COVID-19: Higher Depression, Anxiety Risk for Pregnant Women

Heather Boerner

June 11, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

When Megan Canon gave birth to her son Lucas in December 2019, she expected her first Mother's Day to be a joyful event that included her partner and her in-laws, maybe even friends. She expected to be smiling as she watched Lucas get passed from one family member who loved him to another.

Instead, she found herself on the floor in the entryway to her house in Aurora, Colorado, crying, mind on edge — vacillating between dread, guilt, anxiety, indifference, and fear — as she attempted to leave her house for a backyard, socially distanced and masked Mother's Day at her in-laws' house. She just wanted to hide under the covers, she said.

Would it be safe enough? Was it the perfect compromise with in-laws who understandably wanted to see their grandchild? Or was it a dangerous mistake that could result in illness in one or more people? As a biomedical intervention coordinator at the Colorado Department of Public Health and Environment with an MPH degree, Canon knew more than most about SARS-CoV-2. And she knew what strict precautions were necessary to protect everyone from the virus, which just added to her anxiety.

After 2 months with little help, limited interaction with friends, intensive lack of sleep, "daily meltdowns," and baby blues that never went away, Canon said Mother's Day ended up being notable for a different reason.

My coping skills just disappeared.

It "is what cued me in that something from a mental health perspective wasn't right," she told Medscape Medical News. "My coping skills just disappeared."

If early data are accurate, Canon is far from alone.

Women pregnant during the pandemic are twice as likely as their pre-COVID-19 counterparts to meet the criteria for major depressive disorder or anxiety disorder, according to a recent study conducted in Quebec, Canada.

In that study, 496 women filled out a mental health survey — designed to measure prenatal distress and psychiatric symptomatology — before COVID-19. Then, after the pandemic started, 1258 pregnant women completed the survey online. The participating women were largely from above-poverty-level backgrounds, and 95% of them were white.

The researchers found that women pregnant during the pandemic were more likely to experience symptoms of severe depression and anxiety, more negativity and less positivity, and greater changes in cognition and mood than women who were pregnant before the pandemic, even after they controlled for gestational age, income, history of psychiatric diagnoses, and education.

And clinically significant levels of anxiety and depression were more common in the COVID-era pregnancy group than in the pre-COVID group (10.9% vs 6.0%).

Rates of PTSD were slightly higher in the COVID-era group than in the pre-COVID group, but not significantly so, said study investigator Nicolas Berthelot, PhD, associate professor of nursing at Université du Québec à Trois-Rivière.

And although the Quebec study looked only at women who were pregnant, not those who had already given birth, Berthelot pointed to data showing that anxiety, depression, and traumatic events during pregnancy are the strongest predictors of postpartum depression.

"We, unfortunately, observed all the ingredients for postpartum depression in a considerable number of women who are pregnant during the COVID-19 pandemic," he told Medscape Medical News.

Berthelot’s study confirms data from China and Turkey, which showed that uncertainty, social isolation, and alterations in people's support networks are having a deleterious effect on pregnant women, potentially affecting their infants.

"It should be a public health priority to screen and to inquire about mother's distress," Berthelot said.

An Undercounted Epidemic

In its 2018 committee opinion on screening for perinatal depression — defined as depression during and up to 1 year after pregnancy — the American College of Obstetricians and Gynecologists (ACOG) recommends that women undergo a full mental health screening at least once during pregnancy.

In 2019, the US Preventive Services Task Force recommended that clinicians refer women who meet the criteria for postpartum depression to counseling, noting that one in seven new moms experience postpartum depression.

Despite these guidelines, clinicians still fail to screen one in five pregnant women and one in eight postpartum women, according to recent data from the US Centers for Disease Control and Prevention (CDC).

The Quebec study is a call to action for clinicians, said Caitlin Jago, MD, from the Department of Obstetrics, Gynecology and Newborn Care at the University of Ottawa in Canada, who was not involved with the study.

"It's always a balance of how much time you have with each visit," she told Medscape Medical News. "I like the idea of normalizing it. When you come to your prenatal visit, you get asked about blood pressure, baby moving, bleeding — all those things. But then, also, you get asked: How is your mood?"

Postpartum depression is more than baby blues, which are defined as resolving within 2 weeks. It's a severe mood disorder that, if left untreated, can be associated with poorer physical and mental health, an increase in self-harm behaviors in the mother, and interpersonal strife.

As Canon described it, "I would resort to very intense anger, where I would just say to my partner, 'I don't feel understood. I don't understand why you don't look at this the way I'm looking at this situation. Why is nobody validating that?'"

This left her feeling like a horrible person and ramped up her anxiety about being a good mother. Worst of all, she said she doesn't recognize herself in her thoughts and actions.

When she looks at Lucas, she sometimes thinks, "this is not what your mom normally is like." She considers herself "normally a very optimistic person." Then she adds, silently, "she's trying her best, bud."

Overwhelmed With Information

There are few data showing whether screenings for postpartum depression are happening during COVID-19, said Felipe Moretti, MD, also from the University of Ottawa. Most of the attention since the pandemic hit has focused on getting a handle on disease-control measures.

"The last 3 or 4 months, we've been overwhelmed with so much information, emails, articles," Moretti said, not to mention the webinars, statements, and recommendations from medical societies.

That's why he, Jago, and one of their colleagues wrote a commentary in Obstetrics & Gynecology about the mental health effects of isolation during pregnancy and COVID-19.

"We wanted to highlight that there is still a patient who comes to your office, who is very anxious," Moretti said. "We have to recognize that and support the patient, not only to try to protect them against any possible transmission, but also to understand that pregnancy is a very particular time in a woman's life."

Empathy, Understanding, and Referrals

The isolation of the COVID-19 era is essential for pandemic control. But it also runs counter to actions that protect against depression and anxiety: social support.

"Think about birth, of starting with the community and welcoming a baby into the world in the ideal setting," Jago said.

"There are a lot of benefits to community and of having support," she explained, including help with the baby that allows the mother to take a break or nap, commiseration, and not being alone with the difficulties of early parenthood. In contrast, isolation and a loss of control can be an issue from a mental health perspective during and after pregnancy.

This is where nurses, physicians, and other clinicians can intervene. When clinicians meet with pregnant women — either in person or virtually — they can offer perspective, Berthelot told Medscape Medical News.

"Clinicians should be sure to normalize the mother's reaction, just to be empathic," he said. "Reflect that it's normal to be so anxious in such circumstances."

COVID-19 FAQs on the ACOG website suggest that clinicians connect women to mental health resources in their communities, and offer links to reputable organizations, including Lifeline4Moms' Perinatal Mental Health Toolkit and Perinatal Psychiatric Access Programs, and support groups.

Access to mental healthcare is far from universal, especially for new moms, said Christopher Zahn, MD, vice president of practice activities at ACOG. But he said he’s hopeful that loosening the restrictions on telehealth for mental healthcare during the pandemic will lessen that gap permanently.

Telehealth has "phenomenal potential" when it comes to mental health issues, he explained. "The ability of a patient to participate in a behavioral health counseling session is likely markedly improved if she can be home where the baby is and in a supportive environment."

"It's Not a Bad Thing to Seek Treatment"

The day after she spoke with Medscape Medical News, Canon had an appointment to talk about her mental health with her obstetrician. She received an official diagnosis of postpartum depression and anxiety, as well as mild depression, and has started taking medication. She also started seeing a counselor who focuses on postpartum mental health.

Plus, she's begun knitting back together the support system that frayed with the emergence of COVID-19. In fact, it was her mom friends who experienced postpartum depression during non-COVID-19 times who encouraged her to reach out for help.

"They validated that, 'yes, you are under a very high level of stress that is unusual on top of the usual'" new-parent stress, she said of her friends. They told her, "it's not a bad thing to seek treatment."

American College of Obstetricians and Gynecologists (ACOG) 2020 Annual Meeting.

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