HAMILTON, Ontario—At a local hospital on a recent Monday, four women, all pregnant or new mothers, were learning how to cope better with their anxiety and depression—medication not required.
Psychologist Sheryl Green asked participants in her treatment program to share the results of their “behavioral activation” homework, a strategy of regularly scheduling pleasurable activities and making yourself do them even if you don’t feel up to them. The technique can improve mood.
Mercedes Elmore, 27 and pregnant at the time with a girl, told the group she took time to text with a friend while her husband and 8-year-old son played videogames. Jennifer, mother of four-month-old Sienna, dashed out for a solo trip to the mall to buy a new outfit for her 30th-birthday dinner. (Jennifer said she was uncomfortable with using her last name in this article.) Rachel Bakker, a 31-year-old mother of three, had a friend come over to watch television.
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“It was something to look forward to,” Ms. Bakker said, while her youngest child, five-month-old Winston, sat on her lap and clutched a fuzzy toy chick.
The group is part of Dr. Green and her colleagues’ treatment program for perinatal anxiety at St. Joseph’s Healthcare Hamilton. It is one of a small but growing number of psychological therapy programs that are specifically designed for pregnant and postpartum women who struggle with anxiety and depression. They address a critical need. While scientific studies have generally found that antidepressant medications are safe to use during pregnancy and breast-feeding, there are still some concerns about their impact on babies.
Some doctors encourage women to avoid the drugs during the perinatal period, especially those patients with mild illness. And many women, even some with severe depression and anxiety disorders, simply refuse to take them while pregnant or breast-feeding.
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For “women who cannot or choose not to take medication, you need an alternative,” says Dr. Green, an assistant professor in the department of psychiatry and behavioral neurosciences at McMaster University.
Also, some women who stay on medication continue to have symptoms: Adding psychotherapy to antidepressants could help keep them well.
Anxiety disorders and depression are common during pregnancy and the postpartum period. About 13% of women experience depression during pregnancy. And studies estimate that anywhere from 12% to 39% will have an anxiety disorder. Many women experience both. “Hormones may contribute to worsening of mood or anxiety in some women,” says Marlene P. Freeman, associate professor of psychiatry at Harvard Medical School. “Pregnancy and postpartum is a major life transition. There are sleep changes, stress and worry about having a baby.”
About 10% of pregnant women in the U.S. receive prescriptions for selective serotonin reuptake inhibitors, the family of antidepressant medications that include Prozac and Zoloft. Studies have found that about two-third of women with a history of depression who stop their medications while pregnant will relapse.
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“If you have untreated depression and anxiety disorders during pregnancy, you’re bound to have a higher exposure to things that are not good for the baby such as alcohol or smoking or drugs,” says Maureen Sayres Van Niel, a reproductive psychiatrist in Cambridge, Mass. and president of the American Psychiatric Association’s Women’s Caucus. “And it’s going to have an effect on the amount you can attach with your baby.”
The new perinatal programs adapt longstanding, effective psychological treatments for anxiety and depression. St. Joseph’s uses cognitive behavioral therapy (CBT), a treatment where patients are taught to identify unhelpful thoughts, challenge them and replace them with more realistic ones. Researchers at Washington University School of Medicine in St. Louis are using interpersonal psychotherapy, which focuses on improving relationships as a way to relieve depression symptoms, with pregnant patients. Massachusetts General Hospital and the MGH Institute of Health Professions are studying the use of mindfulness-based cognitive therapy, which involves yoga and meditation practice, to treat pregnant women with anxiety disorders.
The new programs modify treatments to be more accessible and relevant to pregnant women and new mothers. They often consist of fewer sessions: St. Joseph’s program, for example, meets only six times, whereas a typical course of CBT would include 12 to 18 sessions. Babies are welcome.
The program at St. Joseph’s is covered by Canada’s universal health insurance system and is free for participants.
Katelyn Hodgson, one of the program’s participants, has struggled with depression and anxiety for several years. Antidepressants helped alleviate her symptoms but she stopped taking the medication as soon as she found out she was pregnant with her daughter Frances, who goes by Frankie, now four months old. “I was just worried [the medication] was going to go to her and I didn’t know what it would do,” said the 27-year-old social-media and public-relations manager.
But her symptoms surged during her third trimester, and Ms. Hodgson went back on medication. “I was feeling unmotivated, unhappy and worthless. I didn’t understand how I could feel so bad when something so great was happening,” she said. Ms. Hodgson stopped taking the medication again, worried that Frankie would be exposed to it through her breast milk. She began St. Joseph’s perinatal program when Frankie was two months old. Her anxiety “is less intrusive now,” she says.
During St. Joseph’s program, women learn to identify and change their “thinking errors,” those catastrophic thoughts that can fuel depression and anxiety (If someone else holds my baby, she will get sick, for example). They learn to put them on trial, writing down tangible evidence for and against the thoughts. They are also taught to change behaviors that can fuel anxiety, such as spending hours online researching labor and delivery complications. Every week, the women get homework assignments to practice the new skills.
On that recent Monday, Dr. Green’s colleague, psychologist Eleanor Donegan, led the women in a deep breathing exercise. “It is just a message to your brain to slow down and relax a bit,” Dr. Donegan said. The women closed their eyes and the room went silent except for the occasional coos and gurgles from Frankie and Winston.
In a small pilot study of the program published in 2015 in the Archives of Women’s Mental Health involving 10 women with no control group, the treatment led to a statistically significant reduction in anxiety and depression symptoms. Dr. Green and her colleagues are finishing up a larger randomized controlled trial.
Ms. Elmore has found the strategies to change thinking errors particularly helpful. She has seen a psychiatrist for several years for generalized anxiety disorder and post-traumatic stress disorder, but has always resisted medication. With this pregnancy, her anxiety surged.
“At first, I worried about miscarriage. As time went on and I hit 20 weeks, I worry about her being stillborn,” said Ms. Elmore, an early childhood educator. Now when she gets anxious, she “looks at the evidence for that anxious thought and the evidence against it,” she said. “I find myself thinking more balanced thoughts.” Ms. Elmore gave birth Thursday to a baby girl.
Ms. Hodgson said perhaps the biggest benefit from St. Joseph’s program was the validation and support she received from the other women. “It makes you feel like there are other people that struggle just as much and that is OK,” she said. “We can find a way to get through it.”
How safe are antidepressants during pregnancy?
There is a robust body of research trying to answer this question, but study results conflict. And some of the risks attributed to the use of selective serotonin reuptake inhibitors, or SSRI, are similar to those found in children exposed to their mother’s psychiatric illness. So it can be difficult to distinguish between the effects of the medication and the impact of the disease.
Some studies found that babies whose mothers took antidepressants during pregnancy were more likely to be born prematurely and at lower birth weights. But babies exposed to their mother’s depression in utero face these same risks. Some studies found a higher risk of heart defects and neural tube defects among babies whose mothers took SSRIs. But others, particularly more recent research, found babies exposed to SSRIs are no more likely to have heart defects than the children of women who didn’t take medication.
The longer-term impact of antidepressant exposure is also not clear. Some studies reported an increased risk of autism and ADHD in children exposed to medication, while others found no link. Some research found an association between a mother’s use of SSRIs during pregnancy and language and behavioral problems in her children. Other studies found no such association.
There is some concern that children exposed to antidepressants in utero could be at higher risk for depression later on. A large study of nearly 65,000 women published in 2016 in the Journal of the American Academy of Child & Adolescent Psychiatry found that adolescents whose mothers took certain antidepressants while pregnant with them were more than four times as likely to become depressed by age 15, compared with children whose mothers had psychiatric disorders but didn’t take the drugs during pregnancy.
“We never want women to take any medication they don’t need in pregnancy and breast-feeding,” said Marlene P. Freeman, associate professor of psychiatry at Harvard Medical School. “The SSRI antidepressants are among the best studied medicines in pregnancy and breast-feeding. Medication for many women is really required in terms of staying well.”
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