Depression in

Depression in
Pregnancy
Pregnancy
PRESENTATION BY: SYLVIE TELLIER
May 27
th
2011
Objectives

Facts about Depression in Pregnancy

Risk Factors

Depression Scales How to assess?

Untreated Depression - Risks to Mother and

Fetus

Treatment Guidelines

Weighing the Pros and Cons

Barriers to Treatment

Hidden Truths

Approximately 10% of women in the general

population will experience depression during
pregnancy.

50% of women with postpartum depression

had symptom onset in pregnancy

Estimated that only 25-35% of pregnant

women with a mood or anxiety disorder
receive mental health treatment
H
i
d
d
e
n

T
r
u
t
h

Overlap of
symptoms of
depression
with
symptoms of
pregnancy
may obscure
diagnosis

Risk Factors for antenatal Depression

History of Mood Disorder

History of pregnancy-related Depression

Abrupt or premature discontinuation of

antidepressants

Unwanted pregnancy

Lower SES, poor marital relationship, lack of

support

Family history of Depression

Significant medical/obstetrical problem

Others...
Detecting Depression in Pregnancy

Often unrecognized, diagnosis is missed

DSM IV diagnostic criteria identical for gravid

and nongravid women

Overlapping symptoms common in both

pregnancy and depression:

Edinburgh Postnatal Depression Scale and the

Center for Epidemiologic Studies Depression
Scale

UNTREATED DEPRESSION

The consequences
Untreated Depression
Maternal risks

Risk of post-partum mental illness

Increased risk for substance abuse, lack of

prenatal care, lower appetite and poor
weight gain.

Discontinuation of antidepressant during

pregnancy may increase risk of relapse of
major depression. [level 2]

Maternal Suicide

Transfer of Depression to the Fetus

Maternal depression/anxiety affects

expression of a gene poss l
m n sm or t(s
o m t rn l moo on t l
n uro v lopm nt?

Infants born to women with depression group

have significant ACTH elevation at birth

Changes in the HPA axis r

m t rn l n t l
p n p r n n N

Untreated Depression
Risks to the Fetus

Increased Incidence of preeclampsia, pre-term

birth, LBW

decreased fetal growth, smaller head

circumference, lower Apgar scores, postnatal
complications.

Increased newborn cortisol, catecholamines,

infant crying, rates of NICU admission

Impaired Bonding

NON PHARMACOLOGICAL
TREATMENT OPTIONS
Non-Pharmacological interventions

Current guidelines suggest psychotherapy be

considered as a primary treatment option for
depression during pregnancy

Especially in the first trimester (when

organogenesis is most active)

ECT 57 articles evaluated by Anderson et el.

85% of patients had at least partial
response

Light Therapy, Exercise

TMS - case reports showed improvement in

maternal depression, but there have been
no systematic study yet
TREATMENT OF MOOD
DISORDERS

Recommendations
Recommendations: Pregnant
women currently on medication
for depression
Continue with
Current Medication
DiscussRisk/Benefitswithpsychiatristand
Ob/Gyn
WouldliketoD/ C
Medication
MayattempttaperingandD/Cifnot
symptomatic.
Womenwithahistoryofrecurrent
depressionareatahighriskofrelapseif
medicationisdiscontinued.
Recurrent
depression ,
symptoms despite
medication
Maybenefitfrompsychotherapytoreplace
oraugmentmedication.
Severe depression
(suicide attempts,
functional
incapacitation, weight
loss)
shouldremainonmedication.
Ifapatientrefusesmedication,alternative
treatmentandmonitoringshouldbeinplace,
preferablybeforediscontinuation.
ECT,TMS
Recommendations: Pregnant
women not currently on
medication for depression
Women who would
like to avoid
antidepressant
medication
Psychotherapy
Prefer to take
medications
DiscussRisksandBenefitsinclude
factorssuchastageofgestation,
symptoms,historyofdepression,and
otherconditionsand
circumstances(e.g.,asmoker,difficulty
gainingweight).
Psychoeducationforpatientandpartnerisimportant.
Otheroptions:Individualorgrouptherapy,interpersonalor
CBT
WHICH ANTIDEPRESSANTS
ARE APPROPRIATE?
Treatments Of Depression During
Pregnancy - Antidepressants
Treatments Of Depression During
Pregnancy - Psychotropics
Maternal and Fetal Risks With Medical
Treatment

SSRIs

Increased risk of congenital malformations [level

2]

Increased risk of septal heart defects [level 2]

Paroxetine congenital malformations [level 2]

Poor neonatal adaptation syndrome (PNAS) -

occurs with all antidepressants

Irritable, hypertonic, tremor, jitteriness, difficulty

feeding

Adverse perinatal events: preterm delivery,

neonatal RDS, NICU admission [level 2]

Persistent pulmonary hypertension of the newborn

reported to occur after exposure to SSRIs

TCAs

relatively safe profile

PNAS has been reported

Barriers to Treatment

Patient Barriers: social stigma, cost of

treatment, insurance coverage?, lack of
knowledge about where to seek treatment ,
fear of potential complications

OB/GYNs identified time constraints, along

with inadequate reimbursement for
screening and treatment, as the primary
impediments to delivering appropriate
referral and treatment for depression.

Another barrier is the lack of training to treat

depression; a study by Dietrich et al.
reported that fewer than half of newer
obstetricians felt their residency had
prepared them to diagnose depression.
Bibliography

Public Health Agency of Canada (PHAC). (2005). Depression in

Pregnancy. Accessed online 2011-05-16 at [
http://www.phac-aspc.gc.ca/mh-sm/preg_dep_e.html]

Bonari L, Pinto N, Ahn E, Einarson A, Steiner M, Koren G.

Perinatal risks of untreated depression during pregnancy.
Can. J. Psychiatry 49(11), 726-735 (2004)

Einarson A, Selby P, Koren G. Abrupt discontinuation of

psychotropic drugs during pregnancy: fear of teratogenic
risk and impact of counselling. J Psychiatry Neurosci 2001;
26: 44-8

Lundy B, Field T. Newborns of mothers with depressive

symptoms are less expressive. Infant Behav Dev 1996; 19:
419-24

National Institute for Health and Clinical Excellence

(NICE).Antenatal and postnatal mental health: Clinical
management and service guidance, Clinical Guideline No.
47. London: NICE, 2007

Marcus, SM, Flynn, HA, Blow, FC, Barry, KL. Depressive

Symptoms among Pregnant Women Screened in Obstetrics
Settings. J Womens Health (Larchmt) 2003; 12:373.

Bibliography Cont...

Dietrich AJ, William JW, Ciotti MC, et al.

Depression care attitudes and practices of
newer obstetrician-gynecologists: a national
survey. American Journal of Obstetric and
Gynecology, 2003; 189:267-273.

Field T, Diego M, Hernandez-Reif Met al.:

Comorbid depression and anxiety effects on
pregnancy and neonatal outcome.Infant
Behav. Dev.2003; 33(1), 2329

Williams JW Jr, Rost K,DietrichAJ,etal.

Primary care physicians approach to
depressive disorders. Effects of physician
specialty and practice structure.Arch Fam
Med.1999;8:58-67.