BY ANDREA MONGLER ILLUSTRATION BY ABIGAIL GOH
Whether it’s monthly menstrual cycles, pregnancy, childbirth or menopause, women’s bodies change a lot over a lifetime. But often, these life changes aren’t just physical. They can affect women’s mental health, too, in ways large and small.
For some women, that means premenstrual mood swings and baby blues, certainly affecting mental health but, for many, not debilitating. For others, though, these biological transitions that are a normal part of life can lead to significant mental health problems, for reasons that aren’t fully understood. Because of this, women are at higher risk than men for depression and anxiety throughout their lives. And that increased risk begins in puberty.
Puberty is known as a period of mood swings and teenage angst. And it’s true that some level of emotional ups and downs is to be expected in any adolescent. But it’s also true that when children start puberty, their risk of experiencing a serious mental health issue—such as depression or anxiety— increases substantially.
In the United States, just 2% of children ages 6 to 11 have depression, according to the U.S. Centers for Disease Control and Prevention. About 6% have anxiety. For 12- to 17-year-olds, though, rates are much higher, with about 13% having depression and 32% experiencing anxiety, as reported by the National Institute of Mental Health.
WE KNOW THAT WOMEN SUFFER FROM DEPRESSION AND ANXIETY DURING PREGNANCY AT PRETTY MUCH THE SAME RATE AS THEY DO AFTER CHILDBIRTH.
Those numbers, however, vary significantly between genders. In adolescent girls, rates of depression and anxiety are 20% and 38%, respectively. In adolescent boys, rates are 7% and 26%.
“Prior to puberty, when we look at childhood depression, we don’t see a gender gap,” says Washington University psychiatrist Cynthia Rogers, MD, director of the Perinatal Behavioral Health Service at the Women & Infants Center, a collaboration by Barnes-Jewish Hospital, Washington University Physicians and St. Louis Children’s Hospital. “The gender gap in depression really emerges around the time of puberty. And the reasons for that are poorly understood and an important area of research.”
Some research has shown that puberty changes the brains of boys and girls differently, with boys having an increase in connectivity in some mood-related areas of the brain and girls experiencing a decrease. Whether these changes can actually cause depression or anxiety is still being studied. Hormones may play a role as well. Girls’ bodies start producing estrogen during puberty, and while some research has shown estrogen to have a positive effect on mood in women, it’s possible those findings don’t hold true for adolescents.
The ovaries also produce another hormone—progesterone—as part of the menstrual cycle, and it, too, could be tied to mood differences in adolescent girls. In addition, recent research points to early puberty as a driver of depression in girls. This is especially troubling because, on average, girls are starting puberty earlier than they used to. There could be a biological basis for the link between early puberty and depression, but social factors— imagine being the first girl in your class to get a menstrual period or need a bra— also likely play a role.
The same holds true for girls who don’t experience early puberty: Biologic or genetic factors are likely to interact with environmental factors, including increasingly complicated social relationships, academic pressures and a growing list of responsibilities, to raise girls’ risk of depression and anxiety even further.
“As in all things that have to do with mental health, I think the reason that girls are more likely to have depression and anxiety than boys is multifactorial,” Rogers says. “I think there is likely a biological basis as well as societal and environmental reasons. And this gender difference that begins at puberty lasts throughout women’s lifespans.”
Pregnancy and postpartum
Pregnancy is supposed to be a time of joy, or so many women are often made to feel thanks to movies, books and other cultural influences. But for some women, it’s not. Though there’s been increased attention on mood problems in women after they give birth, with a focus on postpartum depression in particular, perhaps less well known among the general public is the fact that women are also at increased risk of depression and anxiety during pregnancy. The health care providers who treat them, though, know otherwise.
“We use the term ‘perinatal mental health’ because it encompasses both pregnancy and the postpartum period, and we know that women suffer from depression and anxiety during pregnancy at pretty much the same rate as they do after childbirth,” Rogers says.
Research has shown that at least one in eight women in the United States experience depression or anxiety during pregnancy or the postpartum period. Women with a history of depression or anxiety are at even higher risk. In the postpartum period, so are women who had significant complications related to childbirth, multiple babies or babies with their own serious medical problems.
The symptoms these women experience are the same as those in someone dealing with depression or anxiety during another phase of life. They may feel hopeless and overwhelmed, have difficulty concentrating, oversleep or be unable to sleep; they may withdraw from friends and family, and lose interest in activities that were previously enjoyable. Additionally, they may have trouble bonding with the baby.
This is different from the blues that affect many women after they give birth. The baby blues can involve crying spells, worry and unhappiness, but these symptoms are much milder than depression symptoms and typically last no longer than a week or two.
“As a loved one, when you see a woman who’s really had a significant change from her prior level of functioning or who isn’t able to care for herself or her baby, that’s when you should be concerned and seek help,” Rogers says. “And certainly anytime someone talks about not wanting to live or not caring if they live, those are emergencies.”
Though depression may be more commonly discussed, many women also experience anxiety in the perinatal period. “It’s important for loved ones to keep in mind that some women who are experiencing perinatal mental health problems aren’t depressed,” says Camaryn Chrisman Robbins, MD, MPH, Washington University obstetrician-gynecologist at Barnes-Jewish Hospital. “There is also the anxiety side of the spectrum, and those symptoms are different.”
IN THE AGE OF PINTEREST AND INSTAGRAM, THERE ARE INTENSE INTERNAL AND EXTERNAL PRESSURES THAT WE AS A SOCIETY HAVE REALLY NEVER EXPERIENCED BEFORE.
For example, she says, a new mother experiencing anxiety may refuse to walk on the second floor in the mall with her baby because she’s afraid the stroller might tip over a railing. Or perhaps she obsessively washes her hands until they bleed. Or she’s angry all the time.
“Anger is very common with pregnancy-related mood problems, and it’s a really common part of the spectrum of anxiety,” says Chrisman Robbins. “So if a woman is constantly angry—maybe she’s furious with her partner all the time when she never was before—that’s a red flag.”
The increased risk of anxiety and depression during pregnancy and the postpartum period is likely due in part to hormones, particularly changes in progesterone levels.
“When you’re pregnant, you are a progesterone-forward, progesterone-dominant being,” Chrisman Robbins says. By way of explanation, she notes that the placenta produces progesterone, and as the placenta grows throughout pregnancy, progesterone levels rise. For some women, this might lead to a mood disorder. Women with an underlying history of anxiety or depression are especially at risk.
Conversely, after a woman gives birth, her progesterone level drops rapidly, returning to a pre-pregnancy level. This decrease may trigger depression or anxiety, too. But Chrisman Robbins emphasizes that hormonal changes in pregnancy and after delivery aren’t the only factors contributing to the increased risk for depression or anxiety.
“Layered on top of these hormonal changes are the incredible anxieties and pressures about parenting, partnership and career that come with this life change,” she says. “And in the age of Pinterest and Instagram, there are intense internal and external pressures that we as a society have really never experienced before.”
The kind of treatment needed to address depression or anxiety during the perinatal period depends on its severity. Rogers says psychotherapy is often effective for women with mild symptoms. For women with moderate or severe symptoms, psychotherapy combined with medication is often needed.
As with any medication, there are some potential risks involved with taking an antidepressant or anti-anxiety medication during pregnancy or while breastfeeding, but many options have been shown to be safe for both mother and baby. Indeed, the American College of Obstetricians and Gynecologists recommends medical treatment for women with serious psychiatric illnesses during pregnancy or the postpartum period.
Notably, in 2019 the Food and Drug Administration approved a medication called brexanolone, the first drug approved specifically for postpartum depression. “Having depression or other mental health issues during pregnancy has been shown to increase risks to the baby,” Rogers says. “So, deciding whether medication is needed isn’t ‘risk versus no risk’ but ‘risk versus risk.’ It’s important that we have a conversation with the mom so that she can make the best decision for herself and her baby. The goal is to get her well, just as it would be for any other medical illness she might have.”
And Rogers emphasizes the importance of shared decision-making with patients. “At the Perinatal Behavioral Health Service, we take shared decision-making seriously,” she says. “It’s important that we are partners in a woman’s treatment. First, it’s her body and her illness. And second, people who feel like they have come to the decision to get help on their own are much more likely to follow through on treatment recommendations.”
Preventing perinatal and anxiety disorders is just as important as treating them. In fact, in 2019 the U.S. Preventive Services Task Force released recommendations on interventions to prevent postpartum depression.
One of these interventions, called Reach Out, Stand Strong, Essentials for New Mothers, involves group sessions that teach pregnant women about the baby blues, postpartum depression, stress management, development of a social support system and other preventive measures. Another program, called Mothers and Babies, is similar but designed specifically for women at higher risk for perinatal depression. Rogers says that, under the direction of clinical psychologist Shannon Lenze, PhD, director of research at the Perinatal Behavioral Health Service, the group is in the process of implementing these interventions at the Barnes-Jewish Hospital Center for Outpatient Health OB-GYN Clinic.
“We want to focus not only on treatment but also on intervening before symptoms start so that women can have healthy pregnancies and can stay healthy after delivery,” she says.
As women age, they experience yet another biological change that’s unique to their sex: perimenopause. Often confused with menopause, which occurs 12 months after a woman’s last period, perimenopause is the lead-up to menopause and usually begins when a woman is in her 40s.
Perimenopause often lasts a few years but can be shorter or longer—perhaps lasting a decade—for some women. Symptoms include hot flashes, irregular periods, decreased libido and mood swings. But as may be the case in other life transitions, including puberty, pregnancy and motherhood, some women going through perimenopause experience mood problems that are much more serious than mood swings.
A major long-term study called the Study of Women’s Health Across the Nation, or SWAN, found that among women ages 42 to 52, those with no history of depression had a 28% risk of developing depression. Those with a history of the condition had a much higher risk: 59%. This connection between perimenopause and depression is well known. Less understood are the causes.
Anxiety appears to be more common during perimenopause too, but again, the reasons aren’t totally clear. “Perimenopause is so varied from woman to woman, and that’s made it hard to study,” Chrisman Robbins says. “I think there’s a biological root to it, but at this point no one knows exactly what that is.”
Hormones may very well play a role in the increased risk for depression and anxiety during perimenopause. During this life-stage, the ovaries begin to produce less estrogen and progesterone,
though production of both varies greatly throughout perimenopause, and these fluctuations may be tied to mood problems. The connection between hormonal changes and mood problems during perimenopause may in part be an indirect one. For example, fluctuating hormones can cause hot flashes, which may lead to interrupted sleep cycles that cause fatigue, which affects mood.
And Chrisman Robbins says social and environmental factors matter too. “Maybe you’re embarrassed at work when you turn bright red and start sweating while giving a presentation. Or maybe you’re struggling to find middle ground with your partner when you have a genuine lack of libido and they don’t,” she says. “All of it can be quite distressing.”
As is true with any mental health issue, there’s stigma attached to depression and anxiety in women—perhaps most significantly during pregnancy and the postpartum period. “Women are told that this is supposed to be a time of exceptional joy,” Rogers says. “They’re made to feel that it’s wrong of them if they don’t feel that way. We take that stigma very seriously.”
She emphasizes the importance of making sure women know how common perinatal mental health issues are. In fact, they’re some of the most common complications of childbirth. “Having depression or anxiety is not a character flaw and doesn’t make someone a bad mother. It just means they are having biological symptoms related to being pregnant or having a baby. One of the best ways to reduce stigma is to normalize perinatal depression and anxiety, and to educate women, their partners and other caregivers for the infant. Having these conversations is so important.”
For more information about the Perinatal Behavioral Health Service, visit: pbhs.wustl.edu.
To speak with someone at the Substance Abuse and Mental Health Services Administration’s National Helpline, call 800-662-HELP (4357).