Depression During Pregnancy and After Birth: What You Should Know

Depression is an illness that affects up to 1 in 4 women at some point in their lives.

It often begins when women are in their 20s and 30s, at the same time they may be considering having children. One in 4 women has a risk of developing depressive disorders during pregnancy and after delivery of the child, a stretch called the perinatal period.

As everyone expects, pregnancy does not provide any protection against depressive disorders in the perinatal period.

Risk intensifies in case of past episodes of depression

The woman is at a higher risk if there are past episodes of depressive disorders, substance abuse, a family history of mental illnesses, or non-compliance with current medications.

Untreated perinatal depressive disorders are associated with complications

Untreated and undertreated depressive disorders during pregnancy and postpartum (after the birth of the child) hamper the woman's mental wellbeing, and are associated with higher rates of malnutrition, infrequent antenatal checkups, IUGR (intrauterine growth retardation), infant and mother bonding problems, and poor infant cognitive development.

What is Major Depressive Disorder (MDD)?

It is a mood disorder. Mood disorders are illnesses that affect a person's ability to experience normal mood states. They occur due to several factors, mainly biological disturbances involving brain chemicals and receptor sensitivities. Emotional stressors and substance abuse can trigger the occurrence of these changes. Sometimes, there will not be any visible trigger to cause these changes.

Women with MDD may experience two or more of the following:

• Depressed mood most of the day, nearly every day, for two weeks or longer*
• Loss of interest or pleasure in activities that the person usually enjoys*
• Recurrent thoughts of harm to the unborn or newborn baby
• Recurrent thoughts of death or suicide
• Fatigue or lack of energy
• Anxiety or feeling slowed down
• Feelings of guilt or worthlessness
• Difficulty concentrating
• Trouble sleeping, or sleeping too much
• Changes in appetite

*More characteristic of MDD.

Depression during pregnancy: special issues

Contrary to popular belief, pregnancy does not protect a woman from becoming depressed.

About 20% of women experience some depressive symptoms during pregnancy, and about 10% of women develop major depression.

Risk intensifies when

Women who have had major depression in the past have a higher risk of becoming depressed in pregnancy, especially if they stopped taking antidepressant medication while trying to conceive.

A woman whose close family members suffered from mood disorders or depression during their pregnancy and postpartum periods may also be at a higher risk of developing major depression during her pregnancy.

What to do? Whether to use medications or not?

In pregnancy, concerns arise about using medications to treat depression since they cross the placenta and may be present in the fetal circulation. At the same time, untreated major depression has serious potential risks for mother and fetus, since it may lead to poor nutrition, nicotine and alcohol abuse, suicidal behavior, prolonged or premature labor, low birth weight, and congenital malformations too.

Unfortunately, research information about the safety of antidepressants in pregnancy is limited because there are important ethical concerns about conducting such research.

However, the available research suggests that most antidepressants, such as SSRIs (serotonin reuptake inhibitors) and TCAs (tricyclic antidepressants), are safe to use during pregnancy and during lactation.

Research on the risk of congenital malformations with antidepressants shows mixed results: some studies report no increase in risk compared to infants not exposed to these medications in-utero, while others report a slightly higher risk than in the population where these medications have not been given.

In deciding whether a woman should use antidepressant medication while pregnant or trying to become pregnant, a woman and her doctor have to balance the possible risks of the medication against the severity of the depression.

Collaborative care with your treating psychiatrist, obstetrician, and radiologist/sonologist is recommended, to identify congenital abnormalities at the earliest and to plan the further course.

Electroconvulsive therapy is considered safe and effective for pregnant women, especially in their second trimester. It can be considered as an adjunctive treatment for women whose illness is severe enough to cause imminent harm to self and baby, and also for women who don't respond satisfactorily to relatively safer antidepressants.

Depression during the postpartum period

The birth of a baby is generally considered a joyful time, but it is also a time when women are susceptible to depression. Such feelings make it very hard for a new mother to take care of herself and her baby, and put strain on the family. Depression that occurs after the birth of a baby is called postpartum depression.

What are the types of postpartum depression?

There are two main kinds of postpartum depression:

• Postpartum, or maternity "blues," a mild mood problem of short duration. Fifty to eighty percent of women in their postpartum period may experience maternity blues. It is a self-limiting condition that usually resolves in the first month after the baby's birth. One in 5 women with postpartum blues may go on to develop postpartum depression.
• Postpartum major depression is a severe and potentially life-threatening illness. It usually starts in the first two weeks and may last for a year or longer if left untreated. The symptoms are similar to major depressive disorder; the woman predominantly experiences thoughts of harm centered on the newborn baby.

Around 5 to 10% of women with depressive disorders also have psychotic symptoms like delusions and hallucinations. This condition is called postpartum psychotic depression. They may fear that some harm to the child or herself from a third party is imminent, or claim that the child may not belong to her, distancing herself from the child. They may also hear unreal voices with frightening content. You may notice her talking to herself or responding to those unreal voices in her mind. Psychotic depression is considered a very severe condition requiring immediate attention and treatment, which may include admission to a mental health facility.

Women with postpartum depression may also experience distressing thoughts of harm intended toward themselves and the baby.

She may not show interest in handling the baby, or may have gripping fears about handling the baby herself. On the other hand, she may be extremely fearful of turning her attention away from the baby, for fear of harm to the baby if unattended.

About 10 to 15% of new mothers develop postpartum major depression, but it is often not diagnosed until several months after the birth. Family members and physicians may also fail to recognize the symptoms as depression, believing instead that the mother's mood is a normal reaction to the stress of caring for the infant.

What causes postpartum depression?

We don't know the exact cause of depression. Research points out that women who develop postpartum depression are sensitive to changes in estrogen and progesterone. The brain chemistry of postpartum depression is probably similar to abnormalities that researchers believe are present in other types of depression. This view is supported by the fact that postpartum depression occurs more often in women who have had depression at other times, or who have close relatives with depression, where there may be a hereditary factor.

Who is at risk for postpartum major depression?

The most important risk factor for postpartum depression is having had a similar episode before. Over half of the women who have had a previous depression after the birth of a child will become depressed again when they give birth.

If a woman has been depressed at any other time in her life, her risk of developing postpartum depression also increases, from about 10 to 25%.

There is a 70 to 80% risk of developing postpartum depression if the woman has a prior history of bipolar disorder.

Women are also more vulnerable if they have been depressed during pregnancy, if they had significant premenstrual mood symptoms before they were pregnant, or if they have close relatives with depression or bipolar disorder.

It is very important for a woman with a personal or family history of a mood disorder to talk to her doctor, so that she can be monitored closely.

Stressful situations (such as health problems in the baby, marital discord, or not having a partner) may also place a woman at increased risk for postpartum major depression.

Untreated postpartum depression can affect the baby's overall development

Studies of depressed mothers have shown that postpartum depression can have significant negative effects on the baby that can persist into childhood. Mothers who are depressed may be less involved with their children. When interactions between mother and infant are impaired, this can have an effect on the child's later behavior. Studies have shown that such children may not perform as well on some developmental tasks as children of mothers who were not depressed. Their ability to interact with other children may also be affected, and they may have behavioral and learning problems. It is therefore considered very important to identify and treat postpartum depression as early as possible.

How is postpartum depression treated?

Postpartum depression is a severe condition and must be treated with medications and counseling. Your doctor may prescribe antidepressants, in case postpartum depression symptoms are severe enough. Antipsychotics would be prescribed in case of postpartum depression with psychotic symptoms. Sometimes, you may also be advised to have electroconvulsive therapy (ECT), depending on the severity of your symptoms and also your response to treatment.

Deep TMS for Major Depressive Disorder

A non-invasive treatment option for depression.

Deep Transcranial Magnetic Stimulation (Deep TMS) is a non-invasive neuromodulation treatment that uses magnetic pulses to stimulate specific areas of the brain involved in mood regulation. It does not involve surgery, anesthesia, or medication exposure, and is generally well tolerated. TMS is an established treatment option for major depressive disorder, particularly when adequate improvement has not been achieved with medication and/or psychotherapy.

Deep TMS may be considered for individuals with moderate to severe depressive illness, including those who have had an inadequate response, intolerance, or difficulty continuing conventional treatments.

Potential advantages include:

• Non-invasive treatment
• No systemic medication exposure
• No need for anesthesia
• Usually allows patients to continue their normal daily activities
• Can be used as an alternative or adjunct to medication and psychotherapy, depending on individual clinical needs

The most commonly reported side effects are temporary headache and scalp discomfort, while serious complications are uncommon when appropriate safety screening and treatment protocols are followed.

Why consider TMS during pregnancy?

1. No systemic medication exposure. One of the important potential advantages of TMS during pregnancy is that it is a localized physical treatment rather than a medication delivered through the bloodstream. This can be particularly relevant for women who are concerned about fetal exposure to psychiatric medications.

2. An option when medication decisions are difficult. Some women may have concerns about starting, changing, or increasing antidepressant medication during pregnancy. Others may have experienced an inadequate response or troublesome side effects with medication.

TMS can provide an additional treatment pathway that can be considered alongside psychotherapy and, when appropriate, medication.

Importantly, TMS does not necessarily mean stopping medication. In selected patients, it may be used as an adjunct to existing treatment.

3. Evidence of improvement in perinatal depression. Studies of rTMS in peripartum depression have reported meaningful reductions in depressive symptoms, with response rates in several studies comparable to those seen in the broader depression literature. However, pregnancy-specific studies remain relatively small, and larger controlled studies are still needed.

Recent clinical guidance recognizes rTMS as a potential option in selected perinatal patients, while also emphasizing the currently limited certainty of the evidence, particularly during pregnancy.

4. Reassuring safety findings so far. Available studies have not identified a clear signal of serious harm to mothers, fetuses, or newborns from conventional rTMS used during pregnancy. A systematic review of 23 studies found that reported maternal adverse effects were generally mild, and that no major adverse effects were reported in newborns.

A review of published pregnancy cases involving 67 births also found no serious adverse events in mothers or babies, although the authors emphasized that larger, standardized studies are still required.

5. No anesthesia or hospitalization is usually required. TMS is delivered while the patient is awake and does not ordinarily require anesthesia. Treatment sessions are conducted in a clinical setting, allowing patients to return to their usual activities after treatment.

Common treatment-related effects are generally mild and may include headache or scalp discomfort. Serious complications are uncommon, although appropriate screening is essential.

6. Potential benefit of treating depression itself. It is important to consider not only the potential risks of treatment, but also the risks of leaving significant depression untreated.

Untreated maternal depression has been associated with difficulties in antenatal care, nutrition, substance use, postpartum depression, maternal-infant attachment, and certain adverse pregnancy and developmental outcomes.

Therefore, the decision is not simply about whether to treat or not treat. It is about identifying the most appropriate and balanced treatment for the mother and baby.

Can postpartum depressive episodes be prevented?

Previous episodes of depression increase the risk that a woman will develop postpartum depression. The risk is highest in a woman who has actually had postpartum depression after an earlier pregnancy. If a woman has a history of depression, her doctor may discuss treatments to lower the chance it will return after delivery.

Careful monitoring of symptom development during the postpartum period is warranted. The woman might benefit from counseling in case of mild symptoms. However, if a woman has had postpartum depression in the past, most experts recommend beginning preventive treatment with antidepressant medication and psychosocial interventions right after delivery. Your doctor might start preventive therapy as early as your third trimester if you're at very high risk.

Breastfeeding and psychiatric medications

Given the many benefits of breastfeeding, some women may wish to continue breastfeeding their infants while receiving psychiatric medications. Antidepressants are considered relatively safe during breastfeeding, and SSRIs are among the best-studied classes during breastfeeding.

Smaller quantities of the prescribed medications do get excreted in the breast milk. With the available information on antidepressants while breastfeeding, serious adverse events related to these medications have not been reported. However, there have been reports of milder adverse events such as jitteriness, irritability, excessive crying, and sleep disturbances in infants exposed to antidepressants. Depending on the adaptability of the infant, and with close observation by the pediatrician, an informed decision can be made regarding medications while breastfeeding.

Depression during pregnancy or after birth is treatable. If something feels off and it's not lifting, reach out to your obstetrician or a perinatal mental health specialist. For a broader look at emotional wellbeing through pregnancy, see Pregnancy and Your Mental Health: What to Expect, and When to Ask for Help.