Depression During Pregnancy and Postpartum Part 1: Prevalence and Diagnosis
Depression is the leading cause of disease-related disability among women in the world. In particular, women during their reproductive years are at high risk for major depression (MDD) (Robins et al, 1991). Perinatal depression, defined as depressive episodes that occur either during pregnancy or within the first 6 months postpartum, can have devastating consequences for both the woman experiencing it as well for her children and family (Marmorstein et al, 2004; Flynn et al, 2004).
Studies have demonstrated that perinatal depression has a prevalence rate of at least 10%, making it one of the most common complications of both the prenatal and postpartum period (Yonkers et al, 2001; Gaynes et al, 2005, Dietz et al, 2007). One of the primary risk factors for the development of postpartum depression (PPD) is the onset of depressive symptoms during pregnancy. Depression during pregnancy, also called "antenatal depression" has been associated with low maternal weight gain, increased rates of cigarette, alcohol and other substance use, ambivalence about the pregnancy and overall worse health status (Zuckerman et al, 1989; Suri et al, 2007; Orr et al, 2007). Other risks of untreated depression during pregnancy include the risk of ongoing depressive illness in the mother into the postpartum period, which may impair bonding between the mother and child, as well as the potential risk of impaired cognitive, emotional and social development in the child (Murray et al, 1999).
The first three months postpartum appear to be the most vulnerable period for the appearance of maternal depressive symptoms (Stowe et al, 2005; Munk-Olsen et al, 2006).
Baby Blues versus Postpartum Depression
Although most women will have some mild mood and anxiety symptoms in the first few days to weeks postpartum (the "baby blues"), these symptoms usually resolve spontaneously. More severe and persistent mood and anxiety symptoms in the postpartum period should arouse suspicion of the syndrome of PPD. The initial onset of PPD is usually within the first month of the postpartum period. Symptoms of PPD can differ in important ways from those of routine major depression (MDD) (i.e. depression that occurs in times outside of pregnancy or postpartum).
Symptoms of Postpartum Depression:
- Feeling sad, depressed, and/or crying a lot
- Intense anxiety, rumination, obsessions
- Loss of interest in usual activities
- Feelings of guilt or worthlessness
- Feeling incompetent or inadequate to cope with the new infant
- Fatigue, irritability, sleep disturbance
- Change in appetite
- Poor concentration
- Sleep problems (not being able to sleep even when the patient is sleeping, or wanting to sleep all the time).
- Excessive worry about the baby's health
- Suicidal thoughts
- Thoughts of wanting to hurt the baby.
Classic features of PPD include severe anxiety, agitation, difficulty making decisions, and suicidal thoughts or thoughts of hurting the newborn (Bernstein et al, 2008). PPD is also characterized by symptoms classically seen in major depressive disorder including feelings of being overwhelmed, feelings of guilt or worthlessness, tearfulness, changes in appetite, difficulty sleeping (even when the baby is sleeping), difficulty concentrating, and loss of interest or pleasure in activities. Because the mother's ability to function and attend to the child is impaired, PPD has been associated with lower quality interactions between mothers and their children (Stein et al, 1991), missed pediatric appointments and greater use of emergency department services (Flynn et al 2004), higher levels of psychiatric disturbances among children (Murray et al, 1989) and greater child insecurity in attachment relationships (Mamorstein et el, 2004).
As with most forms of psychiatric illness, identification of postpartum depression occurs after the onset of symptoms and when the new mother is already suffering. Although there is a literature on specific groups at increased risk, (i.e. women with a previous history of PPD or history of other mood disorder) (Robertson et al, 2004), many women develop PPD without a previous history of depression. The best care we currently have to offer is to provide routine screening of all postpartum women (i.e., diagnose PPD after it has already started), and well-validated screening instruments developed specifically for use during the perinatal period are readily available (e.g., Edinburgh Postnatal Depression Scale, EPDS) (Cox et al, 1987).
Bernstein IH, Rush AJ, Yonkers K, Carmody TJ, Woo A, McConnell K, Trivedi MH. Symptom features of postpartum depression: are they distinct? Depress Anxiety 2008;25:20-26.
Cox JL, Holden JM, Sagovsk R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987; 150: 782-6.
Dietz PM, Williams SB, Callaghan Wm, Bachman DJ, Whitlock EP, Hornbrook MC. Clinically identified maternal depression before, during and after pregnancies ending in live births. American Journal of Psychiatry 2007; 164:1457-9.
Flynn HA, Davis M, Marcus SM et al. Rates of maternal depression in pediatric emergency department and relationship to child service utilization. Gen Hosp Psychiatry 2004; 26(4): 316-22.
Gaynes B, Gavin N, Meltzer-Brody S. et al. Perinatal Depression: Prevalence, Screening Accuracy and Screening Outcomes, 2005 Agency for Healthcare Research and Quality (AHRQ).
Marmorstein NR, Malone SM, Iacono WG. Psychiatric disorders among offspring of depressed mothers: associations with paternal psychopathology. Am J Psychiatry 2004; 161(9):1588-94.
Munk-Olsen T, Laursen TM, Pedersen CB, Mors O, Morensen PB. New parents and mental disorders: a population-based register study. JAMA 2006;296:2592-99.
Murray L, Stein A. The effects of postnatal depression on the infant. Baillieres Clin Obstet Gynaecol 1989;3(4):921-33.
Murray L, Sinclair D, Cooper PJ et al. The socioemotional development of 5-year old children of postnatally depressed mothers. J Child Psychol Psychiatry 1999;40:1259-71.
Orr ST, Blazer DG, James SA, Reiter JP. Depressive symptoms and indicators of maternal health status during pregnancy. J Women's Health, 2007; 16(4) 535-42.
Robins L, Regier D. Psychiatric Disorders in America. New York: Free Press, 1991.
Robertson E, Grace S, Wallington T, Stewart DE. Antenatal risk factors for postpartum depression: a synthesis of recent literature. Gen Hosp Psychiatry 2004;Jul-Aug;26(4):289-95
Stein A, Gath DH, Bucher J, Bond A, Day A, Cooper PJ. The relationship between post-natal depression and mother-child interaction. Br J Psychiatry 1991;158:46-52.
Stowe ZN, Hostetter A, Newport DJ. Timing of symptom onset in postpartum women presenting with depression. Am J Obstet Gynecol 2005;Feb;192(2):522-26.
Suri R, Altshuler L, Hellemann G, Burt V, Aquino A, Mintz J. Effects of Antenatal Depression and Antidepressant Treatment on Gestational Age at Birth and Risk of Preterm Birth. Am J Psychiatry, 2007; 164:1206-1213.
Yonkers KA, Ramin SM, Rush AJ et al. Onset and Persistence of postpartum depression in an inner-city maternal health clinic system Am J Psychiatry 2001; 158(111):1856-63
Zuckerman BS, Amaro H, Bauchner I, Cabral H. Depression d uring pregnancy: relationship to poor health behaviors. Am J Obstet Gynecol 1989:160:1107-1111.