After going through a harrowing bout of postpartum depression with her first child, my patient, Emily, had done everything possible to prepare for the postpartum period with her second. She stayed in treatment with me, her perinatal psychiatrist, and together we made the decision for her to continue Zoloft during her pregnancy. With the combination of medication, psychotherapy and a significant amount of planning, she was feeling confident about her delivery in April. And then, the coronavirus hit.
Emily, whose name has been changed for privacy reasons, called me in late-March because she was having trouble sleeping. She was up half the night ruminating about whether she’d be able to have her husband with her for delivery and how to manage taking care of a toddler and a newborn without help. The cloud that we staved off for so long was returning, and Emily felt powerless to stop it.
Postpartum depression and the larger group of maternal mental health conditions called perinatal mood and anxiety disorders are caused by neurobiological factors and environmental stressors. Pregnancy and the postpartum period are already vulnerable times for women due in part to the hormonal fluctuations accompanying pregnancy and delivery, as well as the sleep deprivation of the early postpartum period. Now, fears about the health of an unborn child or an infant and the consequences of preventive measures, like social distancing, have added more stress.
As a psychiatrist who specializes in taking care of pregnant and postpartum women, I’ve seen an increase in intrusive worry, obsessions, compulsions, feelings of hopelessness and insomnia in my patients during the coronavirus pandemic. And I’m not alone in my observations: Worldwide, mental health professionals are concerned. A special editorial in a Scandinavian gynecological journal called attention to the psychological distress that pregnant women and new mothers will experience in a prolonged global pandemic. A report from Zhejiang University in China detailed the case of a woman who contracted Covid-19 late in her pregnancy and developed depressive symptoms. In the United States, maternal mental health experts have also described an increase in patients with clinical anxiety.
Samantha Meltzer-Brody, M.D., M.P.H., who is the chair of the department of psychiatry at the University of North Carolina at Chapel Hill and the director of the Center for Women’s Mood Disorders, said, “The natural vulnerability of this major life transition is exacerbated when you just have sort of global anxiety, and things like going to the grocery store to pick up diapers suddenly become a much more anxiety-producing event than it ever was before.”
Dr. Meltzer-Brody explained that the higher levels of stress in perinatal women increase their risk for developing a clinical disorder, such as perinatal depression or anxiety.
In my clinical practice and in a Covid-19 maternal well-being group I co-founded, women have voiced their fears about a number of possible distressing scenarios: delivering without a support person; being one of the 15 percent of pregnant women who is asymptomatic for Covid-19 and facing possible infant separation; and recovering during a postpartum period without the help of family or friends to provide support. There’s also grief about the loss of a hopeful time that was meant to be celebrated with loved ones.
Pregnant women and new mothers must also deal with the constant low-grade panic that comes with making decisions that have no specific medical guidelines, such as: What should I do if I have other kids at home and the only person who can help me is a grandparent who is at high risk? What kind of precautions should I take if my partner is a health care worker? Is it OK to send my kid back to day care? Without clear right answers, the mental load of these decisions defaults to mothers.
As part of its ongoing Pregnancy During the Pandemic research program, the University of Calgary has been examining symptoms of depression, general anxiety, pregnancy-specific anxiety, as well as levels of sleep and social support of pregnant women in Canada using self-reported questionnaires. Early findings, which have not yet been published nor peer reviewed, indicate higher than normal levels of clinically relevant depression and anxiety symptoms in pregnancy in those who took the survey.
The study’s lead author, Catherine Lebel, Ph.D., an associate professor of radiology at the University of Calgary, said higher levels of depression and anxiety are “particularly concerning in pregnancy because struggles with mental health can impact not just the pregnant woman herself, but also her baby.”
As part of the Parenting During the Pandemic research program, researchers at the University of Manitoba have been examining how mothers are faring while pregnant and parenting children up to age 8 during the pandemic. Early findings, which also have not yet been published nor peer reviewed, suggest an increase in self-reported symptoms of clinically relevant depression and anxiety in mothers with children in all age groups.
Given that many mothers are caring for infants while home-schooling children, the study’s lead author, Emily Cameron, a doctoral candidate at the University of Calgary and a clinical psychology resident at the University of Manitoba, said there’s a clear need to develop affordable clinical services that take into account the increased parenting demands during the pandemic.
Women who lack social support after the birth of a baby are more likely to develop postpartum depression. Supportive relationships during pregnancy can protect against postpartum depression. While it’s still too early in the Covid era to point to conclusive data about which populations are most vulnerable, Dr. Meltzer-Brody noted that if we extrapolate from what we know about risk factors for perinatal mood and anxiety disorders pre-Covid, it’s reasonable to believe women who have a lifetime history of anxiety or depression are going to be harder hit by the negative effects of social isolation.
Leslie E. Roos, Ph.D., an assistant professor in the department of psychology at the University of Manitoba and principle investigator of the Parenting During the Pandemic project, said, “A potential important point of public health intervention would be to reach out to families where there were prior mental health concerns to check in proactively about how those families are doing.”
While acknowledging we are just beginning to learn about the magnitude of the virus’s effect on pregnant women and new moms, Stacey D. Stewart, the president and chief executive of the March of Dimes, said, “We just have to assume that during times when the health systems are stressed the way they are, that those already existing systemic issues are probably made even worse.”
In the case of my patient Emily, we caught her symptoms early, increased her medication dosage and met more frequently for psychotherapy. Her postpartum period was not at all what she expected it to be, but with proper treatment and support, she began to feel like herself again.
Still, I’m scared for the woman with bipolar disorder who may lose her insurance, go off her medication and end up hospitalized. And the pregnant health care worker who is faced with balancing the needs of her unborn child, and the needs of her patients.
I’m urging women not to wait to seek help. It can be tempting to dismiss your symptoms as just stress. But, perinatal depression or anxiety that may be caused by Covid-19 is still perinatal depression or anxiety. It responds to treatment. Call your obstetrician-gynecologist to get an evaluation or ask your pediatrician for a list of referrals. Check out Postpartum Support International’s help line at 1-800-944-4773 or their provider directory to find a clinician who specializes in maternal mental health.
