COMMENTARY

Mental Health Issues in Pregnancy and Options for Treatment

Ann M. Sweet, RN, BS, NP-C; Thomas L. Schwartz, MD

Disclosures

July 07, 2009

In This Article

Introduction

Motherhood is supposed to be a wonderful and fulfilling experience. Pregnancy, childbirth, and caring for a new infant are considered to be a time of great joy. This is true for many new mothers. But for women with perinatal or postpartum depression, the experience of childbirth can be overwhelming. It can be filled with feelings of sadness, hopelessness, anxiety and fear. Although there is evidence of the negative consequences of depression during pregnancy, treatment is often limited and difficult to obtain. Women with mental health issues during pregnancy may:

  • Be unable to care for themselves properly;

  • Fail to obtain proper prenatal care; and

  • Be involved in dangerous behaviors.

After the birth of the baby, continued depression may lead to a negative effect on infant development and maternal-infant bonding.

Pre-, Peri-, and Postpartum Use of Psychotropic Medications

The use of psychotropic medications during pregnancy may be appropriate in certain clinical situations. The most commonly prescribed antidepressants in pregnancy are the selective serotonin reuptake inhibitors (SSRIs). Studies in this specific population have been published regarding fluoxetine (Prozac®) since 1993. According to Ward and colleagues, psychopharmacologic medications and their metabolites cross the placenta by simple diffusion and can affect the fetus in several ways[1]:

  • Structural teratogenesis (birth defects that can occur in the first trimester);

  • Behavioral teratogenesis (behavior or neuropsychiatric symptoms after in utero exposure to a drug); and

  • Perinatal syndromes (use of drugs proximate to delivery possibly causing drug intoxication or withdrawal).

Therefore, the benefit of using psychotropic medications must be weighed against exposure of the fetus to these medications.

Reaching This Population

Addressing the mental health of pregnant women is frequently overlooked or minimized. These women often feel ashamed to admit to anyone that they are feeling depressed or anxious. Sometimes they even have obsessive thoughts and/or thoughts about death. The pregnant woman not only has to deal with these symptoms, but also with feelings of guilt and shame. Using strict criteria, the Agency for Healthcare Research and Quality estimated that at different times during pregnancy the range for major depression is from 3.1% to 4.9% and during the first postpartum year the range is 1.0% to 5.9%.[2] When minor depression was included, the ranges rose to 8.5% to 11.0% when pregnant and 6.5% to 12.9% in the postpartum period.

In an editorial for The Canadian Journal of Psychiatry, Dr.Shaila Misri stated that in British Columbia, a screening program has been implemented using the Edinburgh Postnatal Depression Scale at 28-32 weeks gestation and at 6-8 weeks postpartum.[3]The Edinburgh Postpartum Depression Scale has been used to identify patients with symptoms of depression during pregnancy as well as postpartum. The scale was developed in 1987 as a self-report scale to screen for postnatal depression. "It was found to have satisfactory sensitivity and specificity, and was also sensitive to change in severity of depression over time."[4] It is easily understandable and has a simple scoring method. This scoring tool is also used for prenatal screening of depression and has been validated for screening during pregnancy. "The EDPS is the only rating scale for depression validated during both the antenatal and postnatal period."[5] Dayan and associates studied prenatal depression and anxiety and spontaneous preterm birth. They used the Edinburgh scale with pregnant women to screen for depression. A total of 681 women participated and the study concluded that women with high depression scores were at greater risk for spontaneous preterm birth and that these findings were persistent even when they were adjusted for relevant confounding factors.

Pros and Cons of Treatment For Pre-, Peri-, and Postpartum Depression

After a diagnosis of depression is made, treatment must be initiated to alleviate symptoms. The risks and benefits of treatment options must be evaluated so that the treatment is safe for the mother and the unborn baby. Early screening and intervention are imperative. Most pregnant women do not want to be on an antidepressant during their pregnancy, as the rule is often mandated not to "expose" the fetus to drugs, toxins, etc. They will, however, consider counseling or therapy for the most part. From a standard of practice and a medico-legal point of view, therapy and counseling should be offered and chart documentation should be clear in this area. Individualized therapy should be started with a focus on the role of motherhood and the perceptions or misperceptions of the patient regarding this role. Oftentimes, this supportive, interpersonal approach about the significant role of this transition may be helpful in alleviating depression symptoms. This type of supportive therapy does not require delivery from a psychologist; most clinicians should be able to start and encourage discussions in this area. Often a lack of support, or perceived lack of support, from the spouse is noted. This is one of the risk factors for postpartum depression. It may also make sense to have a session or time spent with the couple as well.

Overview

The main focus of this article will be on women who have depression during pregnancy and some individualized options for treatment. Three cases are presented as teaching tools. The first case is a patient with depressive symptoms that were managed during her pregnancy with therapy alone. The second case is a patient who stopped her medication when she found out she was pregnant. She had a relapse of depressive symptoms and was started on an antidepressant during her pregnancy. The third case is a patient with untreated depression during her first pregnancy and the negative effects that occurred as a result. She was treated for postpartum depression with an SSRI and while on the medication became pregnant with a second baby. She stayed on medication during her second pregnancy with a better outcome. An overview of treatment options for other mental health issues will be presented at the end of the article.

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