The Impact of Depression on Fertility and Pregnancy - (Summer 2010)

THE IMPACT OF DEPRESSION ON FERTILITY AND PREGNANCY

Janet Takefman, PhD

When I think of the mind-body interaction, I immediately think of the impact depression has on fertility and pregnancy as a classic example of this duality. We all know depression is a common outcome of infertility. The crisis of infertility is characterized by four factors that make it a prime circumstance for the development of depression: it is unpredictable and unexpected, it is beyond one’s ability to reverse once it has occurred, it is chronic and unremitting, and it has life-altering ramifications. These four conditions describe any life crisis, and the aftermath of an unresolved crisis is depression.

In 1967, Dr. Martin Seligman operationally described depression as “learned helplessness”; that is, “the hopelessness and resignation learned when a human or animal perceives no control over repeated bad events.” In a landmark study, Seligman tested his theory by conducting experiments on dogs in which he administered unpredictable electric shocks to their hind legs. In one group, the dogs could escape the shock by learning an escape route. In the other group, the shock was inescapable. The dogs who received the unpredictable, inescapable shock learned they were helpless to prevent it and gave up; that is, they behaved as if they were depressed. “Unpredictable, inescapable shock”… does that sound like the experience of infertility? I have no doubt that for many it does.

Allow me to digress a moment and elaborate on the different meanings of depression. We use the word depression in three different contexts. There is depression as a descriptor, as in, “He is depressed.” By this people usually mean a person is “down,” “has the blues,” or is sad. Then there is depression as a psychological symptom. In this sense depression can be one of many symptoms. For example, depression might be a symptom of menopause along with hot flashes and joint pain.

Finally, there is Depressive Disorder as a syndrome. The syndrome of depression is a mood disorder and is characterized by a combination of symptoms including diminished interest in most things, poor concentration, feelings of worthlessness, and so on. Most who have experienced fertility difficulties have felt depressed (the adjective or symptom) at one time or another. But depression, the syndrome, is only experienced by 10%–15% of infertility patients and usually requires a direct intervention like medication or psychotherapy to bring about improvement. For the purposes of this discussion, I will use the term loosely to mean any of these three types.

Depression and infertility have been studied quite extensively. For example, we know that depression usually increases for the first few years a person is in treatment, then peaks and begins to level off around the third year of treatment. We know that regardless of who is found to have the fertility problem, women feel more severely depressed than men when they cannot conceive and remain depressed for a longer period of time. These gender differences are likely explained by the fact that women rate childbearing as a more vital life goal than men and rate the meaningfulness of life without children poorer as compared to men. Finally, we know that common coping strategies such as distraction and problem-solving, which people employ to deal with various stressful events in their lives, are not effective in lowering depression related to infertility. It is hypothesized that the lack of control patients feel during this process makes coping especially difficult.

The problem becomes even more complicated, however, when we consider that depression is not only an outcome of infertility but can prolong it as well. For instance, we know that depression lowers treatment persistence. The number one reason why couples drop out of treatment prematurely is not a lack of finances as one might expect, but because of depression. We know this because there are many countries around the world in which the cost of assisted reproduction is covered by the government. Yet many patients discontinue treatment and cite depression as the reason. We also know that women who are more depressed prior to treatment are less likely to achieve success and that depressed women require more treatment cycles to achieve pregnancy than non-depressed women. The bottom line: depression contributes to lowering pregnancy rates.
Furthermore, if one does conceive while depressed, depression can carry over to a pregnancy and lead to gestational and delivery complications and an increased risk of postpartum depression (PPD). A new book written by the actress Brooke Shields entitled Down Came the Rain documents her struggle with PPD. Shields describes the many risk factors she had for PPD that should have been red flags. Two of these were her infertility and treatment with IVF. She writes about her sadness at not being able to conceive naturally and her several failed attempts at IVF. When she finally did succeed, she had a complicated labor in which her baby was delivered via an emergency C-section. These and other circumstances made her a textbook case for experiencing PPD.

Another concern, which was recently stated in a public advisory released by Health Canada on March 10, 2006, is that women who are pregnant or intend to become pregnant who are taking antidepressants known as selective serotonin re-uptake inhibitors (SSRIs) such as Celexa, Paxil, Wellbutrin and Effexor should discuss the situation with their doctors due to the potential risks to the baby. This finding is particularly troubling in light of a recent study which showed that pregnancy does not confer a protective effect on women with major depression if they stop taking antidepressants, as many experts have long thought.

There is thus little doubt that, in the case of infertility, “mind does matter.” To summarize, depression is a likely secondary effect of infertility. The more depressed one is, the less likely they are to conceive, and if one beats the odds and does conceive, depression could continue into the pregnancy and after birth, causing further complications. Although this analysis may seem bleak, the good news is that with early identification and proper treatment, depression can be managed and in most cases reversed after a few months. So I implore all physicians and medical staff to refer patients who may be suffering from depression to a mental health professional with expertise in infertility and depression. Similarly, to all individuals who are facing the emotional challenges of infertility; if you feel you are depressed, there is help available. I cannot tell you how many times I have heard patients ask me, “what can you do? You can’t get me pregnant, and that’s what I need to fix my depression.” However, after a short period of therapy or counseling, most understand what someone like me can do and are thankful for the experience.

About the Author
Reproductive Health psychologist Janet Takefman, PhD, is Assistant Professor in the department of Obstetrics and Gynecology, McGill University Health Centre and Director of Psychological Services at the McGill Reproductive Centre. The author of over 60 articles, monographs and research presentations, Dr. Takefman also runs a private clinic in Montreal, where she can be reached by phone at (514) 912-4952 or by e-mail at j_takefman@hotmail.com.