related to untreated symptoms, medication treatment, or neither.  It is a complex web of data that requires expert interpretation, and is always a risk-risk calculation. However, to treat or not to treat is not the only question.

The physical stress of depression and anxiety symptoms impacts the fetal development in a way that is being termed “epigenetic” with concern for preeclampsia, preterm labor, poor growth, and temperament. Many years down the line, after in utero exposure to mom’s low mood, children can be more likely to develop psychiatric symptoms themselves3.  It turns out that the in utero environment, as determined by mom’s physical, emotional, and environmental state has a primary influence on what genes are expressed and what ones are kept quiet.

While there are many cases in which medication may be safe relative to the risks of severe symptoms, there are some women who may feel strongly about alternatives to medication.  In this case, we consider devices like cranial electrical stimulators, light boxes, biofeedback, or supplements with some degree of supportive safety data (like SAMe (S-adenosylmethionine) or St. John’s Wort)4.  Breathwork, yoga, and meditation are also excellent tools for supporting the nervous system and preparing for a healthy birth.

Regardless of the treatment choice, the exploration of the root causes of symptoms is paramount.  Think about depression and anxiety as analogous to a pain in your foot.  If you discover there’s a splinter in it, it makes more sense to remove it than to take Tylenol for the pain.

To this end, I look into several arenas – digestive health, hormone health (including thyroid, insulin, adrenal), and toxic exposures. I look at the presence of thyroid antibodies, gene variants, and vitamin levels.  Unfortunately, many conventional doctors turn a blind eye to autoimmunity when it comes to thyroid health.  Not only are we learning that the presence of this type of inflammation can negatively impact the pregnancy, it can also signal a risk for psychiatric symptoms that look like depression and even psychosis postpartum5.  Your thyroid controls the energy access to all of the cells in your body.  This tiny bowtie like gland in your neck really does “tie” the whole outfit together.

We all have micro variances in our genes that can account for the different ways our environment effects us.  Screening for a genetic profile called MTHFR is not typically done by conventional OBs until a woman has had three miscarriages!  It is a simple blood test that can tell you how much at risk you are for problems converting B9 or folate into a form of the vitamin that your brain can use to make neurochemicals.  If you do carry a partial or complete mutation it’s a simple thing to supplement, and can help support mood.

Your baby is looking out for number one and is taking what it needs – for many women, the postpartum period reveals accumulated nutritional deficiencies.  At times, there are clinical clues to deficiencies like magnesium (Charlie horses, muscle soreness, constipation, headaches), and zinc  (stretch marks, white spots on nails), but you can also play it safe by incorporating sources of B vitamins, omega 3s, vitamin D – my favorite one stop shops are avocado, salmon/sardines, pastured eggs, and fermented foods like kimchi and traditional sauerkraut.  I can’t emphasize enough the importance of eating nutrient dense foods and the mindful avoidance of processed/packaged food (full of hidden MSG, vegetable oils which are inflammatory, soy) and sugar.  To compensate for the undernourishing modern American diet, I recommend women take a preservative/additive free multivitamin (typically non-prescription), vitamin D (depending on blood level), omega 3 fish oil with evening primrose oil, and a multi-strain probiotic.

When considering treatment it’s also important to work to minimize less well-studied exposures like the 80,000 toxic substances in commercial and industrial use in this country.  Start with your food by prioritizing organic produce, meat, and dairy.  Think about the plastics you eat and drink from, never heat them, and discard those with 3,6,7 on the bottom.  Monitor your personal care products for parabens, “fragrance”, sodium lauryl sulfate, and petroleum. Filter your water and your air. Sleep with your cell phone away from your body and say goodbye to that nutrient-zapping microwave – buy some glass cookware on eBay and start using that stove top.

How will you know if you need help?  If you have a history of mood or anxiety symptoms, make sure you have a specialized MD and/or therapist in mind to contact. Make arrangements for support so you can take a half hour to walk outside or exercise. If you feel that your mood is flat, you feel agitated or out of control of your thoughts, or are having trouble sleeping, reach out.  Otherwise, eat well, rest when you can, and put your visitors to work taking out the garbage, doing dishes, and folding laundry!

1. Heron J, O’Connor TG, Evans J, Golding J, Glover V. The course of anxiety and depression through pregnancy and the postpartum in a community sample. Journal of Affective Disorders. 2004;80(1):65–73.

2. Lorenzo L, Byers B, Einarson A. Antidepressant use in pregnancy. Expert opinion on drug safety. 2011;10(6):883–9.

3. Newport DJ, Ji S, Long Q, et al. Maternal depression and anxiety differentially impact fetal exposures during pregnancy. The Journal of clinical psychiatry. 2012;73(2):247–51.

4. Freeman MP. Complementary and alternative medicine for perinatal depression. Journal of affective disorders. 2009;112(1-3):1–10.

5. Bergink V, Kushner S a, Pop V, et al. Prevalence of autoimmune thyroid dysfunction in postpartum psychosis. The British journal of psychiatry : the journal of mental science. 2011;198(4):264–8.

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