Perinatal Depression: Still Overlooked, Undertreated

Denver, CO—A packed room for a presentation on perinatal depression at the Association of Women’s Health, Obstetric and Neonatal Nurses 2011 annual convention made clear that although the risk for depression in pregnancy and postpartum is well known, its treatment still frustrates healthcare providers and patients.

Jeanne Watson Driscoll, PhD, PMHCNS-BC, is a clinical nurse specialist in adult psychiatric-mental health, and President, JWD Association, Wellesley, Massachusetts. She provides psychotherapy and pharmacotherapy for women who experience mood and/or anxiety disorders through the childbearing years, and currently is writing a book on posttraumatic stress disorder related to childbearing. “

While psychopharmacology works in many patients, psychotherapy is a priority with me,” Dr Driscoll said. “Every woman’s metabolic system is different, but the typical approach is, ‘She’s crying. Give her Zoloft.’”

Dr Driscoll takes a decidedly comprehensive approach to her patients. She pointed out that “context is critical,” and emphasized the need for a collaborative approach that involves psychotherapy, not just medication.

Understanding the Condition:

Perinatal depression is not limited to the immediate postpartum period; it can strike anytime up to 1 year after delivery. Early recognition is important to avoid a “public health emergency” that places both mother and baby at risk. “This patient does not have time to wait,” she emphasized.

The probable etiology of perinatal depression is a convergence of hormonal factors, genetics, and life stressors and the woman’s response to them, according to Dr Driscoll. Women most at risk for major depression during the perinatal period are those with a history of depression or bipolar disorder or a family history of mental illness. Posttraumatic history, poor coping history, history of infertility, marital conflict, lower socioeconomic status, and lack of social support are also part of the risk factor constellation that should be assessed during antenatal visits.

“I tell patients at risk that they have a 72% chance of developing postpartum depression if they have a prior history of depression, and that they deserve a wonderful postpartum, so they need to be treated,” she said. “I promise them they will get better. And, in truth, I’ve never seen anyone not get better in my 30 years of experience.”

“But bear in mind, in your assessment, if you ask questions the wrong way, you won’t get enough information,” she added. “And if you pick up on something during questioning, reschedule another visit and listen to your gut.”

Dr Driscoll recommended screening with the Edinburgh Postnatal Depression Scale and the Postpartum Depression Screening Scale. Typical symptoms of major perinatal depression include:

• Disturbed sleep (ie, too little or too much)
• Appetite changes
• Mood lability
• Sense of failure in the maternal role
• Anxiety or irritability
• Excessive fears regarding the baby’s health
• Inability to be reassured
• Panic attacks
• Suicidal ideation
• Physiological symptoms, such as headaches, stomach aches, and bowel changes.

“Assessment is critical. Listening to your patient’s story is important, and devaluation of her mental status will just make things worse,” Dr Driscoll said. “Never say, ‘You’ll be fine, it’s just your hormones.’”

Treatment Issues

When a woman is known to be at risk or is already receiving antidepressants, planning is critical, she stressed. Because any woman of childbearing age can become pregnant, providers should prescribe any antidepressant cautiously before a pregnancy. They should stay abreast of the latest data regarding medication safety in pregnancy, use those with proven track records in the lowest effective doses, obtain informed consent, document the decision-making process, and communicate with all care providers (Sidebar).

Ideally, antidepressants would be avoided in pregnant women, but often this is not possible, she noted. “Unfortunately, there are still obstetrical providers who will say a pregnant woman cannot be on these, but I would tell this patient to get a new doctor who is up to date and listening to you,” she said.

In a 2011 study, a small increased risk for spontaneous abortions and preterm delivery were the only adverse outcomes definitively associated with the use of antidepressants in pregnancy (Lorenzo L, et al. Expert Opin Drug Saf. 2011 May 5. Epub ahead of print).

Women should try to avoid starting antidepressants until the second trimester. For those who present for perinatal care and already are receiving medication, the medication should not be rapidly discontinued, because of the potential for withdrawal effects.

Dr Driscoll emphasized that women with perinatal depression should receive not just a pill, but also psychotherapy. This can enlarge a woman’s capacity to bear the symptoms, reinforce coping strategies, and provide a safe place for her to work on problematic issues, she said, adding that “this relationship is vital.”

Finally, she emphasized that there is no excuse for a woman to remain symptomatic throughout her pregnancy, because with collaborative interventions, virtually all women can be helped. However, patients and providers should not expect a quick fix. “Remember, pregnancy and postpartum are processes that take about 2 years,” Dr Driscoll pointed out.