How to Manage Anxiety during Pregnancy with Dr. Lauren Osborne

Faith: Welcome to the podcast, Dr. Osborne.

Dr. Osborne: Hello!

Faith: Would you please give us a rough estimate of the size of this problem? What percentage of pregnant women struggle with anxiety?

Dr. Osborne: We actually know a great deal more about depression during pregnancy and postpartum. We don’t have as much information on anxiety statistics, but we can estimate that between 15 and 20 percent of women will experience anxiety symptoms during pregnancy and after delivery. This number may be higher for certain populations. I’m currently working on a research study in Pakistan where the rate of anxiety in pregnancy is about 48%.

Faith: Frankly, I’m almost surprised that the number isn’t higher.

Dr. Osborne: That’s people who have really clinically significant symptoms of anxiety that might impair their functioning, but we are really talking, a much larger group of women are going to have some form of anxiety. And when you think about it, it’s natural, right? It’s natural to have some anxiety about the changes in your life and about your new role as a protector.

Anxiety can be beneficial. You can become more vigilant and take the necessary steps to maintain a healthy pregnancy. It’s only when it becomes impairing to the way you function that it becomes really problematic.

Faith: Yeah, the image of pregnancy is that it’s so joyful and that you’ll Never give up on your dreams. You may have mixed feelings about the birth of a child.

Dr. Osborne: Yeah, and I think that’s part of what feeds into the anxiety as well, right? Because when people start to have these feelings of whether it’s anxiety or depression, at any point in the pregnancy, they have shame and they don’t talk to other people about it, so they don’t realize how incredibly common it can be.

Faith: This may seem obvious to someone who is a mother and has experienced a dramatic change in her body. Can you explain what about pregnancy can trigger anxiety, and how it manifests?

Dr. Osborne: Some of the ways in which our bodies react to anxiety are similar to the symptoms of being pregnant, don’t you think? Many people describe anxiety as a feeling of a pit in their stomach. You might feel short of breathe, or you might sweat. These are all normal symptoms of pregnancy. And so a lot of people may not even realize that they’re feeling anxious, they’re feeling these symptoms, they chalk it up to pregnancy. And so that’s one of the reasons I think that we under recognize and under diagnose anxiety in pregnancy because a lot of people minimize it.

And there’s so much as you mentioned that we can know and look for in terms of what’s wrong with the baby. And there’s a constant message of, “Let’s do this test. Let’s publish a book that tells you what you need to do and not do during pregnancy.”

And so when we have a culture that’s filled with those kinds of messages, It makes people who are pregnant be kind of paralyzed with fear about what they might or might not be doing to harm their baby.

Faith: We talk a lot together about the feelings and pressures which can lead to anxiety. Do physical changes that occur in our bodies during pregnancy contribute to anxiety symptoms?

Dr. Osborne: Research on this is just beginning. We know that there’s huge hormonal changes that occur across pregnancy and postpartum.

Estrogens and progesterone levels rise dramatically during pregnancy and then drop precipitously in the postpartum. These hormonal changes are also associated with other changes in our bodies.

So, for instance, how we respond to stress during pregnancy changes. The variability in your heart rate, which is a symbol of how healthy that heart muscle is in responding to stress — that changes during pregnancy.

We also know that there are enormous changes in the immune system, and we’re just at the very beginning of studying that. And we’ve shown that there are vast differences in the types of immune cells that are circulating and the types of immune responses that we have in pregnancy, depending on whether women have anxiety or don’t.

We don’t know enough yet to say that’s causal, right? We don’t know that immune system changes are causing anxiety or maybe anxiety is causing immune system changes. But there’s definitely physical changes going on.

Faith: What about sleep?

Dr. Osborne: Absolutely. In two ways, sleep can be a major factor in anxiety. If you are experiencing anxiety, you may find it harder to fall asleep at night because you’re anxious, you’re ruminating, you’re thinking about things that are going around and around in your mind, right?

And then once you’re sleep deprived, that can fuel anxiety. You’re going to be more keyed up, more restless, more agitated, because you’re sleep deprived and that can lead to even worse sleep and even more anxiety. During pregnancy, the first trimester is when people sleep more. They’re incredibly tired. The energy required to build the placenta can be incredibly exhausting.

In the second quarter, sleep returns to normal.

Third trimester. It’s kind of a disaster. Right? It’s uncomfortable. Things are pressing against each other. Sleep deprivation can result. This can exacerbate anxiety.

Faith: Is someone more likely to develop anxiety and depression during pregnancy if they’ve already experienced anxiety and depression in their life?

Dr. Osborne: Yes, absolutely. So what we actually think in terms of depression and the research just isn’t there yet to be able to state this about anxiety. But in terms of depression, we don’t think that there’s any increased biological risk for depression during pregnancy, that the period of pregnancy is not any greater risk biologically than any other time.

Postpartum is a period of time following childbirth.

But pregnancy, no. Many women become depressed during pregnancy. This is often due to recurrences of pre-existing illnesses. Why do they have another occurrence? People will stop taking medications.

Faith: Let’s go right to that. That’s a very important question.

Dr. Osborne: This is a big question. I think it’s part of this idea that you have to be pure, that you have to stop eating tuna and stop eating brie, or whatever it is. This culture, along with the stigma surrounding mental illness is always present.

So I’ve had numerous other physicians say to me, “Well, she can take that medicine only if she really needs it” when the person has a mental illness. They would never say this about a medication for a physical disease, right?

So there’s this culture among both patients and doctors that maybe these medicines aren’t really necessary if it’s a mental illness and that leads a lot of people to stop their medications and there’s a lot of fear over what are the risks of these medications to my baby.

And I ask that people think differently about it. I say we’re not going to talk about the risks of the medications versus the benefits of not taking the medication. We’re going to talk about the risk of taking the medication versus the risk of not treating your illness.

And we’re going to think about the fact that the medication may be an exposure for the baby to something from outside your body, just like air pollution is an exposure, or a glass of wine is an exposure. The psychiatric medication is an exposure.

The psychiatric disease is also a form of exposure. We have data to show that women who suffer from depression or anxiety during pregnancy can be at risk for harming themselves and their children. So if we are not treating the illness, we’re exposing the pregnancy to that, and that’s what we need to compare to the risk of the medications.

In addition, the risks of the medications are actually quite minimal if we’re talking about basic antidepressant medications, extremely minimal.

Faith: When will a woman who is pregnant know if her anxiety is hindering?

Dr. Osborne: There’s some amount of anxiety that’s not only normal, but is healthy as you’re preparing for this big change in your life.

I define impairment as a condition that interferes with the ability to perform your normal functions. So for example, if you are so worried during your pregnancy that your thoughts are racing around about your worries, and you’re not able to get your work done the way you usually are, you are having more difficulty in your interpersonal relationships because your anxieties are making you seek reassurance a lot from people around you. You are calling the doctor repeatedly for reassurance or going in for visits that we doctors would think were unnecessary because of your anxiety, because of your worry, then it’s reached a point where you’re not functioning the way you were before and that’s something that needs treatment, that needs help.

Faith: I know people give lots of unsolicited advice when one is pregnant, but I do remember a really good friend saying “Look, I know this isn’t going to make sense once you have your baby, but you really don’t have to stand over your baby all night to make sure he’s breathing.” And, and I was like, “Oh, that’s silly.”

And then once I had my firstborn, I was like, “He’s got to be wrong. I need to watch this child breathe for the next 18 hours.”

Dr. Osborne: Right. Many people feel the same way, but did you stand over him for that long? No, you didn’t, right?

Faith: No. Exactly.

But, Dr. Osborne… this type of conversation should become normal for anyone who becomes a parent. There doesn’t – you don’t have to have a diagnosis of anxiety. We should all talk about how you’re going feel like you might drop the baby.

Dr. Osborne: Absolutely. And in fact we have a national curriculum in reproductive psychiatry that we teach into fellows across the country in women’s mental health. And I’ll say to this group of fellows, what percentage of new moms have intrusive thoughts that harm will come to their baby? The answers I get are 10%, 20%, or 50%.

And then I wait for it and I say “a hundred percent.” And they’re almost universally shocked, right?

That’s that “really?!” and that’s because we don’t talk about it and we don’t normalize it, and we don’t say what’s common and what’s not common.

Faith: How can I tell what emotions to expect? What emotions and fears are considered normal versus those that should be discussed with a mental specialist?

Dr. Osborne: During the first two weeks after giving birth, nearly all women experience the so-called baby blues. This is when their emotions are at the surface. They may be more emotional than usual. They may laugh more than normal. These emotions may be visible. That’s normal, that’s healthy. It happens to everyone. It’s not necessarily associated with any kind of mental illness.

But if those things last more than two weeks after the postpartum, or if they’re occurring during pregnancy, if they’re associated with any more serious or alarming thoughts, like maybe thinking that this anxiety is so terrible that you wish you could go to sleep forever so that it would go away. That of course is something that means you need to consult a mental health professional, but also even if it’s at the point where you and other people notice that you’re not functioning the way you should be or the way you usually are.

And that doesn’t mean necessarily you have to go on medication. Maybe you do, maybe you don’t. Other treatments are available, but we need to be aware of them and take care of mental health just as we do our physical health.

Women go to the obstetrician every month, right? Women are checked out and undergo all these tests but rarely receive a mental check-up during pregnancy.

Faith: If someone were listening to this and is like, “sounds great, but I don’t have time to go find someone to talk to.” What are some things they could do right now? What are some actionsable items?

Dr. Osborne: There’s a lot of actionable items. Speak to your OB. There are more and more programs in the United States that recognize that mental health should be a part of pregnancy care. Here at Weill Cornell, we’ve just launched a perinatal wellness program, which embeds mental health screening and treatment within OB-GYN.

We haven’t rolled out to all of our clinics yet, but those in that are part of the program, everybody’s being screened three times across pregnancy and postpartum for mental health conditions, and we’re referring them to mental health right there within their OB-GYN setting.

Many great resources are available in the United States. In fact, across the world, there’s an organization called Postpartum Support International, which provides both trainings and access to mental health services during pregnancy and postpartum.

Support groups are common. We have some support groups associated with – with our psychiatry department here at Weill Cornell, but there are also other support groups run by PSI and run by other places.

Faith: It also sounds like if you are a partner to someone who’s pregnant or just had a baby, or a relative or a friend, you can check in and say, how are you doing?

Dr. Osborne: Yes, exactly. How are you? How do you feel? That’s really important. Not making the assumption that the answer to that is, “I’m fabulous, I’m glowing!” Right? The answer might be, uh, “not so great.” Right?

Faith: Yeah, is there any research you’re excited about or, or gives you hope to better manage anxiety during pregnancy?

Dr. Osborne: I think that there’s a lot of research that gives me hope. In my experience, patients who are anxious will be less inclined to accept the medication I recommend to them even if I tell them the risks are low. I believe that if we could learn more about how these diseases are caused, we might develop more treatments that would be more acceptable to the patients.

There’s a groundswell of people doing just what we’re doing here at Cornell with our perinatal wellness program, of trying to embed mental health services within OB-GYN and show that that affects not only mental healthcare, but physical healthcare.

Faith: We appreciate your time, Dr. Osborne. We appreciate your time.

Dr. Osborne: It was a complete pleasure. I’m always happy to share what I enjoy!

We would like to thank Dr. Osborne for his excellent work. 

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