Growing concern: Why it's critical to speak up if pregnancy brings you down

Growing concern: Why it's critical to speak up if pregnancy brings you down

As a specialist perinatal mental health model of care is rolled out nationally, a study shows Ireland has a high 16% rate of depression during pregnancy. Helen O’Callaghan reports.

YOUR body’s in a state of flux – hormones all over the place, morning sickness, exhaustion, weight gain. Yet, despite the momentous physical shift, you never expected pregnancy would bring emotional and mental turbulence. You thought — and so did everybody around you — that you’d be consistently up, on top of the world, or at the very least on a fairly even emotional keel, calm and serene as you waited for baby.

May is Maternal Mental Health Awareness Month, when expectant and new mums are encouraged to speak up about feeling down. While there’s been lots of focus on post-natal depression (PND), it often goes unsaid that pregnancy doesn’t protect against depression – that 10%-15% of women in developed countries are affected by depression while pregnant.

Growing concern: Why it's critical to speak up if pregnancy brings you down

Ireland’s rates are even higher, says Veronica O’Keane, professor in Psychiatry at Trinity College Dublin and lead investigator in Well before Birth, the first all-Ireland screening study of depression prevalence during pregnancy. “There’s a 16% rate of depression, which is higher than EU rates.”

Other mental health problems rear their heads in pregnancy too. The British Colombia Medical Journal cited several reports suggesting women may be at increased risk for OCD onset during pregnancy and post-natally. In one study of OCD-diagnosed women, 39% reported the problem began during pregnancy. While the onset of psychosis during pregnancy is extremely rare, relapse rates are high for women with a history of psychosis.

Krysia Lynch, chairperson of the Association for Improvements in the Maternity Services (AIMS), says pregnancy is very much touted as a time of being in bloom, a time of looking forward to having a baby, a great time in a woman’s life. 

For many women it is. But when pregnancy’s uncomfortable, it’s always the physical side we talk about – the back pain, the bump and the special oils you can use to stop stretch marks. We don’t talk about the emotional problems.

Lynch describes pregnancy as a hormonal cauldron with many triggers that can propel women into a low place mentally and emotionally. “A woman may have experienced a difficult birth already. She may have had past sexual abuse or very great fear of childbirth – all of these can get triggered.”

Pregnancy can be a tipping point for women already highly stressed by daily life pressures, e.g. accommodation/financial/relationship difficulties, says midwife Siobhán O’Connor, volunteer facilitator with Aware, who ran the organisation’s perinatal mental health self-care and support group in Galway. (Perinatal refers to the period from conception to a year after delivery).

“None of us are ever fully prepared for a new baby. There are many emotional and physical changes to adjust to, which can be overwhelming,” says O’Connor.

Among problems reported by pregnant women attending the group were: disrupted sleep, feeling unmotivated to get up in the morning, racing thoughts and inability to mentally switch off, difficulty focusing and getting tasks done.

Growing concern: Why it's critical to speak up if pregnancy brings you down

“They constantly worried about the pregnancy and how the baby was doing. Some, though functioning, felt unconnected to what was going on. They felt unable to talk about intrusive thoughts. They couldn’t remember when they last felt happy.”

Irene Lowry, chairperson of Nurture — which offers counselling support around pregnancy/childbirth mental health issues — says emotional troubles during pregnancy can be due to anything, from a woman overwhelmed trying to juggle other small children, to feeling she doesn’t recognise her changing body. And women already unsupported through post natal depression (PND) can be definite candidates for depression during a subsequent pregnancy. “She thinks will I get PND again? Or maybe she has lost a baby before and she’s wondering will this baby make it.”

Lowry says a woman’s past life can create vulnerability on many fronts. “Pregnancy’s a time for a woman to come into her own. If she’s had a difficult relationship with her own mother, she’ll be thinking: where am I in all of this? How am I going to be as a mother?”

Last November, the HSE launched the specialist perinatal mental health (SPMH) model of care. This envisages all 19 maternity services in the country networked in a ‘hub and spoke’ format. In each hospital group, the hub will be the maternity service with the highest number of deliveries: Coombe Women & Infants University Maternity Hospital, National Maternity Hospital, Rotunda, Galway University Hospital, Cork University Maternity Hospital and University Maternity Hospital Limerick (UMHL).

Each of these six hospitals will have a specialist, multi-disciplinary perinatal mental health service, led by a consultant psychiatrist in perinatal psychiatry. In the remaining 13 maternity services (the ‘spokes’), the liaison psychiatry team will continue to provide the input to the maternity service. This team will link to the hub teams for advice, regular meetings, training and education.

Growing concern: Why it's critical to speak up if pregnancy brings you down

So how far along is rollout? Margo Wrigley, clinical lead for the SPMH Model of Care, confirms the appointment in recent months of two full-time consultant psychiatrists for specialist perinatal mental health — one in National Maternity Hospital and one in UMHL. At the time of writing, two further full-time and an additional two part-time posts (all consultant psychiatrist posts) are at various stages in the recruitment process.

“Once a full-time equivalent consultant is in place, funding for two further members of the specialist perinatal mental health team will be released by [the] HSE. This is currently in train for the National Maternity Hospital and UMHL,” says Wrigley.

O’Keane welcomes the perinatal mental health services now being planned but says “we’re starting from a very low base-line”. Up to now, with an annual birth-rate of 70,000, we’ve had four part-time psychiatrists working in the area. “We’re miles behind the rest of Europe,” she says, adding that — despite depression being a very common disorder — mental health in Ireland gets just 6% of the health budget, compared to 12%-13% in Britain.

According to O’Keane, every British maternity hospital has a full-time perinatal psychiatrist and team. The new HSE-proposed model could work, she says. “But it needs implementing very quickly.”

Krysia Lynch represented women’s voices in discussions about the new SPMH Model of Care. She’s concerned the focus is on women with moderate-severe mental health problems – schizophrenia, bi-polar disorder, severe post-traumatic stress.

But women with low mood or whose pregnancy is difficult [mentally] but not bad enough to be categorised or diagnosed, we could be doing more to support them.

Wrigley acknowledges the model is for specialist moderate-severe mental health difficulties but says an overall perinatal mental health pathway has been designed that will “ensure women at the milder end also have a response”.

Key to this, she says, will be mental health midwives in each maternity service, who’ll “understand the mental health aspects of pregnancy and post-natally”.

Following GP referral to booking clinic in any of the maternity hospitals, Wrigley says women will routinely be asked very open-ended questions about their mental health: During the past month, have you been bothered by feeling down, depressed or hopeless? During the past month, have you often been bothered by having little interest or pleasure in doing things?

“We’re also suggesting each woman is asked by the midwife if this is something she needs or wants help with. If she answers yes to either question and she wants help, she’s referred to the mental health midwife or the specialist perinatal mental health team.”

Professor John Sheehan, perinatal psychiatrist in the Rotunda, believes the new model of care represents genuine commitment by the HSE and is delighted it has been designed using a ‘bottom-up’ approach. “There was very strong service user involvement in the design, as well as detailed discussions with clinicians. It hasn’t been handed down from on high.”

Like other experts interviewed, he says women can be reluctant to report feelings of unhappiness or inability to cope.

“Because there’s still stigma — women are concerned about what disclosing mental health issues will mean for them and their baby,” says O’Connor.

Growing concern: Why it's critical to speak up if pregnancy brings you down

O’Keane believes depression in pregnancy is “definitely” under-reported and under-diagnosed. “I think women don’t tell their doctors. Maybe when they’re really depressed they do, at an advanced stage of pregnancy when birth’s imminent. At that stage, it’s difficult to get better.”

Depression is very damaging to a woman’s health and to her ability to parent her child, once born. “Our research shows if mum’s depressed during pregnancy, then baby’s stressed up to the first six months. It’s physiological stress — cortisol levels are up,” says O’Keane.

Wrigley points to studies that show 75% of impact is on the child and his/her subsequent development when mum has significant mental health problems.

A woman, very depressed, not interested in doing things or in engaging, probably won’t engage with her baby. Yet, right from when baby emerges, it’s so important s/he’s held by mum, dad — so baby grows up to be an adult with secure attachment, less prone to developing emotional/behavioural problems.

Professor Sheehan says historically — faced with depression — the medical view was ‘don’t do anything because she’s pregnant’.

But most recently it’s acknowledged problems should be addressed during pregnancy.

Yet, he understands expectant mothers’ fear of taking medication.

“In Ireland and in Europe, doctors are cautious about using medication in pregnancy.

In the US, 10% of [pregnant] women take anti-depressants. At the Rotunda, the figure’s 3% — consistent with European figures.”

Confirming there are safe meds to take for depression during pregnancy, he says the key question is: do the benefits of medication outweigh any risks?

If a woman becomes very depressed, she’ll struggle to care for herself. So how does she bond with her baby, care for her baby? A well mother engages with her baby, interacts with it. If mum’s sick and under-treated, it could affect the cognitive, social and emotional development of the baby.

Ireland currently has no Mother & Baby Unit (MBU), where mum and baby are admitted together for treatment of maternal mental health issues, thus facilitating bonding. Britain has about 20 such units. While the SPMH Model of Care provides for one MBU, it’ll be a national unit, based in Dublin.

“We would like not just one national centralised unit but maybe one in the Mid-West too, so that journeys wouldn’t be so long for women’s families [visiting].

“If you had other children, they and your family wouldn’t be able to come and see you so often — and you could be in three to six weeks.”

We measure safety in maternity services by how many women survive childbirth.

Lynch says it’s a very crude measurement.

“Safety in maternity services isn’t just physical safety. To keep the woman a well mother, she needs to be emotionally safe too.”

AT FIRST I PUT IT DOWN TO HORMONES AND EXHAUSTION

Mum-of-four and secondary schoolteacher Suzanne suffered depression while pregnant with her third child.

Growing concern: Why it's critical to speak up if pregnancy brings you down

“It was there all the time from when I knew I was pregnant. At first, I put it down to hormones and exhaustion and a demanding job and almost feeling like a single parent because my husband works at sea.

“I was crying all the time. I’d wake up crying in the night. I’d hold it together during the week for work. I rang in sick two Mondays — my face would have betrayed me if I’d gone in. I felt very apathetic. Everything was grey. I’d put emotion in my voice when I was talking, think of conversation topics before meeting friends. I became a bit of a shell. I started getting panic attacks.

“I knew I couldn’t keep it up. At my 20-week scan, I was crying going into the midwife and also with the consultant. He took one look and said this isn’t normal.

He said I couldn’t work like this and he’d sign me off for ‘pregnancy-related reasons’. I felt huge relief, but shock too — I’d never been depressed before. I’m used to being able to cope. And he mentioned medication. He said he wasn’t in a position to prescribe — it would be my GP’s job.

“My GP was hugely sympathetic and explained this was hormonal and not something I could manage myself — it wasn’t a case of put on a brave face and struggle on. I decided not to take medication — I wasn’t secure about taking it.

“I joined a saltwater swimming pool with the intention of swimming three/four times a week. I saw a cognitive behavioural therapist weekly. I’d had two bad birth experiences with my first two children and the therapist said my depression was due to post-traumatic stress. It made sense — as soon as I realised I was pregnant, I’d had nightmares. My biggest fear was I’d have a dead baby.

“I kept on my childcare and I rested a lot. Because the baby was breach, my consultant said he’d do a C-section. I felt huge relief — I’d have a date, I found out he was a boy, I knew when he’d be coming. It helped, having as many definites as I could get.

“With my fourth baby, now 10 months old, I knew I could get depressed again but thankfully I was absolutely fine. My advice to other women is ‘don’t feel you have to be perfect on all fronts — it’s OK to show weakness’.

When I talk about depression in pregnancy, women say ‘I had that’ or ‘my sister/friend had it’. Yet you never hear about it, the way you do about PND.

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