COMMENTARY

Depression in Pregnancy: It's Not Just the Mothers

Jeffrey A. Lieberman, MD

Disclosures

July 01, 2010

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Hello. This is Dr. Jeffrey Lieberman of Columbia University with your Medscape blog for today.

Peripartum and postpartum depression have been a major public health problem and unmet clinical need for a long time. Only recently within the fields of obstetrics and gynecology and clinical psychiatry has there been more of a focus on women's mental health and the fact that a single physiologic event (eg, pregnancy) is associated with such a high incidence of this serious mental disturbance.

One of every 4 women who undergo pregnancy and delivery experiences a significant psychiatric disturbance. Usually this comes in the form of depression, but it can take other forms, including psychosis and anxiety disorders, and is often complicated by substance abuse. Psychiatric disturbances can occur during pregnancy or in the postpartum period. In the postpartum period, depression most commonly occurs within the first 6 months postpartum but can last much longer if it's not actively treated.

In some instances (fortunately a relatively small percentage), depression can lead to devastating and irreversible complications in the form of suicide or in some cases, infanticide. The most dramatic recent example that comes to mind is the case of Andrea Jager from Texas, who killed her young children in the context of a postpartum psychosis, a diagnosis that was made in retrospect.

Peripartum depression is highly foreseeable and eminently treatable; if we really had our acts together, clinically speaking, this type of depression would be preventable to a large degree. One would think that given the frequency of this condition, routine mental health assessment would be done in the context of prenatal care of mothers, and again in the postnatal period. Sadly, it is not done routinely. It is clear that most of these conditions -- depression, psychosis, etc -- are treatable, and respond to treatment in a manner that is similar to idiopathic conditions that occur in the absence of pregnancy and delivery.

Most of these peripartum psychiatric disturbances have been described in the literature and are thought to during pregnancy or following delivery, and this is indeed the case. This very significant unmet clinical need is crying out for our attention.

Our attention should take the form of standard treatment for these conditions, bearing in mind that these women are pregnant or have just delivered a baby. When this mental disturbance occurs during pregnancy, it creates a dilemma for clinicians. The dilemma is this: is there a risk in exposing the unborn fetus -- the developing fetus -- to the effects of psychotropic medications? If a woman is suffering from depression or if she has a history of depression and has now become pregnant and is, therefore, at increased risk of developing a pregnancy-related condition, should her treatment be continued?

The concerns that these medications have potential teratologic effects have not been demonstrated with the exception of some anticonvulsant mood-stabilizing medications such as lithium and valproate. In addition, more recently, work has shown that antidepression medications, particularly the serotonin reuptake inhibitors, can induce lasting behavioral symptoms in the newborn and child as the child grows. This area is still being investigated. We don't know the precise quantitative risk, in the form of behavioral syndromes that might eventuate from exposure of the developing fetus to antidepressant medication.

In the absence of treating depression, what are the effects of depression itself on the developing newborn and child? This is also unknown. The literature suggests that some risk related solely to the effects of depression -- not just in how it may compromise the mother's health during pregnancy -- but that the actual pathophysiologic condition of depression confers on the developing fetus some behavioral consequences that manifest as the newborn develops into a child and into an adolescent and adult. These are unquantifiable risks as of now, and really pose a dilemma for the clinician as to whether the potential effects of treatment are preferable to the unclear effects of the untreated condition on the developing fetus, newborn, and child.

Added to this is a recent study published in JAMA on May 19, 2010,[1] which describes a depressive incident that occurs not only in mothers during pregnancy or the postpartum period, but also in fathers. This study described a significant rate of postpartum depression in the fathers. This is a very interesting phenomenon. It is not the first time that this has been reported, so it's not altogether surprising. However, the point I think should be made is that the frequency of this condition is much higher in women. The public health urgency to address this condition through clinical service is more compelling. The likely cause of peripartum psychiatric conditions in women is the physiologic changes that occur in the context of pregnancy and delivery, whereas when postpartum depression occurs in fathers, it is likely due to the stress of having a child and the changes it will bring.

All of this could easily affect the relationship between the father and the mother who has just given birth, and who can't devote the same kind of attention or have the same kind of relationship as before the baby was born. This could pose added stresses to the father who is now responsible for a child in addition to his wife and his other responsibilities as an adult. The difficulties of having to deal with the sleep deprivation associated with having a newborn, and the impositions that a young child has on family life and each parent's lifestyle, are significant. These stresses are likely to be the cause of depression or other untoward psychiatric disturbance in a new father, as opposed to the physiologic changes that occur during and after pregnancy in the mother.

The bottom line is that pregnancy is a significant event for parents, particularly so for mothers, who experience a high frequency of peripregnancy and postpartum psychiatric conditions. It affects fathers as well, albeit at a lower frequency. In any case, these conditions should be under surveillance by clinicians during prenatal and postnatal care. In addition, the mental healthcare community should develop a specific focus on the mental health needs of parents during and following pregnancy.

That's all I wanted to say for today. This is Jeffrey Lieberman from Columbia University thanking you for your attention and looking forward to seeing you again on Medscape.

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