As many as one in five new mothers will experience depression just before or after giving birth, at risk to their own health and the growth and development of their newborns. And while previously it was thought that psychiatric medication was harmful to the unborn child, there is growing scientific evidence of the safety of antidepressants in pregnancy and that stopping medication may in fact cause more harm to both mother and baby.
The risks posed to a fetus from antidepressants are consistently overestimated, while the risks of untreated depression are consistently underestimated because of the pervasive stigma against mental illness. Depression in pregnancy is often undiagnosed and goes untreated, as the focus is primarily on the physical health of mother and baby, and can lead to premature labour, low birthweights and developmental delays.
Postnatal mental illness, which mainly occurs as depression and anxiety, is second only to malnutrition as the biggest risk factor for poor development in newborns and young children, which in turn impacts on their own mental and physical health, intellectual abilities and future potential. Life changes around pregnancy make women more vulnerable to mental illness, and women who have been diagnosed with depression before or during pregnancy are at higher risk of developing postnatal depression.
Depression and anxiety cause significant suffering and disability – leading to a higher risk of substance abuse and suicide, hampering the mother’s ability to bond with and care for her child, and disrupting family and partner relationships. Maternal mental health is considered a major public health challenge both locally and globally. South Africa’s national Health Department has maternal and child health as one of its key priorities for the health of the nation, while reducing maternal and infant mortality leads the targets of the United Nations Sustainable Development Goal 3 to ‘ensure healthy lives and promote well-being for all, at all ages’.
Virtually all women can develop mental disorders during pregnancy and in the first year after delivery, but pre-existing mental illness, alcohol or substance abuse, a lack of social support, poverty and unwanted pregnancies put them at greater risk, along with exposure to extreme stress or domestic, sexual or gender-based violence.
Pregnant women or new mothers experiencing symptoms of depression – including sleeping difficulties, feelings of inadequacy, helplessness or panic, lack of motivation, or feeling like crying for no reason – should consult their doctor, obstetrician or psychiatrist to develop an individual treatment plan. While these are all common symptoms of depression, women and their partners should also look out for feelings of detachment from the baby, feeling like she doesn’t love the child as she should, and thoughts of harming herself or the baby.
Psychotherapy was always the first line of treatment, along with mobilizing family support, especially by the father or significant partner, and community resources such as antenatal and baby clinics. Medication such as antidepressants could be prescribed, depending on the nature and severity of the condition, and after weighing up the risks and benefits of medication for both mother and baby.
Clinicians should weigh the growing evidence of detrimental and prolonged effects in children due to untreated antenatal depression and depressive symptoms during pregnancy against the known and emerging studies on the safety of in-utero exposure to antidepressants. Women who fall pregnant while taking antidepressants do not necessarily have to stop taking the medication, but rather to consult with their doctor or psychiatrist, who would determine whether the specific medication should be continued, changed or stopped.
The SSRI (selective serotonin reuptake inhibitors) class of antidepressants were the most well-researched and safest for use in pregnancy at relatively low risk to the unborn baby, but stressed that any decisions on medication should be made in consultation with the patient’s psychiatrist and obstetrician.
Dr Bavi Vythilingum is a specialist psychiatrist and member of the South African Society of Psychiatrists (SASOP).