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Caring for Our Mental Health During Pregnancy

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Pregnancy can be an exciting time for many people. A person may feel joy at the prospect of having a baby, yet also experience anxiety about physical changes, childbirth, parenthood, or uncertainties in their life.  The World Health Organization reports that approximately one in 10 pregnant women worldwide experiences a mental health challenge during pregnancy (WHO, 2015). Additionally, newer studies also reflect dyadic distress in caregivers during the pregnancy period (Smythe et al., 2022). Even though the rates in different studies vary, studies highlight the importance of addressing mental health during pregnancy as part of prenatal care. Of course, not every instance of anxiety or emotional change during pregnancy indicates a mental health issue. However, if intense anxiety, low mood, or difficulty managing daily life persist for an extended period during pregnancy, it may be helpful to discuss this with a mental health professional. In this therapy sketch, we will discuss mental health during the pregnancy period.

Prenatal Distress is a spectrum.

Mental health challenges during pregnancy encompass conditions or symptoms characterized primarily by depression, anxiety disorders, and pregnancy-specific distress in the literature. However, they do not fit into a single framework. Moreover, they span a broad and highly personal spectrum. Globally, it is reported that about 10% to 20% of pregnant women experience mental health challenges (Howard & Khalifeh,2020; Tilahune et al., 2021; Lugo et al., 2023).

Common changes experienced during pregnancy

  • Recognizing and accepting one’s pregnancy
    • While some individuals can accept pregnancy early on, some individuals may also experience a condition called pregnancy denial which can affect their physical and mental wellbeing early in the pregnancy
  • Developing a sense of connection
    • Individuals may experience the fetus both as separate or as a part of their bodies. This sense of connection and separateness can change throughout one’s pregnancy and can be guided by feeling the baby move or seeing ultrasound images. For example, some people may feel deeply connected to their baby, while others may initially experience the pregnancy as strange or distant. These experiences can influence bonding, expectations about the baby, emotional adjustment, and how caregivers relate to the baby after birth.
  • Internal representations of fetus and attitudes toward pregnancy
    • Often, pregnant individuals report having certain understandings or mental images of the fetus, which are called “internal representations,” where they assign certain characteristics to their baby based on certain changes in their body (e.g., the baby kicks too much, she is very stubborn), as well as existing or new attitudes toward pregnancy (e.g., toward childbirth), which can affect their overall experience of pregnancy, including the birthing experience itself
  • Body image changes
    • As pregnancy involves significant body changes such as weight gain, people may experience a discrepancy between their ideal body image and existing body image, which can affect other areas of their mental health
  • Adjusting to changing social roles (caregiving)
    • Individuals can go through significant changes, sometimes also including confusion and a sense of grief as they are transitioning to role of a caregiver
  • Changes to sleep, physical and s-xual activity, eating patterns
    • For most individuals, changes to sleep, such as sleeping less or more and feeling less energy and more fatigue, decrease in mobility and movement, and changes to s-xual habits and functioning, are common, which can affect overall quality of life
  • Other bodily and somatic changes (nausea, vomiting, etc.)
    • Individuals may differ in terms of how they will react to somatic changes experienced during pregnancy, such as nausea and increased sensitivity to odors, which can lead to more overwhelming symptoms for some people

Here are the mental health challenges that can present during pregnancy

  1. Antenatal Depression: Depression is a mental health issue that can affect a person’s mood, thoughts, energy, and daily life. For depression that begins during pregnancy, the term “antenatal depression” is used. It is reported that the estimated prevalence of depression during pregnancy ranges from 10% to 20% (WHO, 2015; Smythe et al., 2022). Depression may have begun before pregnancy, may first appear during pregnancy, or may become more pronounced during this period. Symptoms such as fatigue, sleep disturbances, and changes in appetite are common parts of depression. However, they can also happen during pregnancy for different reasons (American College of Obstetricians and Gynecologists, 2023). Consequently, these symptoms need to be evaluated with their duration and impact on daily life, along with symptoms such as persistent low mood or loss of interest. 
  2. Anxiety During Pregnancy:  Anxiety disorders can take different forms, so symptoms may vary. More generally, anxiety may involve worry or fear that feels difficult to manage, restlessness or tension, trouble concentrating or sleeping, or avoiding situations that cause distress. These experiences can impact daily life, but symptoms and diagnosis duration vary across anxiety disorders. Although the prevalence of anxiety during pregnancy can differ based on the types of anxiety, estimates mentioned by Smythe et al. (2022) suggest that up to 13% of women may experience anxiety in certain studies.
    1. Pregnancy-Specific Anxiety:  Pregnancy-related anxiety is considered a specific type of anxiety that is primarily related to pregnancy and childbirth, such as labor pain, losing control during childbirth, or the baby’s health or development. Currently, it is not considered a specific diagnosis. However, a lot of different studies and scales can be found in the literature (Székely et al., 2020; Stoll et al., 2018).
  3. Mood Swings: Pregnancy is often described as a time of mood swings, but this image does not reflect everyone’s experience. Some people notice mood changes, while others do not experience significant emotional shifts. In a prospective study of 162 women, the 70 who became pregnant reported more moodiness than nonpregnant participants, but the findings did not support the idea that pregnancy is generally a time of emotional turmoil. Hormonal changes may play a role in mood, although they do not explain everyone’s experience on their own (Striegel-Moore et al., 1996). 
  4. Dyadic Distress During Pregnancy: Dyadic distress refers to the presence of mental health challenges in both caregivers during pregnancy. A 2022 review of 23 studies, including more than 29,000 couples, found that about 1.72% of couples experienced antenatal depression at the same time. This estimate, drawn from five studies with 1,120 couples, emphasizes how common it can be during pregnancy (Smythe et al., 2022) .

Biopsychosocial Perspective on Perinatal Distress

Attributing the mental health challenges to only one dimension (such as biological changes, hormones, etc.) leaves out a significant part of the experience. A person’s previous experiences with mental health, their thoughts and feelings about pregnancy, their relationships, and their living conditions are also part of this process. These factors do not operate independently. Physical symptoms can affect sleep, daily diet, mobility, and overall daily life; past mental health challenges or pregnancy-related worries, uncertainty throughout the process can affect how a person feels; and social, financial, or relationship-related worries, as well as expectations about how pregnancy should feel, can increase stress. For this reason, it is more comprehensive to assess mental health during pregnancy by considering its biological, psychological, and social dimensions together (Biaggi et al., 2016; Tilahune et al., 2021).

Biological Factors

Pregnancy involves significant hormonal changes, particularly in estrogen and progesterone. Although hormones are linked to emotional regulation, research shows that the relationship between hormone levels and mood is not consistent across studies; some individuals may be more sensitive to hormonal changes. Therefore, hormones are one of several possible factors, but they do not fully explain it on their own (Biaggi et al., 2016).

Physical experiences during pregnancy such as nausea, pain, fatigue, difficulty falling asleep or staying asleep, and changes in appetite can also affect a person’s energy levels and daily life. Moreover, since fatigue, sleep disturbances, and changes in appetite can also be observed in mental health conditions such as depression, these symptoms alone do not support a diagnosis.

During pregnancy, some medications that were used previously might need to be reviewed and adjusted or stopped with medical guidance. These changes in treatment decisions can create uncertainty, as changing medication could impact the management of a health condition and daily well-being, while continuing it may lead to concerns about potential effects during pregnancy.

Psychological Factors

A person’s emotional history can shape the picture. Past periods of mental health difficulty may resurface or become more noticeable during pregnancy. Current stress, other difficult life events, and how manageable uncertainty feels may also influence someone’s experience. Research has found links between antenatal anxiety and depression, perceived stress, adverse life events, and coping styles  (Székely et al., 2020). 

Thoughts about pregnancy and childbirth can also shape how a person feels. It’s common to feel anxious about what might happen during childbirth, the baby’s health and development, preparing for parenthood, or how life will change. For people who have previously experienced a miscarriage, pregnancy loss, termination, or pregnancy complications, concerns about the baby’s health and the course of the pregnancy may become more pronounced (Székely et al., 2020).

Feelings about pregnancy can also be mixed. A person may feel hopeful or excited while also feeling worried, uncertain, or overwhelmed. Experiencing these emotions does not, by itself, mean a mental health challenge; however, their duration, intensity, and impact on daily life help provide a fuller picture.

Social Factors

Pregnancy can change a person’s relationships, social roles, and future plans. Support from a partner, family, friends, and the healthcare team can make this period more manageable. Conversely, conflict in relationships, loneliness, financial difficulties, a heavy workload, difficulty accessing care resources, or experiences of violence can increase a person’s stress  (Biaggi et al., 2016; Tilahune et al., 2021)..

A meta-analysis on the importance of social support synthesized findings from 67 studies involving more than 64,000 pregnant women. The analysis found that low social support was associated with a higher likelihood of anxiety symptoms during pregnancy and a smaller but statistically significant association with depression symptoms (Tilahune et al., 2021). 

Similarly, broader socioeconomic factors also affect well-being and mental health during pregnancy. In fact, WHO’s report reflects that while perinatal depression and anxiety are seen in 1 in 10 women in high-income countries, this number is one in five in low- and middle-income countries (WHO, 2022), emphasizing how systemic and socioeconomic factors may contribute to one’s mental health beyond one’s existing individual psychological and physical health conditions. Such socioeconomic factors that are considered risk factors for one’s mental health include poverty, gender discrimination, stigmatization (e.g., biases in society around what constitutes a fit vs. unfit parent can create shame and silence in sharing one’s mental health needs), limited healthcare access, low educational opportunities, lack of opportunities for generating income, natural disasters, and more.

Protective Factors

Our mental health is not only characterized by the absence of challenging symptoms but also the existence of supporting elements in our lives. In pregnancy and prenatal time, many factors can support our wellbeing and increase our coping abilities, which can protect us against the impact of increased vulnerabilities of mental health challenges. For example, according to WHO’s research on prenatal mental health, the following are important protective factors during pregnancy against mental health challenges:

  • Social support systems
    • Such as supportive, loving relationships with partners, family, friends, and community. This also includes peer-based support from local groups such as neighbors or acquaintances from parenting classes etc.
  • Education and psychoeducation
    • Learning more about pregnancy, including the physical and mental changes we experience, can act as a protective factor and can increase opportunities for coping with overwhelming symptoms, and seek early interventions
  • Financial and healthcare-related support
    • Having access to income and adequate healthcare can improve wellbeing during pregnancy. Especially receiving care that recognizes autonomy, dignity, and one’s own right to their bodily decisions can improve wellbeing and protect against distressing symptoms during pregnancy
  • Receiving stepped-care
    • While mental health-related vulnerabilities may increase during pregnancy and the year following birth, not everyone will experience these changes in the same way. That’s why not every level of care is appropriate for every individual. For example, some individuals may experience overwhelming feelings and changes but still feel capable of dealing with them, or may be affected only temporarily. In such cases psychosocial support and regular monitoring can be helpful. However, in cases of moderate-to-severe symptoms where changes are more frequent, intense, and affecting one’s overall functioning, psychological interventions such as evidence-based therapies and medication options can be more appropriate. Being aware of such options can help us recognize our needs early and connect with early interventions and can act as a protective factor in the long run.

How can therapy help?

Support for emotional challenges experienced during pregnancy is tailored to what the individual is going through and what they need. Psychotherapy can help with coping with anxious thoughts, understanding difficult emotions, adjusting to changes in relationships, or working through fears related to childbirth. For some people, therapy may be an appropriate form of support on its own, while for others, it may be part of a more comprehensive care plan developed in collaboration with healthcare professionals. Modalities such as  CBT, IPT, and mindfulness-based interventions can offer different kinds of support depending on the person’s needs. 

  • Cognitive Behavioral Therapy (CBT): In CBT, individuals work to recognize the connections between their thoughts, emotions, and behaviors, and to address distressing thoughts and develop coping strategies. During pregnancy, this work may focus, for example, on thoughts that increase anxiety, avoidance behaviors that make daily life difficult, or a reduction in the time a person can devote to themselves. Studies exist showing this approach being applied in various ways. For example, in a study, a six-session CBT-based program was provided by trained non-specialist practitioners to individuals experiencing symptoms of anxiety during pregnancy who had not been diagnosed with clinical depression. Six weeks after delivery, the rate of those experiencing a depressive episode was 12% in the intervention group and 41% in the comparison group (Surkan et al., 2024) .
  • Interpersonal Therapy (IPT): Pregnancy can bring about changes in a person’s relationships and daily roles. Interpersonal therapy addresses the impact of these transitions, communication difficulties, the need for support, or tensions in relationships on the individual. In a randomized controlled trial involving 234 pregnant women, participants with high levels of depressive symptoms were offered short-term interpersonal therapy. By the end of the pregnancy, the rate of those meeting the criteria for major depression was 6.1% in the therapy group and 26.1% in the comparison group (Hankin et al., 2023).
  • Mindfulness and relaxation-based approaches: Mindfulness practices can help a person become aware of what they are thinking and feeling in the moment, while relaxation techniques can help them focus on their breathing and physical tension. During pregnancy, these approaches can be used to cope with stress or anxiety related to childbirth. A systematic review and meta-analysis examining relaxation interventions found that these practices were associated with reductions in reported stress, anxiety, and depressive symptoms during pregnancy (Abera et al., 2024).

Takeaways

  • A person may feel joy at the prospect of having a baby, yet also experience anxiety about physical changes, childbirth, parenthood, or uncertainties in their life.
  • Mental health challenges during pregnancy encompass conditions or symptoms characterized primarily by depression, anxiety disorders, and pregnancy-specific distress in the literature.
  • Attributing the mental health challenges to only one dimension (such as biological changes, hormones, etc.) leaves out a significant part of the experience.
  • Physical symptoms impact sleep, diet, mobility, and daily life. Past mental health issues, pregnancy worries, and uncertainty influence feelings. Social, financial, or relationship concerns, plus expectations on pregnancy, can raise stress.
  • Therapy Modalities such as  CBT, IPT, and mindfulness-based interventions can offer different kinds of support depending on the person’s needs. 

References 

  • World Health Organization. “Perinatal mental health. https://www.who.int/teams/mental-health-and-substance-use/promotion-prevention/perinatal-mental-health
  • World Health Organization. (2022). Guide for integration of perinatal mental health in maternal and child health services. World Health Organization
  • Smythe, K. L., Petersen, I., & Schartau, P. (2022). “Prevalence of Perinatal Depression and Anxiety in Both Parents: A Systematic Review and Meta-analysis.” JAMA Network Open, 5(6), e2218969. 
  • Striegel-Moore, R. H., Goldman, S. L., Garvin, V., & Rodin, J. (1996). “A Prospective Study of Somatic and Emotional Symptoms of Pregnancy.” Psychology of Women Quarterly. 
  • Biaggi, A., Conroy, S., Pawlby, S., & Pariante, C. M. (2016). “Identifying the Women at Risk of Antenatal Anxiety and Depression: A Systematic Review.” Journal of Affective Disorders, 191, 62–77. 
  • Tilahune, A. B. ve ark. (2021). “The Relationship Between Social Support and Mental Health Problems During Pregnancy: A Systematic Review and Meta-analysis.” Reproductive Health, 18, 162 
  • Székely, E., Neumann, A., Sallis, H., Jolicoeur-Martineau, A., Verhulst, F., Meaney, M., Pearson, R., Levitan, R., Kennedy, J., Lydon, J., Steiner, M., Greenwood, C., Tiemeier, H., Evans, J., & Wazana, A. D. (2020). Maternal Prenatal Mood, Pregnancy-Specific Worries, and Early Child Psychopathology: Findings From the DREAM BIG Consortium.. Journal of the American Academy of Child and Adolescent Psychiatry. https://doi.org/10.1016/j.jaac.2020.02.017
  • Biaggi, A., Conroy, S., Pawlby, S., & Pariante, C. (2016). Identifying the women at risk of antenatal anxiety and depression: A systematic review. Journal of Affective Disorders, 191, 62 – 77. https://doi.org/10.1016/j.jad.2015.11.014
  • Tandon, S. D., Moskowitz, J., Edwards, R. C., Zhang, Y.-D., Giase, G. M., Sinche, B., Blum, A. L., Krislov, S., Reynolds, H. M., Rangarajan, A., Cummings, P., Petitclerc, A., Alshurafa, N., Grobman, W., Ward, E. A., & Wakschlag, L. S. (2025). Effects of a Personalized Stress Management Intervention on Maternal Mental Health: A Randomized Clinical Trial. Archives of Women’s Mental Health, 28, 1585 – 1595. https://doi.org/10.1007/s00737-025-01619-5
  • Missler, M., Donker, T., Beijers, R., Ciharova, M., Moyse, C., De Vries, R., Denissen, J., & Van Straten, A. (2021). Universal prevention of distress aimed at pregnant women: a systematic review and meta-analysis of psychological interventions. BMC Pregnancy and Childbirth, 21. https://doi.org/10.1186/s12884-021-03752-2
  • Miller, L. J. (2014). Psychological, behavioral, and cognitive changes during pregnancy and the postpartum period. In Oxford University Press eBooks. https://doi.org/10.1093/oxfordhb/9780199778072.013.002
  • Howard, L. M., & Khalifeh, H. (2020). Perinatal mental health: a review of progress and challenges. World Psychiatry, 19. https://doi.org/10.1002/wps.20769
  • Tilahune, A. B., Adams, J., Peng, W., & Sibbritt, D. (2021). The relationship between social support and mental health problems during pregnancy: a systematic review and meta-analysis. Reproductive Health, 18. https://doi.org/10.1186/s12978-021-01209-5
  • American College of Obstetricians and Gynecologists [ACOG], 2023.https://www.acog.org/clinical/clinical-guidance/clinical-practice-guideline/articles/2023/06/screening-and-diagnosis-of-mental-health-conditions-during-pregnancy-and-postpartum?utm_source=chatgpt.com
  • Surkan, P.J., Malik, A., Perin, J. et al. Anxiety-focused cognitive behavioral therapy delivered by non-specialists to prevent postnatal depression: a randomized, phase 3 trial. Nat Med 30, 675–682 (2024). https://doi.org/10.1038/s41591-024-02809-x
  • Hankin, B. L., Demers, C. H., Hennessey, E. P., Perzow, S. E. D., Curran, M. C., Gallop, R. J., Hoffman, M. C., & Davis, E. P. (2023). Effect of Brief Interpersonal Therapy on Depression During Pregnancy: A Randomized Clinical Trial. JAMA psychiatry, 80(6), 539–547. https://doi.org/10.1001/jamapsychiatry.2023.0702
  • Abera, M., Hanlon, C., Daniel, B., Tesfaye, M., Workicho, A., Girma, T., Wibaek, R., Andersen, G. S., Fewtrell, M., Filteau, S., & Wells, J. C. K. (2024). Effects of relaxation interventions during pregnancy on maternal mental health, and pregnancy and newborn outcomes: A systematic review and meta-analysis. PloS one, 19(1), e0278432. https://doi.org/10.1371/journal.pone.0278432
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