Affective dysregulation in pregnancy

Affective symptoms (symptoms of depression and anxiety) are frequently seen during pregnancy. Pregnant women experience depression at a rate of 7-25 % of and anxiety disorders at a rate of 15 -22%. When pregnant women present with affective symptoms, it can have negative effects on their health and that of their (unborn) child. For the mother these effects manifest as complications during pregnancy and delivery, and up to a fourfold increase in the risk of postpartum depression. For the child, there is increased risk of pre-term birth, low birth weight, developmental delay, behavioural problems and psychopathology later in life. For many women depression and anxiety disorders are discovered late during pregnancy or not at all, for the following reasons. At first, symptoms are often confused with physiological changes of pregnancy, such as fatigue or lack of energy. Secondly, pregnant women often are ashamed of their feelings and therefore could find it hard to talk about them. Affective symptoms during pregnancy occur frequently in the immigrant population. Studies show that these women tend to delay their check-ups and have a higher risk of complications during their pregnancy, which means that these complications as well as anxiety and depression are diagnosed at a relatively late stage. Recognizing the symptoms is more difficult within certain cultures where mental problems are often translated into somatic symptoms. Screening might provide a solution for no or late recognition of these symptoms. However, symptoms may fluctuate during pregnancy and opinions differ about the sensitivity and specificity of existing screening tests. The treatment of affective symptoms during pregnancy is equally challenging. The use of medication is sometimes seen as controversial. Some studies on antidepressants, show negative outcomes for mother and child. In these studies, it is often not clear what the clinical relevance of these negative outcomes is and to what extent these are caused by the medication or by the underlying disease. Psychotherapy also has some obstacles, such as long waiting times, lack of time, physical problems, unavailability of childcare and once again, shame. Online psychotherapy could be a solution, but this has not been studied extensively. The focus of my dissertation is on the diagnosis and the treatment of affective symptoms during pregnancy. For recognition it is important that affective symptoms in pregnancy will be destigmatized, allowing women to be more forthcoming in mentioning their feelings. Furthermore, screening might be helpful. Given that symptoms during pregnancy fluctuate, there is a need for multiple screenings. In addition to screening, there need for better schooling for care providers of the pregnant women, enabling them to recognize the symptoms. This is particularly necessary for care providers of women with an immigrant background where affective symptoms might present in a different form. Questionnaires need to be updated and validated continuously, paying extra attention to women with an immigrant background. Concerning medication, further study must be focused on outcomes among women using antidepressants during pregnancy. Are negative outcomes clinically relevant, are they caused by the medication or by an underlying condition? What are the consequences when the medication is not used? In conclusion, the main component of my research was the development and testing of an internet-based intervention which could help pregnant women at home at a time of their own choosing to decrease their affective symptoms. Unfortunately, this intervention did not have the intended effect, in part because of high dropout rates. However, I believe it is possible to adapt the intervention with improved information and guidance and a more appealing design which would result in more women participating and benefiting, and thus giving birth to a successful treatment module.