The Emotional Scars from a C-Section

http://www.chicagotribune.com/lifestyles/sc-psychological-effects-c-section-family-0606-20170518-story.html

For many women childbirth is a happy, fulfilling and empowering experience. For others it can be one of the most traumatic events of their lives. It can bring them a sense of accomplishment or failure, joy or trauma.

Emotional reactions and adjustments to a cesarean birth vary widely. Some women recover quickly from a cesarean and see it as just one more step in their journey as a mother. Other women can experience sadness, disappointment, loss of self-esteem, guilt, and anger, especially in the cases of emergency C-sections or after a long and painful labor, had general anesthesia, or were separated from their newborns after the birth. Some common perceptions are that they were not involved in the decision-making process regarding their care, were submitted to unwanted, invasive and painful interventions, perceived care as inadequate or unnecessary. A lot of women even see it as physical assault and a form of institutional violence (or “obstetric violence”): a form of violation against women’s rights, appropriation of the body and reproductive processes of women by health personnel, which is expressed as dehumanized treatment, an abuse of medication, and to convert the natural processes into pathological ones, bringing with it.

A negative experience of a primary cesarean birth may last years and affect a woman’s future pregnancies. It can be so terrifying that some women choose to  have a cesarean in a future pregnancy rather than experience labor again or even to avoid future children altogether.

A U.S. survey of women’s first births in 2005 revealed that women who had a cesarean birth were more likely to feel frightened, helpless, and overwhelmed and less likely to feel capable, confident, powerful, and unafraid while giving birth. “Assaulted, violated, voiceless, out of control” are some of the things they report.

Several women experience a feeling of loss, grief, personal failure, distress, anger, powerlessness, negative impact on self-esteem and self-confidence as a mother. There is at times a delay in bonding and attachment, the mother is still recovering from anesthesia or is in physical pain, or is taking a lot of pain medications; sometimes breastfeeding can be more challenging for the first few hours or days. And today we see an overwhelming pressure to breastfeed (which is cyclical, a few decades ago there was not that social expectation or pressure to breastfeed). There can be long term effects on spousal relationship and the new mother’s ability to take care of the baby.

C-section is considered a risk factor for PTSD and it is said to be a consequence from a high level of anxiety about a situation which she has no control of. Increased anxiety during the third trimester greatly contributes to increase the risk.

They experience childbirth as a traumatic event, 6% meeting criteria for PTSD in the PP period (their psychological distress is similar to those experienced by war victims and natural disasters, for example). The stress response symptoms include:

• Intrusive thoughts and re-experiencing of the event in flashbacks or nightmares.
• Avoidance of places or people that might trigger a reminder of the event. Symbolic or real reminders of the event bring out intense feelings of distress.
• Numbing of emotions and general responsiveness.
• A sense of hyper vigilance or increased arousal.
• Disturbed sleep, anxiety, lack of concentration, feeling irritable or angry.
• Nightmares and flashbacks
• Difficulties with bonding and attachment
• Sexual issues with partner
• Depression

 PTSD as a consequence of childbirth is vastly understudied and all the data we have are from case reports.

We’re seeing an increasing trend North America, where the c-section rates increased from 10% to 30% in the past 25 years. (As a reference, the WHO recommends between 10-15 C-sections per 100 live births).

It is important to notice that traumatic experiences related to childbirth can happen both ways, with vaginal and cesarean deliveries, but we have evidence that vaginal deliveries typically imply superior physical health, which leads to better quality of life in general. 

Elective C-sections are culturally accepted and are actually the norm in a lot of places and there is a reverse phenomenon in Latin America, for example, where we see rates of up to 50% of C-sections, and numbers close to 70% among higher socioeconomic women with higher educational level and private insurance who opt for an elective CS.

A lot of those women fear complications from a vaginal delivery, like limb fractures, hypoxia leading to speech delays and paralysis etc. Elective cesarean section exemplifies the avoidance behavior typical of PTSD. A lot of them have a higher need to be in control and chose an elective procedure, sometimes influenced by bad experiences reported by their mothers or sisters or friends.

There are several factors to consider that will shape a woman’s feelings about childbirth: the reason for which the cesarean was performed; her cultural values; her beliefs and expectations of her birth experience; prior traumatic events in her life (like sexual trauma or domestic violence); the social support available to her during pregnancy and childbirth; her own perception of how she was treated by her caregivers; her involvement in making decisions regarding her care; and her personal sense of control of her birth. 

So it is really no one’s job to judge the woman’s choice and her rights over her body, or the way she experiences childbirth one way or another. This is one of the most important moments in a woman’s life and each decision and outcome should be individualized and should take into account the woman's prior experiences and perceptions, expectations, control issues, cognitive biases, medical comorbidities, psychological factors and support systems.

What to do?

First of all, it is important to help the woman understand that a normal delivery is not a synonym of vaginal delivery.

A good childbirth outcome is a healthy mom and a healthy baby and everything else is secondary. Some things will be out of our control and that is fine. A delivery may last a few hours, sometimes a little over a day. Motherhood is a lot more than giving birth. It starts with a nine-month experience and it lasts for the rest of your life.

Support groups or new mothers groups can help healing and change perceptions and cognitions.

Promote bonding time and skin to skin contact immediately following the procedure. There’s a movement for humanized C-sections, which limits drug exposure and procedures to the minimum necessary and promotes bonding/ attachment and encourages breastfeeding almost immediately after a C-section.

Lastly, recognize the tremendous power that exists on a C-section scar. If anything, it should be empowering and a source of pride. 

Race, PTSD and Urban Violence

"From elementary school through middle school, I can't remember how many times the White kids asked if they could touch my hair. I'm not kidding when I say it happened pretty much once a week at least. At first, it didn't bother me. But eventually I felt like an exhibit in a petting zoo. And I didn't have the vocabulary to explain to them that it was really weird that they kept asking to touch my hair all the time. See, I was a pretty shy kid. I was the only Black one, I was overweight, and I'd moved three times before I turned 10. So, rather than tell the White kids that no, they couldn't rummage through my hair, I just said yes and sat there quietly while they marveled at how my hair felt.", says Brian Crooks on his Chicago Tribune's essay "What it's like to be black in Naperville, America".
And he continues, "I've never had a Black boss. I played football from middle school through senior year of high school and only had one Black coach in that whole time. Not just head coaches, I'm talking about assistants and position coaches. I've had two Black teachers in my entire life. One was for my Harlem Renaissance class, and one was for my sign language class. I've never been to a Black doctor, or a Black dentist. I've never been pulled over by a Black police officer. What I'm trying to explain is that, in 31 years, I've seen three Black people in a position of authority.".

While the theme of racial discrimination is somewhat outside the scope of this blog, July is National Minority Mental Health Month and I think, more than ever, that it's crucial to talk about it. Racial attacks and protests have become routine on media vehicles. Being a white, green-eyed woman has always put me in a rather privileged condition and I can honestly say I never experienced racism first hand in America despite my Latino background. Having the letters "MD" after my name certainly helped. 
But, in my profession, I get to feel the pain of people who didn't have the same "luck" to receive fair, equal treatment; who didn't get to have the benefit of the doubt; who have to teach their children to protect themselves from the very ones who were supposed to protect them; who were denied opportunities simply because of the color of their skin. Day after day, I see the tears, struggles and challenges of those black women with mental illness-- a triple minority of an unjust society. 

"But what does one's complexion have to do with mental health?", you may ask.
Racial discrimination is closely related to trauma, and can even cause Post-Traumatic Stress Disorder (PTSD).

It is, indeed, one of the greatest misconceptions about PTSD, that it’s limited to wars and combat

zones or to a life-threatening event.  The reality is that one can have PTSD simply from witnessing a 

traumatic event of any nature or even if a loved one has suffered a traumatic event. (A 2014 

study  from the University of Miami showed that almost 50% of women had PTSD 

symptoms after Hurricane Katrina, for example).

The DSM- 5 even broadened the definition to include a person who learns about a traumatic event 

that happened to a close family member or a close friend, and also stress due to a prolonged 

exposure to an aversive situation.


Well, racism itself may be a traumatic experience!

Watching repeated acts of violence is a source of stress and trauma in Black people, particularly


black women. Research has shown that stress and trauma from racially motivated events create 

reactions that can be identical to PTSD.

If I am African American and I see this pattern on television I may identify myself with the entire 

situation. But trauma extends well beyond what we see on cable news and social media. It is an 

everyday challenge that people face with institutionalized racism leading to what some mental health

professionals call RACE-BASED TRAUMA. Racism continues to be a daily part of American

culture and to have an overwhelming impact on the oppressed.

 In the case of racial discrimination, we’re not talking about an issue that’s been around for

years or decades, but centuries. It’s people who were kidnapped and thrown in the bowels of slave 

ships and submitted to forced labor and torture. Later on, that was translated into exclusion from

educational, social and health resources causing disparities that are linked to mental health. 

It's important to have that in mind in order to understand one's perceptions and society's 

(mis)perceptions.


Victims can become distressed by things that are not typically worrisome to white people, for

example. "Microaggressions, or routine slights, can trigger stress reactions: it’s the black man 

followed by a security guard at the department store or the white woman clutching her purse when a 

black man enters the elevator", says Dr. Carl Bell, from the University of Illinois at Chicago.


What is PTSD?

It’s a severe and chronic condition that may occur in the aftermath of a traumatic event.

Symptoms usually develop within the first 3 months after the trauma and the diagnosis is made

if symptoms persist for over a month. Women are more affected than men.

Symptoms include depression, anxiety, flashbacks, fear, intrusive thoughts about the traumatic event, recurrent nightmares (leading to sleep difficulties), anger, apathy, inability to get pleasure, impaired concentration. It may also cause hypervigilance, hyperarousal and an exaggerated startle response (certain sounds or smells make the person relive the trauma) as well as avoidance behaviors leading to social isolation-- the person becomes more seclusive and uninterested, fears getting out of the house, or may change the route they normally take to avoid walking by a police officer or the street corner etc.

PTSD may have short-term or long-term impact. How long? The answer may be shocking:

Studies suggest that trauma is intergenerational and inherited, with memories passed along

through the DNA! That is shown, for example, in several interesting studies with families of

Holocaust survivors, or more recent studies with victims of the 9/11 attacks, that showed that

pregnant women who experienced the bombings passed on biological signs to their babies.

There is another study from Columbia University that revealed that one-third of NYC’s school

children suffered mental health disorders following the WTC attacks.

We must ensure black women have the ability and the right to raise their children in a healthy

environment. It is a matter of Reproductive Justice.



 African-Americans are 20 % more likely to report serious psychological distress than adult whites; 

they are also more likely to have feelings of sadness, hopelessness, worthlessness and more likely to 

attempt suicide (8% vs 6%).

The National Survey of American Life found that AA have a prevalence of PTSD around 9% (vs

6% for Non-Hispanic Whites). In certain populations, this number can get much higher. Inner city

studies in high crime zones of Detroit and Baltimore show something like 30%, which is

comparable to war zones in Vietnam, Iraq and Afghanistan.

AA usually have more serious traumatic events and are more likely to experience child abuse,

sexual trauma, and to witness domestic violence. An Emory study showed that almost 90% AA 

living in impoverished urban areas reported some form of trauma.

A UMichigan study from 2011 with 1600 women (~half AA) showed that the prevalence of PTSD

was 4 times higher among AA, but they were also less likely to get treatment. They also noted

the correlation of PTSD and pregnancy complications, including preterm birth (due to increased

cortisol levels causing placental abnormalities).

 AA are under-represented in outpatient settings but over-represented in inpatient treatment.

They are also over-represented in jails: AA and Hispanics comprise 30% of the US population but

account for almost 60% of the prison population. They’re also 14% of drug users but 37% of

drug arrests.

Police are also at an increased risk for violent behaviors as a consequence of stress. The uncertainty 

about whether they’ll come home alive to their families at the end of their shifts and the pressure 

from being at the front lines may cause depression, and anxiety, and burnout. Stigma is particularly 

significant in this population and a lot of them won’t disclose their feelings and struggles with fears 

of being perceived as weak, or even of losing their jobs.

As a consequence, lot of them will use alcohol or drugs to self-medicate their symptoms, making the

 symptoms much worse and more difficult to treat and contributing to poor judgement and 

inappropriate defenses.

This attitude is thankfully starting to change but the process is really slow: There’s still something 

between 120-140 documented suicides per year among police officers and a very high prevalence of 

PTSD (1 in 8).

What can be done?

We need to understand this phenomenon as a  Public Health Crisis: there are still a lot of underserved 

areas and significant lack of resources to treat mental illness. AA physicians are 5 times more likely 

to treat AA patients but the vast majority of mental health professionals are white. 

Some people have difficulty expressing their feelings and experiences thinking they won’t be fully 

understood.  It’s important to make mental health professionals aware and

teach them how to address this problem and how to actively screen specifically for racial-based

trauma when assessing the trauma or abuse history.

Despite the growing evidence that PTSD is related to racial discrimination, little is being done to

address this problem. Hospital trauma centers are well-equipped to treat the physical injuries

from the trauma, but not its emotional and psychological components.


 We have a number of evidence-based interventions and treatment models for trauma but not

specifically for racial trauma so more studies should be done and more attention should be paid

to this matter.

 Also it’s important to develop interventions to decrease violent crime and increase access to

mental health treatment and to work on decreasing the stigma that surrounds mental illness.

Below is a panel that aired last week on the morning news about the theme of Race, Trauma and Urban Violence:

Treating PMDD without Medications

In an earlier post, we defined PMS and PMDD, and briefly discussed their etiology. Here, we will look into the treatment of PMS/PMDD. While there are many pharmacologic treatments of PMDD, non-pharmacologic approaches may often be considered first. Indeed, just like mild to moderate hypertension is often first treated with lifestyle modifications like exercise and a low-sodium diet, PMS/PMDD is often improved with the following lifestyle modifications:

• regular aerobic exercise 4-5 times a week
• good sleep hygiene, i.e., establishing a consistent sleep schedule 
• dietary changes: limiting alcohol, caffeine, salt, chocolate, red meat, and eating smaller, more frequent meals with complex carbohydrates 
• avoiding stressful activities/ situations during the premenstrual period 

These interventions can often be started in the 2 months (or 2 menstrual cycles) during which a patient is completing the daily symptom ratings needed to confirm a diagnosis of PMDD, and for some women, they may be enough to control their symptoms. 

We have had patients ask us about whether certain vitamins and dietary supplements (like vitamin B6, calcium, magnesium, chasteberry, soy) are helpful for PMS/ PMDD symptoms. For most of these supplements, there is no consistent evidence from research showing that they are are better than placebo, and some may carry risks:   

• vitamin B6; at high doses may lead to peripheral neuropathy and there is only low-quality evidence that it may help with PMDD symptoms, so it is not recommended
• calcium supplementation has benefits beyond those on mood symptoms, but high doses may increase the risk of heart disease 
• soy was found to have reduced physical symptoms but not mood symptoms in women with PMS/ PMDD
• chasteberry (vitex agnus-castus) may also be more helpful for the physical symptoms rather than mood symptoms of PMDD

Some other therapeutic modalities that have been considered in the treatment of PMDD include group or individual psychotherapy, acupuncture, yoga, and bright light therapy. There is little research evidence available for most of these treatments, but bright light therapy in particular has shown some promise, and psychotherapy has shown promise but with small effect sizes. 

Can I take antidepressants while breastfeeding?

Given the high prevalence of postpartum depression in the US (often cited as between 10-15% of postpartum women), and the myriad benefits of breastfeeding for both baby and mother, it's not a surprise that women in our clinic often ask about the safety of breastfeeding while taking antidepressants.

To answer this question, it's important to note that concentrations of psychotropics in breast milk have been found to vary widely. The amount of a psychotropic medication that an infant is exposed to depends on multiple factors, including dosage of the drug, rate of maternal drug metabolism, and frequency and timing of feedings. In the past, a technique called "pumping and dumping" was recommended. However, that has been found to be unnecessary; you can read more about why it is not a good idea to pump and dump in this post.

One of the main ways researchers have investigated antidepressant safety in lactation has been to look at infant plasma (i.e., blood) concentrations. The chart below from Berle and Spigset (2011) shows that of the most commonly prescribed SSRIs, sertraline and paroxetine have the lowest infant plasma concentrations: 

click image to enlarge

Duloxetine (an SNRI) and bupropion (an NDRI) also had undetectable infant plasma levels, but there were fewer mother/ infant pairs studied. The SSRIs fluoxetine and citalopram had higher infant plasma concentrations; it's generally recommended that these be used with caution or avoided during breastfeeding. However, if a woman has been stable on these medications prior to and/ or during pregnancy, it may be fine to continue them during breastfeeding.

Another way to evaluate the safety of medications in lactation has been to look at adverse events. Scalia and Wisner did an extensive literature search to create clinical guidelines for antidepressant use during breastfeeding. They found that sertraline, paroxetine, and nortriptyline are the most evidence-based antidepressants in lactation, because levels are usually undetectable in infants, there have been no reports of short term adverse effects, and findings about them have been consistent among different laboratories. They also created the following decision-tree:

click image to enlarge

As you can see, sertraline and paroxetine are generally considered to be the first-line agents if pharmacological treatment is necessary in lactation. Sertraline is often preferred over paroxetine because of paroxetine's greater anticholinergic side effects (including dry mouth, blurred vision, sedation, constipation, and memory impairment) and its shorter half life/ more significant discontinuation syndrome (marked by flu-like symptoms, insomnia, nausea, imbalance, and anxiety).

Happy Mother's Day.

I've always thought that Mother's Day should be celebrated by ALL women!
For all who haven't had children-- whether by choice or circumstances-- this one's for you:

"Even if she has never birthed a child,
Even if she never comes to do so
Every woman is a mother!
First, of her dolls; then, of her little siblings;
Getting married, she's her husband's mother
before mothering their children.

If childless, she will become an adoptive mother and will give someone else's spawn all her love: nieces and nephews, children of friends, students, animals, a good cause.

How many women weren't chosen to mother
their own children but ended up mothering their own mothers? Or fathers? Grandparents?

Motherhood cannot be suppressed.
Just like a water flow that gets blocked by a stone, it will surely find its way out.

During war, they care for the injured,
even if they wave a different flag
or wear a different uniform.

Motherhood has no borders, colors or preferences.
It's one of those few things that are
sufficient in themselves.

Every woman is a mother!"

On Antipsychotics in Pregnancy and the Problem of Confounding

Second-generation antipsychotics, also known as atypical antipsychotics, are frequently used in psychiatry, prescribed not just for psychotic disorders, but also for treatment of bipolar disorder, and for augmentation of depression or OCD treatment. Studies have shown that there is a very high risk of relapse of psychiatric disorders in pregnancy--for example, women with a history of bipolar disorder who discontinue their medications while pregnant have an 85% chance of recurrence of a mood episode while pregnant, compared to a 37% chance of recurrence when continuing to take their medications. Thus, it's important for women who are taking antipsychotics prior to pregnancy to know about the risks and benefits of continuing these medications while pregnant. Here we will focus on a recent article which looked at how taking antipsychotics in pregnancy may affect maternal and perinatal outcomes.

A large population-based cohort study looked at the question of whether or not antipsychotics affected certain maternal and perinatal health outcomes. It looked at all women who had delivered between April 2003 and December 2012 in Ontario, Canada. Data were collected from multiple linked healthcare administrative databases, which included information about medications women were taking, inpatient and outpatient claims, and demographic information. Antipsychotic exposure was defined as at least 2 consecutive filled prescriptions for an antipsychotic between conception and delivery. There were a total of 41,523 women in the study. Of these women, 1,209 were prescribed an antipsychotic, and 40,314 were not. The women were compared in 2 ways--there was an unmatched cohort, and a matched cohort. In the unmatched cohort, maternal and perinatal outcomes between women who were prescribed an antipsychotic and those who were not were compared directly. In the matched cohort, 1,021 women who were prescribed antipsychotics were matched with 1,021 women who were not, using something called a high dimensional propensity score (HDPS) algorithm.

What is a high dimensional propensity score (HDPS), you ask? It's a method commonly used in pharmaco-epidemiological studies to create less biased estimates of treatment effects. In other words, these epidemiological studies are subject to many confounders--things like age, ethnicity, multiple gestations, multi-parity, pre-existing medical problems like hypertension, diabetes, renal disease, smoking, drug use, other medications, and number of healthcare visits. Many of these confounders are observed, or known (e.g., it's easy to determine age from the databases). Researchers sometimes create a propensity score, which is a summary confounding score. The HDPS algorithm attempts to further minimize residual confounding by also incorporating proxy variables (healthcare diagnoses, procedures, and drug claims), which, when combined, can account for important confounders that are unobserved. This is extremely important, because without controlling for the unobserved confounders, we cannot know if a certain maternal or perinatal outcome is due to medication exposure, or to something else. In fact, women who take medications during pregnancy are often very different from women who do not; they tend to have more severe illness with higher risk of relapse...without controlling for this, we won't know if an outcome is related to a woman's underlying illness (severity), or to the medication she took. And this is how the HDPS is very useful.

Back to the study: the researchers looked at the following maternal medical outcomes: gestational diabetes, hypertensive disorders of pregnancy (gestational hypertension, pre-eclampsia, eclampsia), and venous thromboembolism (VTE), and the following perinatal outcomes: preterm birth (<37 weeks gestation), and extremes of newborn weight (a birth weight <3rd percentile or >97th percentile for the same sex and gestational age). What the researchers found illustrates not only the possible effects of antipsychotics on pregnancy outcomes, but also the importance of controlling for confounding. In terms of maternal outcomes in the matched cohort (where HDPS was used), there were no differences in terms of gestational diabetes, hypertensive disorders of pregnancy, and VTE between women who took antipsychotics in pregnancy and those who did not. However, in the unmatched cohort, there was an increased risk of gestational diabetes and hypertensive disorders in the antipsychotic group. In terms of perinatal outcomes, there were similar differences between the matched and unmatched cohorts. In the matched cohort, the 2 groups had no differences in preterm birth, and extremes of newborn weight. However, in the unmatched cohort without HDPS, the infants exposed to antipsychotics had an increased risk of preterm birth and weight >97th percentile. The study thus shows that when these antipsychotic users were matched with non-users who had similar pre-pregnancy morbidity (e.g., weight,  other medical conditions, diagnoses, and other variables), then the risk was about the same for both groups. Here is an illustration of the potential magnitude of bias that is created by not controlling for confounding variables. However, it also showed that the absolute rates of adverse maternal and perinatal outcomes in antipsychotic users were higher than those in the general population. Thus, for women who require antipsychotics during pregnancy, it's imperative to closely monitor their health before and during pregnancy, paying close attention to diabetes, hypertension, preterm birth and fetal growth.

A Mother's Love- Infertility and Pregnancy Loss

(photo: Sher Institutes)

One could argue that there's nothing more intense than a mother's love, long before her child is even born.

This week we celebrate the National Infertility Awareness Week, a movement that started in 1989.  My interest in Women’s Mental Health and Reproductive Psychiatry began a little less than two decades later, when my husband and I were diagnosed with infertility. Suddenly, this two-physician couple assumed the patient role, with all its emotional and physical pains, challenges and distress. Denial, anger, shock, grief and disbelief, depression and anxiety all followed. A terrifying sense of loss of control marked that turbulent, draining road.

Relationships suffer- marital discord arises, friendships get affected, one’s social life may vanish. Diminished quality of life, complicated grief, major depressive disorder, anxiety disorders, and post-traumatic stress disorder may develop.

Infertility is the inability to achieve pregnancy for one year (or six months if over 35) or being unable to carry a pregnancy to live birth. It is quite common, affecting approximately 1 in 8 couples. One third of infertility is attributed to the female partner, 1/3 attributed to the male partner and 1/3 is unexplained or results from a combination of problems in both partners 

According to Dr. John Rapisarda, Reproductive Endocrinologist and Vice President of Fertility Centers of Illinois, “The most common causes of infertility in women are Polycystic Ovarian Syndrome (PCOS) and other ovulation disorders, blockage of the Fallopian tubes and diminished ovarian reserve while the most common causes of infertility in men are hormonal imbalances, low sperm count, abnormal sperm shape, and poor sperm movement (motility)”.

The frustration, pressure and uncertainty that surround infertility have been shown to cause significant mental stress, particularly anxiety and depression. In addition to that, fertility treatment often involves invasive, time-consuming tests and procedures, and complicated medication schedules that further add to the stress of the diagnosis. That is commonly accompanied by feelings of grief, failure, and guilt. 

The prevalence of depressive symptoms among infertile women has been reported as being twiceas high as that of fertile women. Further, levels of distress and anxiety in infertile women persist over extended periods of time, tending to increase as treatment intensifies and the duration of treatment lengthens. Several factors are involved: 

·         The drugs and hormones that are commonly used to treat infertility often cause a myriad of psychological side effects. Clomiphene citrate (Clomid, Serophene), frequently prescribed because it improves ovulation and increases sperm production, may cause anxiety, sleep interruptions, mood swings, and irritability; Oral contraceptives, often part of the treatment protocols, have higher doses of progesterone, which has been associated with increased depression. GnRH Agonists (Leuprolide/Lupron) are associated with depression, emotional lability, and changes in libido; Steroids and immunosuppresants may also cause depression, mania, anxiety and psychosis. 

·         Financial Difficulties: insurance coverage varies widely, and infertility treatments can be financially draining while still offering disappointing success rates in a lot of cases;

·         Religious ambivalence: fertility treatment goes against several religious doctrines, further adding to feelings of guilt and anxiety or social criticism.

·         Social aspects: patients may find it very distressing to socialize with their friends who are pregnant or have children. They may feel guilty for not being able to fully rejoice with them and end up opting to exclude them from their lives, becoming increasingly withdrawn and seclusive, with fewer support systems at a time when social support could be so helpful.

   

 While it is clear that infertility can affect mental health, researchers are not sure if mental health can affect fertility. Some studies have proposed that high levels of depression, anxiety, and stress can affect some of the hormones that regulate ovulation. The hormonal impact on mood and its correlation with pre-menstrual syndrome, pre-menstrual dysphoric disorder, pregnancy and postpartum depression, and menopause are well-established. The psychological impact of the hormones used in fertility treatments, however, hasn’t been as widely studied.

A Japanese study with 83 women undergoing fertility treatment showed that the rates of anxiety and depression were higher as the age increased. They also found that patients who underwent infertility treatment were more likely to have higher depression scores compared to patients who had not undergone treatment. Additionally, patients whose husbands were infertile had significantly lower total mood and anxiety scores than those whose husbands were not infertile.

“Eliminating psychological stress may be necessary for successful infertility treatment.

Women appear to have a higher rate of infertility-related stress than men. Studies have also found that greater than half of the women receiving infertility treatment feel that infertility is the most stressful experience of their lives", they conclude.

One study of 200 couples seen at a fertility clinic, for example, found that half of the women and 15% of the men said that infertility was "the most upsetting experience" of their lives. Another study of 488 American women who filled out a standard psychological questionnaire before undergoing a stress reduction program concluded that women with infertility felt as anxious or depressed as those diagnosed with cancer, hypertension, or recovering from a heart attack.

Despite the evidence that infertility has a profound impact on mood and anxiety, mental health care during this treatment is often neglected. A couple dealing with infertility may benefit from several treatment approaches observing the biopsychosocial model. Those include counseling and psychotherapy, relaxation techniques, yoga, meditation and exercises (see our post about that here) and psychiatric medications that may alleviate mood and anxiety symptoms. The prevalence of antidepressant use has been reported to comprise as much as 4 and 11% of women undergoing infertility treatment according to some studies.

But is there any evidence that antidepressants increase the fertility rates? 

A study published this year on the Journal of Psychosomatics Research by a Canadian group did a systematic review of databases from January 1950 to November 2015 and did not find that antidepressant use by women receiving fertility therapy impacted gamete quality or pregnancy success. “Collectively, the findings of the four studies meeting inclusion criteria reflect no differences between antidepressant users and comparators in assisted reproductive outcomes (i.e., peak serum FSH or estradiol levels, oocyte retrieval, or embryo maturation, transfer and implantation rates). This is consistent with Worly and Gur's findings that clinical studies have yet to demonstrate a deleterious effect of psychotropic medications on oocyte quality or reproductive success”.

A Swedish nation-wide study including 23,557 nulliparous women undergoing their first IVF cycle between January 1, 2007 and December 31, 2012 found no statistically significant associations between SSRI treatment and IVF outcomes. Conversely, women treated with non-SSRI antidepressants had reduced odds of pregnancy (Adjusted Odds Ratio (AOR): 0.41; 95% CI: 0.21, 0.80) and live birth (AOR: 0.27; 95% CI: 0.11, 0.68) and an increased likelihood of miscarriage (AOR: 3.56; 95% CI: 1.06, 11.9). These risks were also significant for untreated individuals in pregnancy (AOR: 0.58; 95% CI: 0.41, 0.82) and live birth (AOR: 0.60; 95% CI: 0.41, 0.89) but not miscarriage (AOR = 1.28; 95% CI: 0.49, 3.39).

It is crucial to note, however, that each patient should be treated according to the severity of her symptoms and medications are often required to ensure safety and well-being. In fact, a recent study on suicidal risk among infertile women undergoing in-vitro fertilization found that being "childless, depressive and non-positive reappraisal predict suicide risk" and stressed that suicidal risk is recommended for women in the course of IVF.

“The incidence of suicide risk was 9.4%. Suicidal women were more likely to be childless or had fewer children and experienced higher levels of depressive symptoms. In addition, they reported more frequently on denial, social withdrawal and self-blame coping strategies compared to participants without suicidal risk”. 

Perinatal loss (miscarriage, stillbirth) is another major risk factor for depression and other psychiatric issues. A recently-published study entitled “Infertility and Perinatal Loss: When the Bough Breaks” does a comprehensive review on the correlation between pregnancy loss, depression, suicidality and trauma:

"Young women, who lack social supports, have experienced recurrent pregnancy loss or a history of trauma and / or preexisting psychiatric illness are at a higher risk of experiencing psychiatric illnesses or symptoms after a perinatal loss or during infertility.

Perinatal loss is the non-voluntary end of pregnancy or death of the baby from conception until 28 days into a newborns life. The term perinatal loss includes miscarriage, stillbirth, and neonatal death.

Psychological Aspects of Perinatal Loss Understanding and addressing psychological aspects of perinatal loss is critical because of the psychological reactions of women (grief, depression, anxiety, PTSD, suicide) and the impact on subsequent pregnancies and relationships with partners and surviving siblings. The grief that follows miscarriage often declines significantly by 6 months for both men and women, yet sometimes persists for up to 2 years. Perinatal loss leads to complicated grief more frequently than other losses. Several factors may contribute to this. Pregnancy loss is often sudden and unexpected. The grief that parents experience after early pregnancy loss is often not openly acknowledged or socially supported. Perinatal loss is associated with guilt or self-blame, and women may feel that their bodies have failed. Predictors of complicated grief following perinatal loss include lack of social support, previous loss, major depression, ambivalence about pregnancy, and termination of pregnancy for fetal anomaly. Termination of pregnancy for fetal anomaly is associated with higher levels of self-blame, guilt, and social isolation. Other factors that have been reported as predictive in some, but not all studies include older maternal age, having viewed an ultrasound, having experienced quickening (fetal movement), having named the baby or bought things for the baby, and length of gestation.  Whether miscarriage is managed medically or surgically does not have a bearing on the intensity or duration of grief. The presence of living children is protective against grief after perinatal loss. The perinatal loss of a co-twin or a higher order pregnancy is associated with unique challenges such as enduring the trauma of prolonged hospitalization for the surviving twin. Grief following perinatal loss is a normal phenomenon. Nonetheless, women, especially those with risk factors, should be monitored for prolonged or complicated grief and persistence of depression, anxiety, or posttraumatic symptoms. Women who experience a perinatal loss have fourfold higher odds than women with a live birth of screening positive for depression. Risk factors for persisting depression/ psychological distress after miscarriage are infertility treatment, recurrent pregnancy loss, prior history of depression, prior PTSD, intimate partner violence (IPV), and high levels of distress immediately after miscarriage. There is also a higher risk of inpatient or outpatient psychiatric treatment 12 months after fetal death. The highest risk is for women with a loss occurring after 20 weeks of gestation, and the most commonly reported psychiatric disorder is adjustment disorder. However, 5 to 18 years after intrauterine fetal death (IUFD), there are no significant increases in depression scores. Thus, while women with recurrent miscarriages and a past history of depression and fetal death after 20 weeks of gestation are at a high risk of depression/ adjustment disorder in the year following perinatal loss, this risk declines subsequently.

Post-Traumatic Stress Disorder (PTSD) rates are increased after all types of perinatal loss—miscarriage, termination of pregnancy, stillbirth, and neonatal death. Risk factors for PTSD include younger age, lower education, previous trauma, and mental health problems. Longer gestational ages are associated with greater severity of PTSD. Even 9 months after a stillbirth or neonatal death, women have a sevenfold higher rate for screen positive PTSD when compared with women with live births. It is important to encourage the use of available social support because having a support network is associated with less depression and PTSD. The mean annual suicide rate is higher (18.1 per 100,000) in the first year after miscarriage than after live birth (5.9) or in the general population (11.3)”.

They proceed to commenting on the guidelines for the management of psychological responses after stillbirth, which remain controversial, “especially surrounding the parent’s decision to hold the baby. Although there is a dearth of randomized controlled trials of bereavement counseling or specialized psychotherapy for mothers, fathers, and families after perinatal death, there is evidence from studies using other study designs. Some studies have found that holding the baby may increase the risk of depression, anxiety, and PTSD in the mother, sometimes up to 7 years after stillbirth. However, other studies have found that parents appreciate time and contact with their deceased infant, and that parents who see and hold their baby report fewer poor mental health outcomes. Encouragement of parents to see and hold their deceased baby may be best done under guidance from experienced staff , always emphasizing the importance of respecting culturally diverse approaches to neonatal death. In the case of termination of pregnancy for fetal anomaly, observing a deformed baby can be traumatic, but it may also help to reduce guilt if observing the baby convinces the mother that she made the right decision. Other approaches to supporting parents grieving after a stillbirth have included supportive DVDs, internet-based cognitive behavior therapy and mindfulness-based therapy. Physical activity may help as shown in a recent study, which found that in women within a year of stillbirth, those who reported higher levels of physical activity reported lower levels of depressive symptoms. There is a dearth of studies or reviews specifically examining the use of SSRIs or other psychotropics in the aftermath of perinatal loss. However, it is worth noting that the association between SSRI use and miscarriage is controversial, and there is no association between SSRI use and stillbirth. Although all women may not need preventive psychosocial interventions after miscarriage, stillbirth, or neonatal death, it is important that they be monitored, especially if they have established risk factors. Given the lack of evidence for any specific approach, we recommend a customized treatment plan based on the individual’s preferences.

Couples dealing with infertility and pregnancy loss eventually come to some form of resolution achieved through biological children, adopted children, surrogacy, embryo/egg/sperm donation, or a decision to have a life without children. Whatever the outcome is, the experience will change some of the most important aspects of who you are- you may reframe your self-identity and self-perception, strengths and weaknesses, relationships, and even your global view of existence.