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Depression During Pregnancy and After
For too many women, joyfully anticipated pregnancy
and motherhood bring depression as an unexpected
accompaniment. Children as well as mothers
suffer. Depression during pregnancy may result
in poor prenatal care, premature delivery,
low birth weight, and, just possibly, depression
in the child. Depression after childbirth (postpartum
depression) can lead to child neglect, family
breakdown, and suicide. A depressed mother
may fail to bond emotionally with her newborn,
raising the child’s risk of later cognitive
delays and emotional and behavior problems.
Fortunately, if the depression is detected
soon enough, help is available for mother and
child.
Depression During Pregnancy
Depression in pregnant women is often overlooked,
partly because of a widespread misconception
that pregnancy somehow provides protection
against mood disorders. In reality, almost
25% of cases of postpartum depression start
during pregnancy, and depression may peak at
that time, according to a study published in
the British Medical Journal in 2002.
More than 9,000 women recorded their moods
during the fourth and eighth month of pregnancy
and again two and eight months after giving
birth. The questionnaire, which was specially
designed for pregnant women and new mothers,
concentrated on thoughts and feelings—emotional
swings, crying spells, low self-esteem, hopelessness,
irritability, and inability to enjoy normally
pleasurable activities. The researchers paid
less attention to physical symptoms, because
they did not want to mistake physical effects
of pregnancy (such as appetite loss, fatigue,
and insomnia) for symptoms of depression. Depression
ratings were highest at the eighth month of
pregnancy and lowest eight months after childbirth.
Fourteen percent of the women scored above
the threshold for probable clinical depression
just before the child’s birth, compared
with 9% two months later.
Ignoring depression during pregnancy can be
risky for both mother and child. Depressed
women often take poor care of themselves. They
may smoke, drink to excess, or neglect proper
diet. And some research suggests that depression
in pregnant women can have direct effects on
the fetus. Their babies are often irritable
and lethargic, with irregular sleep habits.
These newborns may grow into infants who are
underweight, slow learners, and emotionally
unresponsive, with behavior problems such as
aggression.
Depression After Childbirth
Postpartum depression is usually divided into
three categories: baby blues, nonpsychotic
postpartum depression, and postpartum psychosis.
Baby blues, the most common mood disturbance
after childbirth, may affect nearly 50% of
new mothers. The cause of this usually brief
and harmless condition may be hormonal changes,
especially the rapid fall in estrogen levels
after birth. Some symptoms are appetite loss,
fatigue, confusion, sadness, nervousness, crying
spells, oversensitivity, and a feeling of being
overwhelmed. These symptoms appear within a
few days of delivery and subside in about two
weeks. If they last longer, a woman may be
suffering from clinical depression, a condition
that occurs in 10%–15% of new mothers.
The American Psychiatric Association defines “depression
with postpartum onset” as a depressive
episode that occurs within four weeks of birth,
but many researchers regard the postpartum
period as lasting up to six months after delivery.
Women have a higher than average rate of hospital
admissions for depression during this period
and for as long as three years after childbirth.
The symptoms may include headaches, chest pain,
heart palpitations, and panic attacks as well
as fatigue, sadness, hopelessness, irritability,
and loss of interest and pleasure in life.
Often worrying obsessively about the child’s
health, depressed women feel guilty about their
inadequacy as caregivers—and even about
not being as happy as they think they should
be.
Mood disorders, either major depression or
bipolar disorder, are the most common cause
of maternal psychosis, with delusions, hallucinations,
or both. The danger is especially great when
delusions center on the baby. Many mothers
with postpartum depression are afraid they
will harm the baby. Few actually do, but the
risk is greater if the woman is psychotic.
A woman who suffers a psychotic postpartum
depression once is likely to have similar episodes
after the birth of other children.
The Child’s Response
A mother’s depression itself can make
some of her worries about her child realistic.
Infants are highly sensitive to a mother’s
sadness, silence, and inattentiveness. In one
study, mothers of 3-month-old infants were
asked to simulate depression for three minutes.
They spoke in a monotone, remained expressionless,
and avoided touching the child. Even at that
age infants could respond to fleeting changes
in their mothers’ apparent mood. They
looked away from their mothers and showed signs
of distress, which continued for a time even
after the women began to behave normally.
In the long run, child development may be
affected. Children of depressed parents in
general are highly vulnerable to depression,
and long-term adjustment is sometimes a problem
for the children of mothers with postpartum
depression. In one study, teachers’ reports
were used to compare the children of 55 women
with postpartum depression to the children
of 40 healthy controls over a five-year period
beginning a few months after childbirth. Boys
from lower-class families were affected most.
In that group, investigators found a higher
than average rate of clinically significant
behavior problems (chiefly hyperactivity and
distractibility) after five years if and only
if their mothers suffered from postpartum depression.
With or without depressed mothers, serious
behavior problems were rare in middle-class
children.
Drug Therapy
Depressed women may be reluctant to seek help
because they fear they will be regarded as
bad mothers. Family doctors can help by reassuring
them about their child’s health and asking
about depressive symptoms.
Antidepressant drugs are a standard treatment
for depression during pregnancy and after birth,
but many women are understandably worried about
drug effects on the child. Some potential risks
are birth defects, neonatal toxicity (jitteriness,
difficulty in feeding, and irregular heart
rate or breathing associated with exposure
to a medication before or during delivery),
and longer-term cognitive, emotional, or behavioral
effects.
Fortunately, most antidepressant medications
are fairly safe for pregnant women. Neither
tricyclic antidepressants nor selective serotonin
reuptake inhibitors appear to increase the
risk of congenital malformations, stillbirths,
or miscarriages, even when taken in the first
three months of pregnancy. An infant drug withdrawal
reaction occasionally occurs, with symptoms
that include jitteriness, irritability, and,
rarely, seizures. But there is no evidence
that these medications have long-term harmful
effects on the child when taken during pregnancy.
Antidepressants are se creted in breast milk
in small amounts, but they do not present a
serious risk to nursing infants. Still, to
be as safe as possible, women who take antidepressants
while breast-feeding should use drugs that
don’t accumulate in breast milk; for
example, sertraline (Zoloft) is preferred to
fluoxetine (Prozac).
Despite the mostly reassuring evidence, some
women who are taking antidepressants may want
to quit before conceiving a child, and some
who become depressed while pregnant or nursing
may prefer to avoid drugs. Much depends on
how severe the depression is and how well both
mother and child can cope with its symptoms.
Pregnant and nursing women should be aware
that prolonged depression may be riskier than
drug side effects, both for themselves and
for their children.
Other Treatments
Electroconvulsive therapy is a highly effective
treatment for severe postpartum depression—especially
psychotic depression. It can be safely administered
a week after childbirth. The most important
side effect is some loss of memory for the
period immediately surrounding the treatment.
Another somatic (physical) treatment is bright
light therapy (phototherapy). It is already
thought to be effective for postpartum depression,
and a trial reported in the American Journal
of Psychiatry suggests that it is also
an option for depression during pregnancy.
Sixteen pregnant women with major depression
sat close to a bright light source one hour
a day for three to five weeks. Average depression
ratings improved by 49% after three weeks and
by 59% in the seven patients who had five weeks
of treatment. When the treatment ended, their
symptoms became worse. The results are promising,
but controlled studies are needed.
Psychotherapy is a proven treatment for mild
to moderate depression in three common forms:
cognitive behavioral, psychodynamic, and interpersonal.
Interpersonal therapy may be especially useful
for depression during pregnancy and the postpartum
period because it is designed to help people
cope with changing circumstances and social
roles. Being constantly alone with an infant
is not good for new mothers. Group therapy
and self-help groups can provide needed companionship
and advice, especially for a woman who has
limited family contact or few other social
outlets. Couples therapy may help when marital
problems have been contributing to depression.
Researchers looking for ways to prevent depression
are investigating risk factors during pregnancy
and the postpartum period. An unplanned pregnancy,
an unhappy marriage, or a child with a difficult
temperament may raise the risk. Questionnaire
responses by more than 5,000 Danish women indicate
that emotional distress and social isolation
during pregnancy are associated with postpartum
depression. In another study, 38 new mothers
answered questionnaires on fatigue and depression
one day after giving birth and again after
one, two, and four weeks. Women with a high
level of fatigue after one and two weeks were
more likely to report symptoms of depression
after four weeks.
The studies reflect an understanding that
depression among pregnant women and new mothers
is a serious public health problem. The more
effectively it is prevented and the sooner
it is treated, the better the family environment
and the more hopeful the outcome for both mother
and child.
References
Dalton K. Depression After Childbirth:
How to Recognize, Treat, and Prevent Postnatal
Depression. Oxford University Press,
2001.
Evans J, et al. “Cohort Study of Depressed
Mood During Pregnancy and After Childbirth,” British
Medical Journal (2001): Vol. 323, No. 7307,
pp. 257–60.
Glover V, et al. “Effects of Antenatal
Stress and Anxiety: Implications for Development
and Psychiatry,” British Journal of
Psychiatry (May 2002): Vol. 180, No. 5,
pp. 389–91.
Grush LR, et al. “Treatment of Depression
During Pregnancy: Balancing the Risks,” Harvard
Review of Psychiatry (1998): Vol. 6, No.
2, pp. 105–109.
Miller LJ. “Postpartum Depression,” Journal
of the American Medical Association (2002):
Vol. 287, No. 6, pp. 762–65.
Oren DA, et al, “An Open Trial of Morning
Light Therapy for Treatment of Antepartum Depression,” American
Journal of Psychiatry (April 2002): Vol.
159, No. 4, pp. 666–69.
Resources
Depression After Delivery, Inc.
91 East Somerset Street
Raritan, NJ 08869
Telephone: 800-944-4773 (toll free)
On the Web: http://www.depressionafterdelivery.com
Postpartum Support International
927 North Kellogg Avenue
Santa Barbara, CA 93111
Telephone: 805-967-7636
On the Web: http://www.chss.iup.edu/postpartum
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