After more than a year of trying to get pregnant and just two months after surgery to treat her stage 3 endometriosis, Kelly Glass and her husband found out they were expecting. At first, they were extremely excited they were finally on the path to parenthood.

But shortly after receiving the positive pregnancy test and having it confirmed, Glass started throwing up ― a lot.

“Just a couple of weeks after that positive pregnancy test, I was vomiting uncontrollably. I couldn’t even keep down water,” she said. “My doctor reassured me that things would get better in my second trimester.”

Instead, things continued to go downhill. As the weeks passed and her extreme nausea did not abate, it became progressively harder for Glass to keep up with the demands of work and everyday life. She became a frequent visitor at the hospital due to severe dehydration and malnourishment.

At the beginning of her second trimester, Glass received the first diagnosis to explain why her pregnancy had been so difficult: She had hyperemesis gravidarum, a condition that is best described as extreme morning sickness. Yet even after her doctor had identified the cause, Glass continued to wear down mentally as well as physically.

“Everything was a trigger. I couldn’t be around food and people and became extremely isolated,” Glass said.

At the time of her diagnosis for hyperemesis gravidarum, Glass decided to mention the lack of connection she felt to her 14-week-old fetus. But it wasn’t until much later ― at 26 weeks ― that she had the chance to do something about those feelings. That second conversation led her doctor to ask a few more questions and provide her with a questionnaire to complete. By the end of the appointment, she had been diagnosed with perinatal depression, meaning depression during pregnancy.

A recent study in the Journal of the American Medical Association found the prevalence of perinatal depression was 51 percent higher in millennial women than it had been in the previous generation.

Glass was fortunate that her concerns were taken seriously and that her doctor had the training and tools to effectively screen and diagnose her. Having a black doctor who understood her experiences as a black woman was a key factor, she said.

Like many women who deal with perinatal depression, Glass wasn’t even aware that it was a possibility and wondered why it was so hard for her to be happy during this pregnancy. With the diagnosis, she realized that she’d likely been depressed during her first pregnancy at age 21 as well.

“My first pregnancy 12 years prior was not planned. The constant despair I felt then I attributed to the stress of an unplanned pregnancy as a college student,” said Glass, now 33. “This baby was planned, though. He was not only planned, but I went through the stress of trying to conceive for more than a year and a surgical procedure to make this pregnancy happen.”

But she was still depressed.

Perinatal depression is real and on the rise.

Pregnancy-related depression is under-researched and less of a mainstay of clinical practice than its close relative, postpartum depression ― meaning depression that occurs within the first year of giving birth. That’s because postpartum depression is far more common, affecting roughly 15 percent of new moms. But awareness of perinatal depression may increase as the disorder itself appears to be on the rise, at least among young mothers.

A recent study in the Journal of the American Medical Association found the prevalence of perinatal depression was 51 percent higher in millennial women than it had been in the previous generation. The study looked at two cohorts of pregnant women, both of whom were 19 to 24 years old at the time they were surveyed.

The first group of mothers were pregnant between 1990 and 1992 and reported depression symptoms while pregnant at a rate of about 17 percent. The next group, who were either the daughters of the original set or the female partners of their male children, were pregnant between 2012 and 2016. They reported depression symptoms at a rate about 25 percent ― roughly 8 percent higher.

“There is evidence that depression may be rising in young women and young mums are a high-risk group, so it’s a good place to start,” said Rebecca Pearson, Ph.D., the lead researcher on the project and a lecturer in psychiatric epidemiology at the University of Bristol in the U.K.

Pearson noted that in order to include the most recent generation to give birth ― those born in the 1990s ― researchers had to restrict their study to women under 25 years old. The age limitation meant the findings can’t necessarily be applied to moms who give birth at older ages.

Many women are afraid to speak up.

The research was conducted in the U.K., but American clinicians and researchers believe the findings ring true for their patients as well.

“Pregnancy increases risk factors for depression in all women ― particularly those who experience a high-risk pregnancy, have pre-existing mental health conditions, and are struggling with socio-cultural and environmental stress factors,” said Mayra Mendez, a licensed psychotherapist at Providence Saint John’s Child and Family Development Center in Santa Monica, California.

Having a previous history of depression and anxiety is associated with a higher risk of depression during pregnancy.

Several studies suggest that in the U.S., millennials have higher rates of general depression than any other age cohort. A wide range of potential contributing factors, from loneliness to student loan debt, has been explored in research. But another generational characteristic ― a greater comfort with seeking help for mental illness ― could also be behind the apparent rise, Mendez said.

The psychotherapist said that perinatal depression is still often overlooked. While acceptance of mental health issues and treatment has improved, there remains a level of stigma ― particularly among marginalized groups like people of color and mothers ― that discourages some people from speaking out.

No woman wants to seem overly emotional or unstable during pregnancy. Kelly Glass, a mother who faced perinatal depression

There are many judgments about who is “fit” for motherhood, and those discussions can be particularly influential among women with depression and other mental health issues.

“Women wanting to have a baby or pregnant women may not reveal struggles with depression for fear of being criticized, condemned or stigmatized,” Mendez said. “Thus, social avoidance and stigma contribute to depression symptoms being overlooked and underreported.”

Glass was anxious about seeking help for a similar reason.

“No woman wants to seem overly emotional or unstable during pregnancy. Admitting to your doctor that you are struggling is not something that comes easy,” she said.

Doctors are not always much help.

The American College of Obstetricians and Gynecologists recommends that patients be screened at least once during the perinatal period for depression and anxiety. They also note that without follow-up and treatment, screening is ineffective. Unfortunately, very few medical professionals take the time to follow up and many women don’t speak up, which makes it difficult to diagnose perinatal depression.

“In some clinics or prenatal settings, symptoms can be missed as many of the symptoms of mood concerns during pregnancy may be confused with pregnancy symptoms, such as sleep disturbance or low energy levels. People typically associate ‘moodiness’ with pregnancy and also overlook it as a symptom of a mood concern,” said Melissa Whippo, a clinical social worker.

In her practice, Whippo said she sees about 10 to 15 women per week who report symptoms of depression during pregnancy.

Glass was one of the many women who didn’t receive much follow-up after she was screened for depression. Thankfully, the doctor did refer her to a therapist and she began taking medication. But not all women get the help they need, and many find themselves slipping through the cracks.

Brandy Gonsoulin was depressed during her unexpected pregnancy in 2016. Gonsoulin said she’d never had any intention of becoming a mother, but decided to go through with the pregnancy anyway. She found herself dealing with a lot of confusion about what life post-baby would look like. Despite this profound shift in life plans, she said that the medical professionals she dealt with didn’t consider she might be at an elevated risk for depression.

I feel that the medical community forgets the woman behind the pregnancy. Brandy Gonsoulin, another mother who struggled with perinatal depression

“I was generally unhappy with the fact that I was pregnant. Obvious things like crying or feeling sad/blue about the situation well into my third trimester,” Gonsoulin said in an email. “I generally avoided and didn’t want to talk about it or plan for it [or] accept it even though I knew I had to.”

She was referred to a therapist during her third trimester after she scored low on a screening exam, but she couldn’t find one within her insurance network. So she battled perinatal depression alone, and after giving birth she battled postpartum depression as well.

“I feel that the medical community forgets the woman behind the pregnancy,” said Gonsoulin. “This is a bigger part of how we treat pregnancy, but I feel like special elective therapy should be a part of prenatal care in addition to everything else, i.e., the check-ups, tests and breastfeeding classes.”

Moms need more support.

It’s clear that the health care system needs to do more to ensure that expecting mothers have access to effective mental health screening, support and treatment.

According to Whippo, failing to diagnose depression during pregnancy can have consequences for both baby and mom.

“We know that prenatal depression leads to poor outcomes for infants [such as] lower birth weight,” she said. “Additionally, women who experience depression during pregnancy are also at increased risk to suffer from depression in the postpartum setting.”

For this reason, Whippo and others noted that we need to be attentive to mothers post-birth, particularly if they have faced depressive symptoms during pregnancy.

“New moms need reassurance and inspiration to support their own as well as the emotional stability of their baby,” Mendez said. “When ... moms seek treatment, they are better able to care for themselves and promote a healthy attachment with their baby.”