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What happens when pregnancy and mental health issues collide

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We’re bombarded with physical health advice both before and during pregnancy. But how do you embark on motherhood if you have a pre-existing mental health condition?

The 2018 Charlize Theron film Tully is about an exhausted and overwhelmed mum-of-three. Sounds like a normal plotline. 

Except that it isn’t, because refreshingly – and very boldly – it brings the complex issues of maternal mental health to the fore. This year marks the third Maternal Mental Health Week (April 29-5 May), which shines a light on the dangers of neglecting the mental wellbeing of mothers

And, recently, it was announced that the NHS will receive £23 million in funding to ensure that all pregnant women and new mothers are able to access specialist community mental health support. This is news that is being particularly well-received by women with pre-existing or more severe mental health issues, such as bipolar disorder, who need close supervision during pregnancy to ensure the wellbeing of both themselves and their unborn children.

“Much is spoken of postnatal depression, but maternal mental health is so much more than that,” says Jo Birtwhistle, a midwife with the baby charity Tommy’s. “For a start, many women have mental health issues before they become pregnant. This group is particularly at risk when they become pregnant because pregnancy and new motherhood can, if they’re not properly cared for and monitored, exacerbate mental health conditions.” 

Charlize Theron in Tully

On the whole, the news for women with pre-existing mental health issues who want to become pregnant is good. “There are medications available to treat all types of mental health disorders before, during and after pregnancy and during breastfeeding,” says Dr Alain Gregoire, chairman of the Maternal Mental Health Alliance. “There is absolutely no evidence [these medications] can harm mother or baby and conversely we have evidence that untreated mental illness can be more harmful.”

And Birtwhistle adds that, as long as women encountering difficulties speak to their GPs in case their dose needs altering, “A woman can safely take antidepressants during her pregnancy and while breastfeeding.”

However, although most experts agree that coming off medication for mental health issues causes more potential risk to the mother than the unborn child, there is no guarantee that drugs are 100% safe in pregnancy. This creates difficult dilemmas for mothers-to-be at a time when they are dealing with changing hormone levels and wanting to do their best to ensure a healthy pregnancy. “Pregnancy is a challenging time for most women, and can affect mood and energy levels, let alone somebody with existing mental health conditions,” says Birtwhistle.

Clare Dolman, vice-chair of Maternal Mental Health Alliance says, “I’ve worked with women with bipolar disorder who worry about pregnancy because they think they’ll have to come off their medication, and then what happens? Will they become ill or have their baby taken away?”

Recent studies and reports haven’t helped. Last month, a news story claimed that taking antidepressants during pregnancy can alter an unborn baby’s brain development. And a recent study from the Columbia University Medical Centre in New York looked at mothers and found that some of those who took SSRIs (selective serotonin reuptake inhibitors, a type of antidepressant) for depression during pregnancy had babies with disrupted levels of the chemical serotonin, which can affect the brain’s emotional processing centre.

Furthermore, the NHS recently stopped prescribing sodium valproate, an epilepsy drug also used as a mood stabiliser, to women of childbearing age unless they signed a form saying they understood the risks involved. Since the Seventies, around 20,000 children in the UK have been left with varying degrees of developmental delays after their mothers took it while pregnant.

It is little wonder, then, that women with pre-existing mental health conditions are in a dilemma as to whether to continue their medication while trying for or carrying a baby.

There is no guarantee that drugs are 100% safe in pregnancy

What is clear, however, is that these issues need to be discussed more openly so that more women can discover the options for those suffering with mental health issues before, during or after pregnancy.

“Women need improved perinatal [during pregnancy or in the first year following the birth of a child] mental care services, and with the new funding they will receive it,” says Gregoire. “Whether it’s medication, talking therapies or specialist support from GPs, health visitors or midwives with special mental health training, or in extreme cases inpatient care in one of the new mother and baby units [which provide support for mothers who are experiencing severe mental illness]. With special care, there’s no reason why any woman, even with a severe mental health condition, shouldn’t be able to have a baby.” 

“Over the last couple of years we’ve really started to see big progress being made,” says Dr Jo Black, the national director of perinatal mental health for NHS England. Yet despite this, it’s women with milder mental health conditions who are frustrated that there’s no extra funding for them, and while all aspects of our physical health is monitored throughout pregnancy, mental health can seem to take a back seat.

“If anything, local authorities all over England are reducing the amount they spend on health visitors, with the risk that pregnant women and mothers with less severe problems are falling through the cracks,” says Gregoire. “We know 50% of women with depression don’t have it recognised by their GP or midwife, and of that 50% only half get treatment.”

However, Gregoire says the funding will help eliminate the postcode lottery that currently exists in perinatal health: “Up until now, it really is a case of how lucky you are in terms of who your GP or midwife is. That’s not to say there isn’t help out there and these flaws in the system shouldn’t stop women from asking. We’re a long way off having the perfect perinatal mental health system, but the bits of the jigsaw are starting to come together.” 

We talked to three women about how they’re dealing with mental health issues during pregnancy.

“Coming off my medication was never an option”

Susan*, 35, an insurance underwriter, has post-traumatic stress disorder (PTSD), anxiety and depression, and is 30 weeks pregnant 

“Two years ago my depression became so severe I couldn’t see a way out. If I didn’t have to care for my disabled brother, I would have ended it. Thankfully, I recognised that things had become out of hand, so I booked an emergency appointment with my GP who sent me to see a psychiatrist. He diagnosed me with anxiety, depression and PTSD and prescribed the antidepressant escitalopram, and things improved quickly.

After a few months I told him I wanted to start a family, but he asked me to hold off until I was in a stronger place mentally. Once I’d started to laugh again and feel brighter, my fiancé and I decided to try for a baby. We agreed that even though my psychiatrist explained no drug can be declared 100% safe for a foetus, the benefits of taking the medication far outweighed the risks and there was no way I could come off my medication – the possibility of me having a relapse was too frightening.

I’m now 30-weeks pregnant and the hormones, exhaustion and stress have meant that abuse from my past has raised itself and triggered flashbacks and other symptoms relating to my PTSD. I wanted to address it before it got out of control, but I was reluctant to talk to my midwife because I worried that my baby would be taken away, or social services would want to investigate my childhood trauma. But she was so understanding and immediately referred me to the specialist mental health midwives and perinatal team who recommended I start therapy again. I had my first appointment the next day. It’s so reassuring to know that the team will be there to support me until my baby is a year old, because my anxiety means I do worry about being able to look after it, and about trusting the people around me not to abuse my baby as I was.”

“Medication and therapy are helping me through pregnancy”

Steph*, 37, a copywriter, is dealing with pre-existing OCD and anxiety while pregnant

“I fell pregnant with my third child quickly so I didn’t have time to think about coming off the antidepressant Setralin I’ve been taking for OCD and anxiety for the past year. I didn’t google the effects on my baby because there are just too many opinions online, and as someone who’s anxious anyway it would just make me fret more. However, I am happy and comfortable that I’ve been slowly weaning myself off my medication and tapering my dose to suit my needs. Equally, I’ve found talking therapy is providing me the support I need at the moment.”

“Women with maternal health problems are hiding in plain sight”

Lucy*, 41, a nurse, stopped taking medication for postnatal depression when she fell pregnant with her second child

“I was diagnosed with postnatal depression when my first son was four months old, but in hindsight I developed it just after he was born. He was very poorly with his breathing in his first few days, and even though he made a full recovery I put up this protective barrier, which interfered with bonding. I also think I had PTSD as a result of him falling ill. I went on autopilot, but everything came to a head when he was around four months old and I just lost it. I couldn’t stop crying and felt flat.

I saw my GP who put me on antidepressants, but I came off them before we tried for our second baby. As a nurse I knew I could have stayed on them, but I began worrying that if anything was wrong with the baby I would blame myself for taking medication during pregnancy. I was assured that wasn’t the case, but I decided I was OK without the antidepressants.

But then I moved to a new area where I didn’t know anybody and began to feel low. When I was seven months pregnant I developed a heightened sense of anxiety about everything and despite being pregnant, I lost weight everywhere other than my bump because I was so anxious and not sleeping properly.

I was at a routine hospital appointment and I was telling the midwife how I was doing when a doctor said, ‘I don’t think you should go home – you need to stay in for a few nights’. They gave me a private side room and monitored me for three days. They offered me antidepressants but I refused. But I felt supported, looked after and I got some bed rest, which was enough. My GP then put me in touch with local support groups and I joined baby groups and made friends, which helped.

But I know it’s hard for some women to access support, and I think a lot of women with maternal mental health problems are hiding in plain sight. They go through the motions, feeding, caring for their babies, but inside they’re crumbling. And it’s not a visible injury, so partners, health visitors and family have to look that bit harder. Plus it’s made worse by the way most of us live now – like me, in cities or towns hundreds of miles from their hometowns and families. Motherhood can be incredibly isolating.”

Mental Health Awareness Week runs from 13-19 May in the UK and 6-12 October in the US. If you are concerned about your mental health, please call Mind Infoline on 0300 123 3393 or visit their website here, and in the US call the National Alliance on Mental Illness (NAMI) on 1-800-950-6264.

 Words: Maria Lally

Images: Camila Cordeiro, freestocks.org, Omar Lopez, Unsplash    

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