Pregnancy is supposed to be a happy time. That is what the greeting cards say, and what strangers in the grocery store seem to expect when they smile at a growing belly. Friends ask whether she is excited. Relatives tell her she is glowing.

But some expectant mothers do not feel that way at all. They feel flat, anxious, weepy or hopeless, and then they feel guilty for not feeling the joy everyone expects. Depression during pregnancy is real, and it can be easy to miss, both for the woman herself and for the people around her.

Why it is so often overlooked

Many signs of depression overlap with the ordinary discomforts of pregnancy. Tiredness, poor sleep, changes in appetite and mood swings are all common when a woman is expecting. So when she says she is exhausted or not hungry, it is natural to chalk it up to the pregnancy.

Many women also hesitate to say how they really feel. They may worry that admitting sadness means they do not love the baby, or that they will be judged as unfit to be a mother. So they keep smiling at the baby shower and cry in the car afterward.

Depression can show up in any pregnancy, planned or unplanned, first or fourth. It may be more likely after a past loss, during a stressful time, or when a woman has struggled with her mood before.

What partners and families can notice

The difference is usually in how long the feelings last and how deep they go. Pay attention if she:

• Seems sad, empty or anxious most of the day, nearly every day, for two weeks or more
• Has lost interest in things she normally enjoys, including planning for the baby
• Seems to dread the birth or the baby's arrival rather than look forward to it
• Pulls away from friends and family or stops answering messages
• Says she will be a terrible mother, or feels worthless and guilty
• Talks about feeling hopeless, or about not wanting to be here

Opening the door

The kindest thing a loved one can do is make it safe for her to say the truth. Choose a calm, private moment. Tell her plainly that she has seemed down lately and that you are worried about her. Let her know that plenty of women feel this way during pregnancy and that it does not make her a bad mother.

Then ask how she is really doing, and give her time. Try not to fill the silence with reassurance about how wonderful the baby will be. She may need to be heard more than cheered up.

If what she says sounds hopeless, ask the direct question: Are you having any thoughts of suicide? It is a hard sentence to say. But asking does not plant the idea. It tells her she can be honest with you, and honesty is often the first step toward getting help.

If she says yes, stay with her, stay calm and help her reach care right away. Do not wait for the next scheduled appointment.

Care during pregnancy

Prenatal visits come often, especially later in pregnancy, and they are a natural place to talk about mood. Many offices ask about depression during pregnancy as well as after birth. Encourage her to answer those questions honestly, and offer to come with her or to help her jot down what she wants to say. Her doctor or midwife can talk with her about counseling and other options that are appropriate during pregnancy.

After the baby arrives, her postpartum checkups and the baby's pediatric visits will continue to screen for depression. That means there will be more chances to check in. Her mood during pregnancy is still worth raising now, not later.

The National Maternal Mental Health Hotline serves women who are pregnant, not only new mothers. She or someone close to her can call or text 1-833-852-6262 for free, at any hour, to talk with a counselor and find support nearby.

At home, lighten her load where you can. Help her rest. Go with her on walks. Take on some of the planning and shopping for the baby so it does not all rest on her shoulders.

Not every pregnant woman glows. Some are quietly struggling. Noticing that, and asking plainly, can help her get support before the baby comes.

If you or someone you know is thinking about suicide, call or text 988, the Suicide and Crisis Lifeline, any time. In an emergency, call 911.