COMMENTARY

The Perils of Dismissing Depression as Just the 'Baby Blues'

Arefa Cassoobhoy, MD, MPH; Elizabeth Fitelson, MD

Disclosures

June 20, 2019

This transcript has been edited for clarity.

"I should be able to get through this. I shouldn't be feeling this way." Women who experience depression in the postpartum period can feel not only sadness and hopelessness but also shame. It's all too easy to assume that maternal depression is nothing more than the "baby blues" and that it will fade over time. Differentiating the baby blues from severe postpartum depression is essential to preventing tragic outcomes for families. WebMD's Arefa Cassoobhoy spoke about perinatal depression with Elizabeth Fitelson, MD, director of the Women's Program in the Department of Psychiatry at Columbia University.

(To read about a new treatment option for postpartum depression, see also A Novel Drug for Severe Postpartum Depression: Who Might Benefit?)

Arefa Cassoobhoy, MD, MPH: What differentiates the baby blues from postpartum depression? How common is it for women to experience depression for the first time during the postpartum period? Is there a time during that first year when women are most vulnerable?

Elizabeth Fitelson, MD: Among women who have perinatal or postpartum depression, most of their depressive episodes start before or during pregnancy. About 25% of women will have preexisting depression and they may, in fact, have been depressed at the time they got pregnant. Another third will get depressed during pregnancy, and for about 40%, their depression starts in the postpartum period.

According to DSM-5 [Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition] criteria, "perinatal depression" starts during pregnancy or within the first 4 weeks postpartum. Most experts in the field who treat women consider it to be postpartum depression up to a year postpartum or even longer if the woman is lactating.

Cassoobhoy: Do you recommend screening all new mothers for depression?

Fitelson: Yes. New guidelines recommend screening all women for depression during pregnancy and the postpartum period.

Cassoobhoy: What screening tool do you like?

Fitelson: The Edinburgh Postnatal Depression Scale is probably the best validated tool for perinatal depression because it focuses on the mood and anxiety components of perinatal depression rather than the somatic symptoms. In addition to low mood and loss of interest (the main criteria for major depressive disorder), the somatic symptoms of depression (changes in sleep, appetite, energy, or libido) are all perfectly normal during pregnancy and the postpartum period, as anyone who's had a child can tell you

The PHQ-9 has also been validated during the perinatal period in large healthcare systems that were already using the PHQ-9 in other settings, such as primary care. In that case, it makes sense to use the PHQ-9 and just vary the cutoff.

Cassoobhoy: Which women are most at risk for perinatal depression?

Fitelson: Certainly, women who have a preexisting depressive or anxiety disorder or carry another diagnosis, such as bipolar disorder, or who are in mental health treatment. Some evidence also suggests that women who have mood sensitivity around their menstrual cycles may be at more risk for perinatal depression and anxiety.

Cassoobhoy: Because of the hormone shifts?

Fitelson: Yes. There seems to be a cohort of women who have a particular hormone sensitivity. Not every woman has significant mood sensitivity with hormonal changes, but some women are more sensitive to those shifts than others and that might be a risk factor. Other risk factors for perinatal mood and anxiety disorders include having an unwanted pregnancy, low social support, financial stressors, medical complications, a history of trauma or intimate partner violence (including during pregnancy, which is unfortunately more common than we would like to think it is), pregnancy loss, and obstetrical complications or complicated deliveries.

Cassoobhoy: What are the main treatment options, and how safe are these for breastfeeding mothers?

Fitelson: The mainstay of treatment for perinatal mood and anxiety disorders, especially for mild to moderate disorders, is psychotherapy, enhanced support, practical emotional supports, good nutrition, good care, exercise, and getting out [of the house]. We should all be advocating for women in the perinatal period to have better access to good evidence-based psychotherapy (such as interpersonal psychotherapy or cognitive-behavioral therapy) as well as for interventions that enhance support.

Also, for vulnerable women, to give them the time to stay home with their babies and recover from the experience. Because so much perinatal depression is comorbid with anxiety disorders, anxiety is often the presenting problem. Selective serotonin reuptake inhibitor (SSRI) antidepressants tend to be the first-line treatment in terms of medications. Sertraline, citalopram, escitalopram, and fluoxetine have been around a long time, and we have a good amount of data on them.

SSRI antidepressants in general have fairly low levels of passage into breast milk, and the American Academy of Pediatrics does not consider them contraindicated in breastfeeding, so most women who are on an SSRI antidepressant can breastfeed successfully.

Cassoobhoy: How successful are the nonpharmacologic therapies in preventing that dip into depression?

Fitelson: It really depends. If my patient has had anxiety and depression most of her life, has been through different therapies, or has tried different medications, I try to work with her to see what we can do to maximize our nonmedication interventions, and then use rational decision-making when she needs a medication. There should be more access to psychotherapy, but it doesn't work for everyone. There shouldn't be shame in having to take a medication.

Cassoobhoy: People seem to be familiar with the baby blues and postpartum depression, but they're not as familiar with depression during pregnancy. Do you recommend screening pregnant women for depression?

Fitelson: There is greater recognition now that most postpartum depression actually starts during pregnancy. It's important to recognize depression in pregnancy, both to prevent the postpartum depression but also to help women recover during their pregnancy. Depression is terrible. There's so much suffering, and it's really important to help our patients feel better, especially at this vulnerable time. Women want to go into parenthood feeling as strong and well as possible—that's good for them, their partners, their families, and their babies.

Untreated depression and anxiety have an impact on the pregnancy. Anyone who's experienced anxiety or depression can tell you that it's not all in your head. Anxiety and depression affect the mind and the body, possibly mediated through such changes as increased cortisol levels. Cortisol is a stress hormone. In depression and anxiety conditions, cortisol levels are high and stay high, and don't vary as they do normally throughout the day or in response to stress. In the presence of high cortisol levels, changes can take place in the placenta and the fetus. I'm not saying that all of those changes are necessarily bad, but stress has an impact.

Cassoobhoy: We talked earlier about considering a woman with mental illness as having a high-risk pregnancy. For obstetricians who are watching, how should this change their management of these women?

Fitelson: People get focused on whether or not to medicate women with these conditions. That tends to be what a lot of the research is about—the risks associated with medications in pregnancy. There are fewer concerns about the risks associated with untreated depression and anxiety in pregnancy. When you step back and actually look at women with depression and anxiety (or any psychiatric diagnosis), this is a high-risk group of women.

To use an extreme example that's been in the news recently, Massachusetts just came out with a report on pregnancy-associated deaths. More than half of the women who died in pregnancy or within the first year postpartum had a preexisting psychiatric condition that may or may not have been directly related to the cause of death. Many of these women died from obstetric complications such as hemorrhage or preeclampsia. A significant proportion died from substance-related issues or suicide. Having a mental health diagnosis puts women into a higher risk category for perinatal morbidity and mortality. My opinion is that these women should be seen in a higher-risk category whether or not they're on medication.

Cassoobhoy: That leads to my next question, about talk therapy as a cornerstone of treatment, especially during pregnancy. What do you recommend for women with a lack of access to specialists like psychiatrists and psychotherapists? I know that out in the community, some women don't have access. What other options are there, like telemedicine?

Fitelson: The emergence of telemedicine is really exciting in terms of access for perinatal women, and offering them high-quality treatment, because women are so isolated in the postpartum period, even in the best of circumstances.

In my practice at Columbia, we have some telemedicine capabilities. Telehealth visits have worked great for perinatal women because both have better access (even when they don't feel like they can leave the house yet with the baby) so you can have a session and check in on them and have a real conversation about what's going on. As a clinician, I can get a bit of a snapshot of what home life is like and how that mom is interacting with her baby in her own environment where she is more comfortable.

Cassoobhoy: What other nonmedical options do you recommend for prevention or treatment?

Fitelson: Whenever I'm counseling a woman or a couple about risk for perinatal mood and anxiety disorders, I like to talk about the woman's practical and emotional supports.

One qualitative study[1] asked women who had recovered from postpartum depression what the most important factors were in her recovery. The top four factors were emotional support from her partner, practical support from her partner, practical support from her family, and emotional support from her family. Any psychiatric intervention was way down on the list.

Support really is the name of the game because of the isolation that can happen in the postpartum period and the sense of shame about feeling bad during this period. We have made a lot of progress in talking about perinatal depression and anxiety disorders. Some courageous celebrities have come out, and some courageous non-celebrities have come out, talking about their experiences. Women still feel that "it shouldn't happen to me and I should be able to get through this; I shouldn't be feeling this way."

It's incredibly painful and shameful to be feeling badly or to be having intrusive thoughts about something terrible happening to the baby or doing something terrible to the baby—even women who would never in a million years be at risk of harming their baby. These thoughts can be torturous, and there is a barrier to actually telling anyone about them. Anything you can do to lessen isolation in terms of support is beneficial. Support groups can be very powerful just for that reason.

For more severe depression and anxiety disorders, studies have looked at transcranial magnetic stimulation (TMS), a newer technology that was developed as an alternative to electroconvulsive therapy. Studies have looked at TMS in more significant depression anxiety disorders. A whole range of nonmedication options should be available to women.

Cassoobhoy: Thank you so much, Elizabeth, for joining me today.

Fitelson: My pleasure.

Cassoobhoy: Those in the audience, please send us your comments. We would like to hear back from you.

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