Harla Nolan was three months pregnant when she pinned her rambunctious 3-year-old and prepared to let loose. Sobbing, the child pleaded, "Mommy, don't hurt me."
Terrified at her near loss of control, and weary of her increas- ingly frequent outbursts, the Sacramento mother called a crisis line for help.
"She was being a kid who needed attention," Nolan recalled, describing her daughter, Laura, "and I couldn't give it to her because I was depressed."
Within a day, Nolan was in the hands of professionals who recognized her symptoms and initiated treatment. Nolan enrolled in a new program at Kaiser Permanente in Sacramento for pregnant women experiencing depression or anxiety.
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For Nolan, that meant mental health screening, counseling, a prescription for an antidepressant and an "emotional well- being" class for pregnant women.
Although "prenatal depression" isn't a household term, it occurs with nearly the same frequency as postpartum depression, according to new research.
A study published last month found that among more than 4,000 women who gave birth from 1998 to 2001, nearly 9 percent were depressed in the nine months before pregnancy. About 7 percent were depressed during pregnancy. The same study, in The American Journal of Psychiatry, found that nearly three-fourths of women with postpartum depression also were depressed before they got pregnant.
"Depression is really a chronic disease, and many people get episodes throughout their lifetime," said Patricia Dietz, an epidemiologist with the Division of Reproductive Health at the Centers for Disease Control and Prevention and a lead study author.
Women with postpartum depression are at risk of harming themselves or their newborns, but prenatal depression presents its own dangers.
"The scary one is suicidal thoughts," Kaiser psychiatrist Arlene Burton said. "And if she is not caring for herself -- not getting sleep, not eating appropriately or getting exercise -- it poses problems with the pregnancy itself and with delivery of the baby."
There are barriers to prenatal depression treatment. Physicians rarely screen for the illness in pregnant women. Others are loath to prescribe medication to pregnant patients, or have few alternatives to offer.
Even trickier is getting doctors, psychologists, pharmacists and lactation consultants to agree on treatment.
Kaiser providers all have a medication tip card based on current scientific research to ensure consistent care. Instructions, for example, state that the drug Zoloft is the first choice for patients starting medication during pregnancy, and Paxil should be avoided because of links to birth defects.
"It used to be that you were grasping at straws," said Dr. Diane Dailey, an internist and a health liaison for Kaiser. "Now, everyone is giving the patients the same information."
Many pregnant women brush off symptoms, even when unhappiness, irritability or insomnia affect their ability to function.
Amy James, for example, was rife with anxiety and sadness during her first pregnancy, feelings she said everyone told her not to worry about.
"I didn't know what depression was," said James, 36, a West Sacramento mother with three stepchildren in addition to her two babies. "I had never been depressed, and all of a sudden I was not getting along with myself or anybody in my life."
The feelings persisted after she gave birth, and well into her unexpected second pregnancy six months later.
Depression in an otherwise healthy woman during preg- nancy is rooted in biological changes and environmental realities. These factors can be emotionally devastating.
Pregnancy-activated hormones can produce mood swings and sleep disturbances. Weight gain, exhaustion and stress at home or at work also can contribute to the illness.
For James it was all of the above. She had become impatient with her stepchildren, barking about everything from homework diligence to the number of cereal boxes they'd opened each week. "I thought, I am irritable because I am fat and miserable and tired because this baby is sucking all of the life out of me," James said.
But within weeks of starting medication and with ongoing psychological counseling, her outlook and home life began to improve. Her babies are now 11 months and 2 years old. She said she no longer sweats little things such as open cereal boxes; she invites her older kids to help in the kitchen; and she doesn't mind when bath towels are not arranged by color.