Navigating Pregnancy with a Mental Illness

Pregnancy can be a very exciting and rewarding time in a woman’s life, but for the 1 in 5 women who experience a mental illness—including anxiety, depression, bipolar disorder and other mental health conditions—it might also bring new challenges.

We talked to Mary Kimmel, MD, medical director of UNC’s Perinatal Psychiatry Inpatient Unit about pregnancy, mental illness and the decisions women can make to stay healthy.

How is pregnancy different for women with mental illnesses?

Pregnancy for everyone is a complex mix of physical and mental changes; it’s a continual balancing act. Your body and hormones are changing, and there are also a lot of social and psychological changes, such as considering what it means to become a parent. Those are things that everyone is dealing with, but if you have a history of mental illness such as depression or anxiety, the biological and social factors associated with pregnancy can certainly increase the risk of having an episode. In addition, stopping medications, especially abruptly, for some women may lead to episodes.

Women with a history of depression are also at a higher risk of postpartum depression. For some women, a contributing factor to depression may be a sensitivity to a change in estrogen. There’s a major estrogen change that occurs at delivery, and that can certainly trigger an episode after pregnancy. There are many other changes occurring such as in the immune system that may make certain women more likely to have postpartum depression.

What should women consider when assessing whether to keep taking medications during pregnancy?

It’s a huge decision for a woman to make with her care team. The difficulty in this decision is that there are many factors, and for each woman it’s different. If you have had a patient who has had severe depression in the past and is on medication, that’s going to be a different conversation than someone who might have mild depression and has relied on therapy over medication.

With each medication, you really have to take a broader view. I often liken it to taking any medication for any condition. For hypertension, for example, there are certain medications you might not use during pregnancy, but we still want to treat the hypertension. You want to look into how medications might affect the baby, but I think we always want to make sure we take into consideration that not taking medicine has risks as well. If someone has been very stable in terms of her bipolar disorder taking lithium, but when she’s not taking lithium she has suicidal thoughts, severe depression or does things she doesn’t normally do, not taking medication can be a significant risk to mom and baby.

Depression can have a negative impact on the baby’s development. We have evidence that depression is associated with preterm delivery and the need for C-sections, and it can increase the child’s risk for disorders such as depression, psychosis or attention-deficit hyperactivity disorder. I always say that wanting to be mindful, because we don’t want women to feel shame, guilt or feel like they’re causing harm to their child. But those things could happen because they have a medical condition, and that’s not their fault.

Whatever decision is made, women might need to be monitored closely because they might have higher needs given all the stressors of pregnancy, both biological and psychological.

When should someone consider delaying pregnancy due to mental illness concerns or choose not to have children biologically?

I think that’s such a personal choice. In a perfect world, every person would be able to have preconception counseling and plan out medication changes. Ideally, you want mom to feel that she’s at a really great place mentally. But that doesn’t always happen, and that’s OK. I think it’s important to get the message out that for women who have mental illness, having children is an option they still have. They might need to work with their doctors a bit, but the decision not to have kids isn’t already decided just because they have bipolar disorder, for example.

Do you have any tips for women on how to navigate pregnancy with a mental illness and stay healthy?

That’s a great question, and it’s one that I think we need to continue to work on. When I do visits with women before they get pregnant, a big part of that is talking about medication, what we know about genetics and mental illness, their own history, and what their experience has been in terms of mental health episodes and what has helped them.

It’s also really helpful to think about what we already know about pregnancy and how a woman with mental illness might cope with that. What are the needs that they’ve identified that have helped them stay healthy? For example, sleep can be very disrupted, particularly later in pregnancy and postpartum. And so you have to work with each woman to find out how sensitive she is to decreased sleep and based on that, make a plan and start to think ahead of time. Some women have told me that making sure that they can go for a walk and exercise is really key. It’s about making sure each woman can come up with a plan to feel good, and include her social supports whenever possible. But it’s also important to think about how pregnancy and postpartum might require adjustments in those plans so that the woman can stay healthy.

I think we as health-care providers should ensure all women who want to have a space to talk about preparations for pregnancy. Women should be able to feel comfortable talking to their OB/GYNs, internal medicine and family physicians, and mental health providers about their reproductive goals and concerns in relation to their mental health.

Thinking about getting pregnant? Talk to your doctor. If you don’t have one, find one near you.