The following comes from a presentation held April 7, 2006.
1. CPL All healthcare professionals working with pregnant and postpartum women are very aware of the risks of postpartum depression. We consider depression during pregnancy much less often. Is this a newly noted condition, or have we just been missing a lot of cases?
AB The first reference that I have seen to depression or 'melancholia' in pregnancy dates from the 1840's, so it is certainly not new. However, pregnancy has generally been thought to be protective against depression, if the drop in hormone levels after delivery is considered to be the precipitant for postpartum depression it would seem logical that higher levels would be beneficial. In addition, depression in pregnancy or antenatal depression tends not to grab the attention as much as postpartum depression which carries a much higher incidence of psychosis, and often leads to dramatic and public suicide and/or infanticide. Pregnancy may not be protective against depression, but does seem to be protective against suicide. A report from the UK reported that 12% of maternal deaths, pregnancy to one year postpartum, were due to psychiatric illness with suicide being the number one cause.1
2. CPL How common is depression during pregnancy?
AB It is no less common than postpartum depression. One study in the United States identified 20% of pregnant women studied as being clinically depressed.2
3. CPL Are the criteria for diagnosing depression in pregnancy any different from those outside pregnancy?
AB There is no difference, The DSM-IV criteria are listed on slides 4, 5 and 6 of my powerpoint presentation which is also available here.
4. CPL Could you give a quick review of issues in postpartum depression, which may be related to depression in pregnancy?
AB Of course. We all know that postpartum blues are normal on days 3-5 after delivery, but nowadays most women are discharged before this, while their mood is quite good, in fact this time has been coined the 'pinks'. Many women with severe postpartum blues do go on to postpartum depression, but they are at a significantly more likely to than those who do not experience severe 'blues'3. Depression in pregnancy does not necessarily mean depression after delivery, but 2/3 go on to postpartum depression. Sixty percent of women experience their first episode of major depression in the postpartum period. Possible causes may be the idealization of motherhood and their feelings of inadequacy in this role, lack of family or social support, maybe an older primipara who may be anticipating a perfect baby after a long wait, or hormonal changes, anemia or a multitude of preceding stressors which were present during the pregnancy but unrecognized. Just out of interest, fathers can also get the postpartum blues, which can give rise to impaired bonding with their child.
5. CPL What factors should we be looking for in our prenatal patients to avoid missing the diagnosis of depression?
AB Risk factors for depression are; being single or living with parents, partner discord or family violence, lack of social support, stress, substance abuse, previous depression, mood swings, low income, insecurity of ability to care for her family (food provision, etc.), low educational status, and being a member of an immigrant community or an aboriginal group (aboriginal women have a depression rate double the rate of general population). The findings on age and parity are mixed and inconclusive. Chronic disease, particularly when accompanied by disability or enforced bed-rest is implicated, as is ambivalence about the pregnancy, particularly when the woman has made attempts to receive a termination which have failed. (We are not aware of any studies on women who changed their minds and chose not to terminate). In addition anxiety about fetal health and a history of infertility (depression often precedes the infertility) are also factors. Of course a big factor is discontinuation of existing anti-depressant therapy.
6. CPL Are there any presenting features that should raise suspicion of depression in pregnancy?
AB Somatic complaints are a common presenting feature. The problem is that they often appear to be pregnancy related, although they would be a flag for depression in any other situation. A Californian study in the United States showed 23% of multiple physical presentations were associated with anxiety and depression, with an average of 6 complaints per patient. Nausea is a big factor, 93% of depressed pregnant women complained of nausea compared with 66% of non-depressed women.4
7. CPL There are so many factors to continue in assessing pregnant patients, why is antenatal depression such an important area?
AB Depression in pregnancy affects mother, baby and the family and depression is more common than most of the medical conditions that we screen for during prenatal visits.
One common feature of depression is sleep disorder, and as part of a cycle sleep deprivation feeds back to worsen depression. Women who are depressed tend to socially withdraw, tend to worry excessively about the health of the fetus, the progress of the pregnancy and their future parenting skills. Although they attend their physicians' offices frequently for many somatic complaints, they tend not to attend schedules prenatal visits, or not comply with professional advice and not to take prenatal iron and vitamin supplements as consistently. Lack of prenatal care is often accompanied by poor personal, health and nutrition care; in fact, many depressed prenatal patients do not understand the need for good nutrition and supplements. Although pregnancy is protective against suicidal action, in one study in the United States 40% of women who were depressed in pregnancy admitted to suicidal ideation in the last seven days of pregnancy.4 An issue, new to me, was that of fetal abuse in which women report hitting or punching the abdomen, or pressing the abdomen into table edges, but also by engaging in high-risk behaviours.
8. CPL Is depression in pregnancy related to substance abuse?
AB Yes, although overall depressed women abuse substances less than men. There is a strong correlation between alcohol abuse and depression in pregnancy with all the concerns about Fetal Alcohol Spectrum Disorder, which accompany this, we need to be concerned about co-morbidity. The risk of suicide is also increased when alcohol use in involved. As well as substance abuse, smoking seems to increase with parity and may be a stress management mechanism. The first thing that we do in pregnancy is to advise women to stop smoking and drinking alcohol, while research has shown that smoking cessation and alcohol withdrawal are associated with depression. It is very important that we recognize these risks and observe patients for signs of depression.
9. CPL Has depression in pregnancy been well studied?
AB Stress and anxiety in human pregnancy has been studied more than depression. Animal studies in monkeys and rodents show release of Corticotrophin Releasing Hormone (CRH) and cortisol and other chemicals like catecholamines during stress. Some stress in pregnancy is inevitable, but presentations at a conference in the United States after Hurricane Katrina raised awareness of the issue showed that acute stress, for example earthquake stress, affected women in first trimester in terms of organogenesis, while later stress affected neurological and psychological development. Under stress, the levels of cortisol increase, which affects receptors in the fetal brain. After 35 weeks gestation, this has been shown to produce higher fetal heart rate with reduced variability. (this was contradicted by one small study). Response to stressors is reduced or delayed in fetuses of depressed women. After delivery, the baby continues to demonstrate stress responses (much as diabetic babies produce too much insulin even when the high glucose environment is absent).
There is increased resistance in blood vessels of the placenta with associated Intra Uterine Growth Restriction, uterine irritability, and preterm delivery. High cortisol levels also affect the mood of the mother herself. After delivery it has been shown that depressed women are slower to respond to their infants' cues.
10. CPL What other factors should physicians and nurses be aware of in assessing newborns of depressed mothers?
AB The lives of children of depressed mothers are profoundly affected by their mother's illness. Newborns of depressed mothers have been demonstrated to have lower Apgar scores, and their possible IUGR and pre-term delivery makes them vulnerable to perinatal respiratory and neurological abnormalities which results in more time spent in Neonatal Intensive Care Units. In the perinatal period they are often less active than other newborns and appear to be less consolable when crying. After the perinatal period these babies are more likely to have lower developmental scores and to show features of failure to thrive, are less likely to be breastfed or to imitative behavior, and have a higher incidence of Sudden Infant Death Syndrome. In later childhood they appear to have a higher incidence of ADHD and ADD (particularly in boys), and depression (particularly in girls) and to experience school and social difficulties. To exacerbate this, research has also shown that partners of women with postpartum depression (no details available on antenatal depression) are 50% more likely to be depressed than the norm.
11. CPL It sounds as if health care professionals are not identifying depression in pregnancy very successfully.
AB Unfortunately, this is so. It is a sobering thought that Family Physicians detect only 12% of suicidal thoughts in their patients and 60% of people who progress to suicide have seen a doctor in the last month. In general, pregnant depressed women are under-diagnosed and under-treated despite seeing health professionals more often than other pregnant women. Some provinces are attempting to change this. BC will screen at 22 - 26 weeks and twice in the postpartum period starting in 2007. In Calgary all women are screened for depression at six-weeks postpartum, but not antenatally, in Edmonton screening takes place at their infants immunization visits (again too late for antenatal depression). Hamilton, ON uses a screening tool in doctors' offices, with psychiatrist support available for rapid response to high scorers. The screening tool most commonly used is the Edinburgh Post Natal Depression Scale (EPDS), a scale which has been used for 20 years and has been well validated in pregnancy. The EPDS excludes physical symptoms that may confuse the picture of depression in pregnancy. A score of >10 indicates minor depression and of >13, major depression. Most Family Physicians detect 25-50% of depressed patients without the tool, and up to 70% with tool. The EPDS can be obtained here.
The tool is acceptable to patients and to caregivers, and it also detects anxiety and suicidal ideation. I must stress that this is only a screening tool, and will have false positives and false negatives, a clinical interview and follow-up is essential in response to any abnormal result.
12. CPL If we begin to be more proactive in looking for depression in pregnancy we need a plan for management of what we find. In addition to specific antidepressant pharmacotherapy what modalities have been shown to be effective?
AB Interpersonal or Cognitive Behavioral Therapy (CBT) have not been well studied in pregnancy, but has been shown to be more effective than education in postpartum depression. Patients experiencing this therapy state that the skills learned in CBT provided coping mechanisms in their future lives also. In the United Kingdom supportive listening visits by lay support people have been shown to prevent postpartum depression, and many of these outreach workers are been given training in intervention strategies. Family education about depression is helpful, and support for daily chores and activities may relieve stressors the women experience. Health professionals need to be aware of changes in symptoms, in self care, mood and in eating habits when monitoring progress. Early reports on Bright Light Therapy, which has been used in seasonal affective disorder, are encouraging, and outdoor exercise to make use of passive phototherapy is effective, as is swimming which supports the growing abdomen during exercise. Folic acid that is recommended in pregnancy to reduce neural tube defects also has an antidepressant effect, as have the Omega 3 fatty acids.
13. CPL There will be many situations where these interventions will not be rapid enough to produce the necessary response. What other interventions are available and what are their risks?
AB Medication will be a major factor in women with severe symptoms. 80% of women who become pregnant are taking some medications, and 35% already taking psychotropic drugs. Although the first instinct of women who realize they are pregnant is to discontinue all medications, this not a strategy to be encouraged, particularly since 50% of pregnancies are probably unplanned, and the teratogenicity risk is highest in first month when women often do not know they are pregnant. The first line of treatment for depression in pregnancy is still Fluoxetine (Prozac) and SSRI, though Citalopram (Celexa) a more selective antidepressant, is also used. If the patient is already on a medication which is working for them, there is no indication to change to Fluoxetine, except in the case of Paroxetine (Paxil) which has recently been implicated in cardiac malformations. There have been concerns about increased neonatal pulmonary hypertension with SSRI use, which can be fatal. Neonatal adaptation syndrome can occur in babies born to women taking SSRIs , but although 5% of babies with this condition require NICU admission it is transient and manageable. Other signs of neonatal withdrawal include floppiness, sleepiness, and reduced pain response. Venlafaxine (Effexor) does not appear to have any contraindications at present, but the literature is changing constantly, and all health professionals need to be aware that this is a rapidly changing field. In general, aim for lowest possible dose, but this raises concerns about inadequate therapy i.e. risks without benefit. Studies have shown psychiatrists tend to prescribe lower doses of drugs as compared to neurologists who use the same drugs in different clinical settings with pregnant women, and Family Physicians prescribe even lower doses as compared to psychiatrists. Some advise tapering the dose close to delivery to reduce perinatal effects on the infant, but then we must monitor the woman closely since the intrapartum period is the worst for depression and anxiety. In general, we need also to check that the drug is actually taken, filling the prescription is not a guarantee of this. A word of caution about St John's Wort, this over-the-counter medication is commonly used as a "natural" antidepressant (although it has been proven to be no more effective than placebo). It has a monoamine oxidase inhibitor-type effect and is contraindicated in pregnancy.
14. CPL Sometimes even the delay in achieving therapeutic levels can be too long in a severe case, and some women are not willing to consider medication at all. What can be done in these cases?
AB Electro Convulsive Therapy, although this is counterintuitive in pregnant women, has been found to be very effective in depression management in severe cases. This carries a small risk of abruption, but in extreme cases the risks of not treating are so high that it becomes a reasonable option.
15. CPL Thank you Angela, this has been a fascinating presentation. What do you see as the challenges in providing better care for depression in pregnancy?
AB There are many challenges. Firstly the need to develop teams of health professionals, Nurses, Nurse Practitioners, Family Physicians, Obstetricians and Psychiatrists able to give integrated approach to the care of women in the child-bearing years. We need to encourage the use of an effective screening tool for antenatal depression available to all health practitioners, and to develop a follow up and surveillance process. It would be beneficial to include a section on screening for antenatal depression in the Saskatchewan Prenatal Form. We hope that future research to study the long term effects of prenatal depression on mothers and babies will assist us in focusing our services where they are needed.
Now you're ready to take the quiz!
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