Depression And Pregnancy

pregnancy and depression

Depression in pregnancy is real. It can start just before pregnancy, and can continue up to two years after childbirth.

If you’re a woman between 18 and 45 years of age, two of the most common mental issues you could be dealing with are depression and anxiety. The risk of having these two psychiatric illnesses in women is highest during their fertile years.

Moreover, women who have previously suffered, they are more likely to relapse into depression during their pregnancy.

What Is Depression

Depression is not sadness. To be clear, sadness is just one part of depression.

Sadness is a natural part of human life. It is having unhappy feelings and negative mood for some of the times. All of us feel sad, but the important thing is it’s temporary.

But what happens in depression is more beyond sadness and blues. In depression, sadness is pervasive and continuous. And it needs urgent attention and treatment.

To diagnose depression, mental health professionals use the Diagnostic and Statistical Manual of Mental Disorders (DSM). It’s a standardized manual, which assures there is an uniformity throughout the world when a mental illness is diagnosed anywhere. It is published by the American Psychiatric Association.

If we take the DSM-4 criteria, depression is defined as 5 or more of the following nine symptoms continuously for 2 or more weeks:

  1. Low mood, irritability, or tearfulness, for most of the days
  2. Slowing of movements and speech, or agitation
  3. Lack of drive or interest in most activities
  4. Fatigue and loss of energy nearly every day
  5. Increased or decreased appetite, or weight change
  6. Sleeplessness or excessive sleep, and early morning wakening
  7. Feelings of worthlessness, hopelessness and helplessness
  8. Indecisiveness or dminished ability to think and concentrate
  9. Suicidal ideas or attempts, recurrent thoughts of death

Depression In Pregnancy

At least one in five women suffer from depression during their childbearing years. According to WHO, that figure of 22% doesn’t come down in pregnancy.

Pregnancy is also the time when women are more vulnerable to depression. The hormonal changes during this period can make the condition worse than otherwise. 

Not treating depression adequately may result in loss of life, because the risk of suicide in postpartum depression is all too real.

There can be two specific types of depression during pregnancy:

  1. Antepartum depression
  2. Postpartum depression

Antepartum Depression

The depression that occurs just before or during pregnancy is antepartum depression (APD). The 2001 Avon study verified that depression during pregnancy is more common than depression occurring after childbirth.

The more common symptoms of this depression are:

  1. Insomnia
  2. Tearfulness
  3. Fearfulness
  4. Irritability
  5. Constant low mood
  6. Panicky feelings
  7. Excessive worries

Some women also have early morning awakenings and suicidal thoughts.

The negative mood in the mother can directly affect the brain development of the fetus. The pregnant woman can also take to alcohol, tobacco and psychoactive drug abuse, which then risks the life of fetus.

The US Agency for Healthcare Research and Quality considers that following two simple questions are enough for detection of depression during pregnancy:

  1. Over the past 2 weeks, have you ever felt down, depressed, or hopeless?
  2. Have you felt little interest or pleasure in doing things during the same period?

Early detection is the key to treating it. The earlier the obstetrician or gynecologist starts screening for depression as a routine in any pregnancy-related consultation, the better the chance of preventing and controlling it.

Antidepressants In Antepartum Depression

The treatment of depression with drugs encounters problems during pregnancy because of the possible side effects of antidepressants on the fetus. The greatest potential for drug-related birth-defects occurs in the first 12 weeks of pregnancy.

Antidepressants in the last three months of pregnancy may cause serious problems for neonates, resulting in prolonged hospitalization, breathing support, and tube feeding. In October and December 2005, the FDA issued warnings that the use of the drug paroxetine in early pregnancy  may cause major congenital malformations.

Another effect of antidepressants is a higher stress level in the mother, which further affects fetal growth negatively.

However, antidepressants are the mainstay for treating moderate to severe depression.

Non-Drug Treatment In Antepartum Depression

The Policy Statement of the American Academy of Pediatrics considers psychotherapy as the first option for antenatal depression, and drugs are only indicated if psychotherapy is inadequate or inappropriate. Psychotherapy can be given as a group or individually. The woman should be encouraged to obtain social and family support.

Some recent studies consider the following to be effective: morning light or phototherapy, dietary changes and/or supplements, increase of physical activity (but criticized), chiromassage.

Postpartum Depression

Postpartum depression (PPD) can present at any time up to 1 year after delivery. However, there is a significantly increased risk during the first 5 weeks postpartum.

Postpartum depression occurs in 10 to 15 percent of mothers. Its symptoms are similar to depression in other settings, except that the mother’s lack of coping, and feelings of inadequacy and guilt, erode her relationship with her baby.

Thus, postpartum depression is sometimes described as a thief stealing away motherhood.

Depression after pregnancy strains marriage, wears away the mother’s confidence, limits her social functioning. In serious cases, it may lead to infant abuse, and even suicidal or infanticidal behavior.

Baby Blues

Postpartum depression is diagnostically different from the baby blues (maternity blues or postnatal blues). Baby blues is a commonly occurring self-limiting state of dysphoria. It usually does not require treatment unless it persists for more than 10 days. It is normal reaction to the hormonal changes and stress after delivery.

The Edinburgh Postnatal Depression Scale (EPDS)

Developed by John Cox and colleagues and first published in the British Journal of Psychiatry in 1987, the Edinburgh Postnatal Depression Scale is brief – consisting of only 10 items.

EPDS items

  1. “I have been able to laugh and see the funny side of things.”
  2. “I have looked forward with enjoyment to things.”
  3. “I have blamed myself unnecessarily when things went wrong.”
  4. “I have been anxious or worried for no good reason.”
  5. “Things have been getting on top of me.”
  6. “I have felt scared or panicky for no very good reason.”
  7. “I have been so unhappy that I have had difficulty sleeping.”
  8. “I have felt sad or miserable.”
  9. “I have been so unhappy that I have been crying”
  10. “The thought of harming myself has occurred to me.”

Scoring of the EPDS items

  • 0 – “Yes, as much as I always could.”
  • 1 – “Not quite so much now.”
  • 2 – “Definitely not so much now.”
  • 3 – “No, not at all.”

Depression Threshold

The depression threshold is an EPDS score more than 11, and women who score above this are likely to be suffering from a depressive illness. Mothers should be evaluated at childbirth, 3, 6, 9, 12, 18, and 24 months after childbirth.

Antidepressants In Postpartum Depression

First-line treatment for severe or prolonged postpartum depression includes starting an SSRI with possible addition of a benzodiazepine when extreme anxiety or insomnia is a presenting feature.

Two-thirds of women with postpartum depression recover by the end of the first year, and 90% by the end of the second year.

Breastfeeding: To minimize neonatal exposure to antidepressants in breast milk, the drug should be prescribed at the lowest effective dose, if possible.

Non-Drug Treatment In Postpartum Depression

Psychological counseling and social interventions can treat mild depression. Cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) have been shown to be useful in treating postpartum depression.

The main goal of CBT is to modify patients’ beliefs, which helps mothers change their thinking and behavior patters.. Additionally, increased family assistance and support improve mild forms of postpartum depression.

Effects Of Depression On Newborns

Studies in the UK showed that newborns of women with postpartum depression are more likely to have impairment in terms of socio-emotional and cognitive developments. Postnatal depression symptoms are also a consistent predictor of negative parenting behavior.

On a more practical note, PPD may lead to simple things as infant undernutrition and suboptimal childcare.

Four-year-old boys whose mothers had been depressed after childbirth lagged 15 points behind on IQ scales, and were still behind at 11 years old. They were also more emotionally and behaviorally disturbed.

Girls were not affected in the same way. 

At the age of 11, boys, but not girls, with low IQ saw themselves as having attention, emotional and behavior problems.

Postnatal Depression In Fathers

Mothers do not suffer a monopoly on pregnancy-related depression. It is Paternal Postnatal Depression when it happens in fathers.

Between 5-24% of fathers suffer from depression in the early postnatal period. In addition, what we know from studies is paternal postnatal depression is closely related to maternal depression. Fathers will likely have it if mothers suffer from it.

Other than mother’s depression, causes of paternal postnatal depression could be:

  1. unemployment
  2. low socioeconomic status
  3. psychiatric history
  4. marital discord
  5. neuroticism (excessive tendency to have negative emotions)
  6. younger paternal age
  7. first-time fatherhood

Paternal depression at 8 weeks doubles the risk of behavioral problems in the child at 3½ years of age. The effects is dominantly on boys. Paternal depression is less likely to affect a daughter’s behavior.

Final Words

Women with psychiatric disorders can bear and rear children as good as any other women. All they need is adequate care, support and treatment.

• • •

Source: Psychiatric Disorders in Pregnancy in the textbook Selected Topics in Obstetrics and Gynaecology -5 For Postgraduates and Practitioners, authored by Dr Sandip Roy.