Out of the Shadows

Fifteen percent of pregnant women experience depression. A CU professor seeks solutions. 

Karen Trojanowski was just eight weeks into her pregnancy when her exhilaration about having a second child was overcome by melancholy and second thoughts. She lacked energy and struggled to get out of bed in the morning.

“Things like taking a shower, pouring cereal and making coffee felt like insurmountable tasks — I wasn’t me,” she recalls.

Despite her downward spiral, she was reluctant to tell friends and family. “New moms are supposed to be really happy about the new life they’re bringing into the world. Nobody wants to hear how depressed you are.”

But thanks to the work of Sona Dimidijan, associate professor in CU’s psychology and neuroscience department, she learned she was far from alone.

Trojanowski, 32, is among the 15 percent of women who experience clinically significant depression during pregnancy — an insidious, oft-overlooked condition that can have lasting impacts on both mother and child. Among women with a previous history of mental health issues, the prevalence doubles with more than one in three sinking into a relapse during pregnancy, studies show.

Yet while the topic of postpartum depression has garnered increased interest among both researchers and the media in recent years, antenatal [during pregnancy] depression remains stigmatized and is seldom the subject of research, Dimidjian says. For the past three years, she has been working to fill the research gap, spearheading several federally funded studies on non-drug approaches to addressing or preventing antenatal depression, including an eight-week mindfulness-based meditation program run in collaboration with Kaiser Permanente Colorado.

“It was life changing for me,” says Trojanowski, a Kaiser patient who was referred to Dimidjian’s Mindfulness and Pregnancy Study during her 14th week of pregnancy. “The techniques she taught us made coping with things so much easier.”

The program is rooted in the work of Jon Kabat-Zinn, who founded the first mindfulness-based stress reduction program in Massachusetts in 1979 and describes mindfulness as “paying attention in a particular kind of way — on purpose, in the present moment and nonjudgmentally.”

Up to 10 women meet weekly for two hours, doing yoga, meditating, sharing stories and doing exercises that teach them to practice mindfulness while eating, stretching, breathing and walking. Over time, they learn to apply the skills of awareness and compassion to their own thoughts and feelings, particularly the ones that have been connected with feeling depressed, Dimidjian says.

“Women often have a tape that plays in their mind — one that says, ‘I’m not good at this. Nothing ever works out for me,’ ” she says. “They learn to listen to it but don’t get pulled into the story anymore. They learn that thoughts are not facts.”

Dimidjian’s research comes at a time when prescription drug use is at an all-time high among pregnant women, largely because of a rapid increase in the number of women taking antidepressants, according to a study published in June in the American Journal of Obstetrics and Gynecology. More than 7.5 percent of pregnant women take antidepressants, many of which have questionable safety profiles [assessment of the drug’s risks], the study reports. On the flip side, Dimidjian notes, many women opt to do nothing at all.

“Women will say, ‘Let me just get to the end of this pregnancy,’ ” she says. “But that also comes with risks. To give them a choice between taking medication and doing nothing is not fair. We need to expand the array of options.”

Inaction carries its own series of risks for mom and fetus.

Depressed mothers are less likely to attend prenatal visits or take their prenatal vitamins and more likely to smoke, drink and use drugs, according to a 2009 paper by Dr. Ellen Markus and Dr. Laura Miller in the Journal of Clinical Psychiatry. As a result, their children are more likely to come early, and/or be low birth weight.

Because moms who suffer depression during pregnancy are more likely to suffer postpartum depression, bonding with the baby can be difficult.

And a small but growing body of evidence suggests that maternal depression may also impact a child’s own neurobehavioral development. Some research suggests babies of depressed mothers tend to be born with hormone profiles similar to mom’s (with elevated levels of the stress hormones cortisol and epinephrine and reduced levels of the neurotransmitter dopamine), according to the authors of the 2009 study. They also tend to be more temperamental as infants.

And they may be more vulnerable to emotional and behavioral problems as much as 10 years later, perhaps due to biochemical changes in the womb that impacted the development of their endocrine system.

“Untreated perinatal psychiatric illness is not a benign condition for mother or child,” the authors wrote.

Dimidjian went on her first meditation retreat with her dad during high school and has considered contemplative practices like meditation and yoga an integral part of her life and work ever since. She turned to these practices as she navigated her own pregnancy and the home birth of her daughter in Seattle nine years ago.

She also utilized them as she pursued her doctorate at the University of Washington (graduating in 2005), leading mindfulness-based cognitive therapy courses for those suffering from depression and conducting research on how non-pharmacological approaches stacked up to prescription drugs.

It was there that she got the idea to further sharpen her research focus.

“I had one woman in a class who came to me one day and said, ‘This would have been really helpful to have when I was pregnant with my daughter,’” she recalls. “A bell went off in my head.”

Dimidjian makes no judgment on whether women should take medication for depression or not. But she does stress that the decision should not be made lightly or avoided.

“People always need to understand the risks and benefits and look at what the research indicates,” Dimidjian says. “But what is complicated about pregnancy is that you are balancing the risks and benefits of you and your baby.”

Data on the safety of antidepressants during pregnancy is mixed with some studies suggesting that paroxetine, known as Paxil, is associated with an increased risk of cardiac defects, while some scientific reviews have found no link.

Meanwhile, a groundbreaking 2010 study in the Journal of the American Medical Association called into question the efficacy of such drugs. The paper, which Dimidjian contributed to, concluded that while antidepressants work for patients with “very severe depression” the benefit may be “minimal or non-existent, on average, in patients with mild or moderate symptoms.”

Armed with more than $450,000 in grants from the National Institute of Mental Health as well as support from CU-Boulder, Dimidjian has initiated a half-dozen research projects, including behavioral therapy options for teen moms and online courses to help practitioners better assist pregnant patients. All of these projects aim to arm new mothers with tools they can carry with them through life.

“Some of the earlier research my colleagues and I conducted suggests that psychotherapy has an enduring effect on people, so even after you finish psychotherapy you are protected from future depression,” she says.

Dimidjian is quick to point out that we don’t know yet whether the mindfulness program will be helpful in preventing depression during pregnancy and postpartum, as the study is still ongoing.

In the meantime, Trojanowski says her life has already been changed.

“She taught us you don’t need to have any judgment or guilt about normal human emotions you have,” says Trojanowski, who gave birth to a healthy baby boy on Dec. 17, 2009, and continues to use the skills learned in the class. “I could just say, ‘I am really overwhelmed about this baby and that is OK.’ ”

“Sona knows her stuff, and you can tell she cares so much about her work. That makes a big difference when you are going through something this hard.”