My patient felt ecstatic when she saw the two dark pink lines on her pregnancy test. She wasn’t surprised when fatigue and nausea soon followed. But she began to worry when she couldn’t sleep and became engulfed in sadness that eclipsed her maternal joy.

She confided in a couple of close girlfriends.

“Everyone told me that I was hormonal and that I would begin to feel better during my second trimester,” she said.

By the end of her first trimester, the nausea and fatigue had lifted, but her tearfulness and insomnia lingered. She would toss and turn through the night worrying that she wouldn’t be a “good enough” mother to her baby.

Her husband told her that she had “always been a worrier” and that she just needed to try to rest and relax.

A constant stream of worries raced through her mind: “What if there’s something wrong with the baby and the ultrasound didn’t detect it yet?” “What if I develop gestational diabetes and I have to go on bed rest?” “What if I have one of those difficult babies who cries all of the time because of colic?”

“On top of all that, I began to worry that my thoughts were hurting my baby,” she  said.

Even though she had heard of postpartum depression (PPD), the mental health disorder that affects up to 20 percent of new mothers, she was unaware that depression often begins during pregnancy.

When her obstetrician asked her how she was feeling during her pregnancy, she broke down in tears. Her doctor asked her a few more questions about how she was sleeping and if she was feeling overwhelmed. When she finally opened up to her doctor about her struggles, she learned that she was suffering from prenatal depression.

As a psychologist specializing in prenatal and postpartum depression, I’ve treated many women like this patient, who may not be aware that depression can begin during pregnancy, not just after giving birth.

Similar to postpartum depression, prenatal depression is accompanied by feelings of worry, sadness and anxiety. But there are some unique symptoms as well, which is why researchers at Northwestern University are raising awareness by informing women and their doctors about the signs of pregnancy-related depression.

Results from their recent study suggest that such women who develop depression before or during their pregnancies suffer from a more severe version of this mental-health concern and experience more intense feelings of sadness, along with sleep concerns and, in rare instances, paranoia.

“These women are often juggling a multitude of life stressors, such as pregnancy complications, as well as family and financial stress. In many instances, they struggled with depression or anxiety before they became pregnant,” says Sheehan Fisher, a psychiatry professor and a lead researcher in the study.

“I felt ashamed to tell my doctor that I was struggling during my pregnancy. I wanted to believe that my feelings would go away on their own, like my friends reassured me that they would,” she told me.

This past year, the U.S. Preventive Services Task Force recommended that all expectant and new mothers receive maternal mental-health screenings, yet many women continue to fall through the cracks of the health-care system. Often, it’s not until after the birth of their babies that these women receive the mental-health treatment that they needed during pregnancy.

Even when women are assessed, they are often screened with the Edinburgh Postnatal Depression Scale, a 10-item, self-reported questionnaire that asks women to respond to such statements as “I have felt sad or miserable” and “I have been anxious or worried for no good reason.” While this questionnaire helps screen expectant and future mothers for depression, it asks only about symptoms for the past seven days, which doesn’t account for symptom severity and length of maternal suffering.

“It’s important to recognize that the symptoms of prenatal and postpartum depression vary for each woman,” said Meg Earls, director of the Perinatal Task Force for California Pacific Medical Center in San Francisco. In addition to using screening tools such as the Edinburgh, Earls recommends asking two more questions when working with pregnant and postpartum women: “Do you have any thoughts that disturb you?” and “Are you feeling more agitated or irritable?” She says that these questions can help clinicians garner more accurate data about the patient’s emotional well-being.

Because her doctor asked her those kinds of questions, she recognized that the mother-to-be was suffering. She referred her for psychotherapy at the local mental-health clinic for expectant and new mothers.

“When I began therapy, I was able to connect the dots,” she said. “I had experienced a depressive episode when I left home for college, but I didn’t realize how these two experiences were related. My therapist helped me understand that I was more sensitive to stress, and with her support and weekly therapy, I learned some tools that helped me to feel calmer for the duration of my pregnancy.”

Sometimes, individual therapy is not enough to help women suffering from prenatal depression. “It’s so important for each pregnant woman to have a postpartum team of care providers — doctors, midwives and mental health therapists,” says  Patricia Robertson, an obstetrician at the hospital of the University of California at San Francisco. She recommends that all expectant mothers join a pregnancy support group so that they can connect with their peers as they prepare for the path to motherhood.

This patient is now the mother of a beautiful baby girl. Even though her depression improved, she remains in psychotherapy and hopes to break the stigma associated with maternal mental-health concerns.

“I want all women to know that they are never alone. If you are feeling sad, worried or frightened during your pregnancy or after your baby is born, seek help,” she said.

Wendy Davis, director of Postpartum Support International, echoes these sentiments.

“It’s important for each and every woman to know that she's never to blame, and with help, she will feel better.”

This post has been updated.

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