When Depression Complicates Childbearing: Guidelines for Screening and Treatment During Antenatal and Postpartum Obstetric Care
Section snippets
Background and prevalence
Across the United States, prevalence studies show that 1 in 5 women experience an episode of major depressive disorder (MDD) during their lifetime.1 The onset of depressive symptoms is seen most often between ages 20 and 40, the prime age range for childbearing.2 Studies have shown that 10% to 16% of pregnant or postpartum women fulfill the diagnostic criteria for MDD, and even more women experience subsyndromal depressive symptoms, which frequently are overlooked.3, 4 Because of this
Clinical Features and Risk Factors
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) defines the diagnosis of depression using the same criteria for men and women, although research shows some variation in female presentation. MDD diagnosis must include existence of depressed or irritable mood or inability to experience pleasure. In addition, 4 of the following symptoms must be present: feelings of guilt, hopelessness, and worthlessness; sleep disturbance (insomnia or hypersomnia); appetite or
Screening
In 2002, the US Preventive Services Task Force published findings that a positive answer to either or both of 2 universal depression screening questions was a quick and effective way to screen for depression: (1) “Over the past two weeks, have you ever felt down, depressed, or hopeless?” or (2) “Have you felt little interest or pleasure in doing things?” Affirmative answers initiate a more in-depth screening tool to gather more information toward the diagnosis.14 The 2 measures used most
Consequences of depression in pregnancy
Unidentified and untreated depression can have detrimental effects on mother and child. Suicide is the most catastrophic possible outcome of undertreated depression. In addition, depressed women are more likely to participate in unhealthy practices during pregnancy, such as smoking and illicit substance abuse. These women have higher rates of poor nutrition, in part because of lack of appetite, leading to poor weight gain during pregnancy and risking intrauterine growth retardation. Depressed
Treatment of depression during pregnancy
There are few current medical standards for treatment of women who have depression during pregnancy, in part because ethical constraints preclude randomized controlled trials using pharmacotherapy during gestation. Most women do not seek treatment, but for those who do, many physicians are unsure of how to balance maternal medication needs with risk for exposure to the growing fetus.42 Because many pregnancies are unplanned and undetected for some time, all women of childbearing age should have
Spontaneous abortion
Research results are mixed when examining rates of antidepressant use and its relationship to spontaneous abortion, and may be confounded by methodological problems (small study samples) or the effects of the illness itself.47 Although prior work linked bupropion exposure in pregnancy with significant risk for spontaneous abortion,48 a more recent study using a large sample of 940 women taking various antidepressants (including selective serotonin reuptake inhibitors [SSRIs], bupropion, and
Teratogenicity
The literature on antidepressant use is growing, particularly regarding the use of SSRIs during pregnancy and possible risk for teratogenicity. Although the popular press creates controversy regarding the safety of SSRIs, research to date does not confirm major congenital malformations.50 In 2005, GlaxoSmithKline51 published a report based on a claims database study of 815 infants that showed babies born to mothers who were taking paroxetine during their first trimester had a 1.5- to 2-fold
Neonatal adaptation
Studies show that up to 30% of infants exposed to SSRIs in utero during the third trimester are likely to have symptoms of poor neonatal adaptation.55 These symptoms include short-term self-limited jitteriness, tachycardia, hyperthermia, vomiting, hypoglycemia, irritability, inconsolable crying, abnormal muscle tone, eating difficulties, sleep disturbances, seizures, and respiratory distress,55 which lead to an overall increased rate of neonatal ICU admissions for these newborns. A recent paper
Nonpharmacologic treatments
Psychotherapy also has been studied in the treatment of depression and is considered to be an evidence-based treatment of mood disorders.71 Interpersonal psychotherapy (IPT) or cognitive behavioral therapy (CBT) in particular are commonly recommended psychotherapeutic treatments for unipolar depression.72 IPT is useful in addressing interpersonal conflicts, role transitions, and unresolved grief. In addition to improving symptoms, IPT has been shown also to improve social functioning.71 CBT
Background, Prevalence, and Clinical Features
Postpartum depression develops in approximately 10% to 20% of women who give birth,79 with higher percentages in adolescents, mothers of premature infants, and women living in urban areas.80, 81 Women who have low income and limited partner support also are at higher risk.82, 83 Women with 2 or more risk factors are more likely to have stable depressive symptoms across the first 2 years post partum.84 Postpartum depression often is undetected and commonly underdiagnosed.85 Many women expect an
Risk factors and epidemiology
Risk factors for postpartum depression should be identified before or during pregnancy and discussed at length between patient and provider. Many women who develop postpartum depression have had antenatal symptoms of depression.92 Once a woman experiences postpartum depression, she is at risk for depression relapses with or without additional pregnancies.93 Research shows that women who have had previous episodes of postpartum depression have a 25% risk for recurrence.94 Experts debate whether
Identification and screening of postpartum depression
Health care providers can have difficulty differentiating postpartum depression symptoms from the normative adjustment of a woman to a new infant. Physicians should take into account the circumstances (eg, extreme fatigue, even though a baby may be sleeping through the night) and intensity of the symptoms.85 Routine postpartum visits and well-infant pediatric visits present an ideal time for depression screening.97 Although referral to a mental health clinician can be an important part of
Treatment of postpartum depression
Antidepressant medication and psychotherapy are the foundation of treatment of postpartum depression. SSRIs are medications prescribed most commonly but other agents should be considered with a patient's prior positive treatment response. Because of the high risk for recurrence in women who have a previous history of postpartum depression, 1 study suggests providing prophylactic sertraline to prevent onset of symptoms.94 Some literature suggests that women who have postpartum depression may be
Summary
Obstetric care providers need to be aware that depression in women during their childbearing years is common. Routine depression screening, particularly at prenatal care visits, coupled with the use of physician collaborators to assist in connecting women with care, is paramount. During prenatal interviews, providers should be aware of risk factors for depression, including previous history of depression and interpersonal conflict. Links have been made between depression during pregnancy and
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Cited by (53)
Longer wait time after identification of peripartum depression symptoms is associated with increased symptom burden at psychiatric assessment
2022, Journal of Psychiatric ResearchCitation Excerpt :Untreated peripartum depression (PD) is associated with negative maternal and neonatal outcomes including preterm birth and neonatal death (Accortt et al., 2015), maternal suicide (Howard and Khalifeh, 2020), impaired maternal bonding with the infant (Slomian et al., 2019), and negative neurodevelopmental outcomes in both early childhood and adolescence for offspring of women with persistent or more severe symptoms as assessed by the Edinburgh Postnatal Depression Scale (EPDS) screening tool (Cox et al., 1987). Untreated depression in pregnancy also decreases engagement in prenatal care (Muzik et al., 2009) and corresponds to poorer physical health (Alhusen et al., 2016), which combined with psychological stress may further influence neonatal and child development through epigenetic factors (Robakis et al., 2020). Cases of PD may benefit from psychiatric assessment and potentially psychopharmacologic treatment.
Snoring and depression symptoms in pregnant women
2021, Sleep HealthCitation Excerpt :Prenatal depression is a predictor of postpartum depression35 and intervening in the prenatal period is effective in preventing postpartum depression.36 Untreated prenatal depression is also associated with substance abuse,37 poor birth outcomes,38 impaired maternal-infant bonding,39 and increased risk for developmental delays5 and mental illness in infants.40 In severe cases, depression can lead to death by suicide.
Inflammation and kynurenine pathway dysregulation in post-partum women with severe and suicidal depression
2020, Brain, Behavior, and ImmunityCitation Excerpt :Peripartum depression (PPD), defined as depression with onset during pregnancy and up to four weeks after delivery, affects 15–20% of all pregnant women worldwide (Gavin et al., 2005; Ko et al., 2017; Muzik et al., 2009).
A practical guide to the use of psychotropic medications during pregnancy and lactation
2019, Archives of Psychiatric Nursing
This is an updated version of the article “Depression in childbearing women: when depression complicates pregnancy,” which appeared in Primary Care: Clinics in Office Practice (Volume 36, Issue 1, March 2009).