How to Manage Anxiety During Pregnancy with Dr. Lauren Osborne

Faith: Dr. Osborne, welcome to the podcast.

Dr. Osborne: Hello!

Faith: I would love for you to share with us an idea of how big of an issue this is. Do we know what percentage of pregnant people struggle with some form of anxiety during pregnancy?

Dr. Osborne: We know a lot more about depression, actually, in pregnancy and postpartum. We know less about the statistics with anxiety, but as a rough estimate, somewhere between 15 and 20% of women are going to experience significant anxiety symptoms across pregnancy and postpartum, and that can be much higher in 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.

And some anxiety can be good, can be healthy. It can cause you to be vigilant and do the things you need to do to take care of yourself, to keep the pregnancy healthy. 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 have complicated feelings about a baby entering the world.

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: Now, this may seem very obvious to someone who has grown a tiny human person and felt inexpressibly nauseated and seen her body change in drastic ways. But can you please articulate what it is about pregnancy that can trigger anxiety and how the anxiety plays out?

Dr. Osborne: A lot of the way our bodies experience anxiety is something that can be confused with the symptoms of pregnancy, right? So for a lot of people, anxiety might feel like a pit in your stomach. You might get sweaty, you might get short of breath, right? Those are all things that can happen normally with 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: You and I are talking a lot about feelings and pressures that can cause anxiety. Are there actual physical changes in our bodies that take place during pregnancy that contribute to anxiety?

Dr. Osborne: Absolutely, and I would say the research on that is very much in its infancy. We know that there’s huge hormonal changes that occur across pregnancy and postpartum.

Estrogen and progesterone go up enormously across pregnancy and then fall down like a cliff in the postpartum. And those hormonal changes are associated with changes in other systems in our body.

So, for example, the way we react to stress changes during pregnancy. 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. And sleep is a huge player in anxiety in two directions, right? 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. So during pregnancy, in the first trimester, people actually sleep more. They’re incredibly tired. Building that placenta is incredibly draining of your energy.

In the second trimester, sleep is usually back to about normal.

Third trimester. It’s kind of a disaster. Right? Things are uncomfortable and things are pressing on each other. And that can lead to sleep deprivation. That can further 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.

The postpartum period is.

But pregnancy, no. And yet, A lot of people become depressed or become anxious in pregnancy, and a lot of that is because people with preexisting illness have a recurrence. Why do they have a recurrence? Because a lot of people will stop taking their medications.

Faith: Let’s go right to that. I think that is a huge question for people.

Dr. Osborne: It is a huge 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. And that culture is ever present along with the culture of stigma against mental illness, right?

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. But they would never say that about a drug for a physical illness, 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 people to think about it differently. 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 medicine is an exposure.

But the psychiatric illness is also an exposure, and we have a lot of data that says that for women who are depressed or anxious in pregnancy, that that can have detrimental effects on themselves and on their future 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 does a pregnant person know whether their anxiety is impairing?

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.

To me impairing means if it impairs your ability to function the way you would otherwise function. 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. And a lot of people have those feelings, but did you really stand over him for 18 hours? No, you didn’t, right?

Faith: No. Exactly.

But you know what, Dr. Osborne, this kind of conversation should be normalized for everyone who is becoming a parent, right? 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? And I wait for the answers and they say 10% or 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 you tell what emotions are to be expected? The emotions and fears that are normalized versus what should prompt a conversation with a mental health specialist.

Dr. Osborne: So in the immediate postpartum period, like during those first two weeks, almost all women will experience what we call the baby blues, where their emotions are more on the surface. They might be more tearful than usual. They might laugh more than usual. They might have these emotions on the surface. That’s normal, that’s healthy. It happens to everybody. 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. There are other treatments as well, but we should be alert to it and be taking care of our mental health during pregnancy, just the way we take care of our physical health.

And women go every month to see the obstetrician, right? They get all checked out, they do all of these tests, but they rarely have a mental health check in 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 actionable items?

Dr. Osborne: There’s a lot of actionable items. First thing, talk to your OB. Every day there are more programs around the country that are recognizing that mental health is part of something that we have to care for during pregnancy. 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.

There are some great resources that are available across the country. 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.

There often are support groups. 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. And just that simple question, how are you doing? How are you feeling? 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. My experience working with patients is that patients who are anxious are much less likely to want to take the medications that I want to give them, even when I assure them that the risk is low. And I think if we can learn more about the etiology of these illnesses, we may be able to develop other kinds of treatments that are more acceptable to 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: Dr. Osborne, we appreciate your time. Thanks so much.

Dr. Osborne: It was a total pleasure. Always happy to talk about what I love!

Our many thanks to Dr. Osborne. 

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