Back to Perinatal Depression: For Health Care Providers
Mood and anxiety disorders during pregnancy and the postpartum period
Miriam B. Rosenthal, MD,
Associate Professor of Psychiatry and Reproductive Biology, Case Western Reserve
University Chief of Behavior Medicine, University MacDonald Women's Hospital
This article discusses:
While men and women have
similar rates of mental illness, patterns differ with women having about twice
the prevalence of depressive and anxiety disorders from adolescence through
menopause. These rates are observed worldwide and in varying cultures. The
childbearing years are times of special vulnerability for women and for the
impact that untreated depressive disorders may have on their children and
families, an area still not well researched. This is especially troubling at a
time when treatments have become available! The largest community surveys of
mental disorders in the United States come from the work done by the National
Institutes of Mental Health's Epidemiologic Catchment Area Program (ECA) and the
National Comorbidity Survey (NCS) done in the early 1990s. The prevalence rates
showed about 30% for mental and addictive disorders and lifetime rates of about
50%. Yet services provided would suggest that less than one-third of those with
active disorders were receiving any treatment in a one-year period (Narrow
2002). This
percentage is probably even lower in pregnant and postpartum women, especially
ethnic minorities and women with less resources and no insurance.
Women are more likely to
experience mood and anxiety disorders during and after a pregnancy than at any
other time of their lives. These conditions are considered to be among the least
recognized at the same time that they are the more treatable. Pregnancy and
postpartum mental disorders affect about 10-20% of women having a healthy baby,
with figures being much higher in women who have experienced pregnancy losses or
babies with illness or abnormalities. At a forum last year held by the
Congressional Black Caucus Legislative Conference in Washington, D.C., there was
discussion of passing legislation introduced by Rep. Bobby L. Rush (D-IL) that
should to expand research on postpartum depression. The Perinatal Depression
Project in Cleveland was especially timely.
Pregnancy is a major
developmental life transition involving biological, psychological and social
changes. Most of these are quite normal, and pregnancy and the postpartum period
are supposed to be times of happiness. Often these are periods of mood lability,
anxiety about the health of the fetus and partner compatibility, and family
well-being. There are temporary periods of feeling blue, yet more serious and
debilitating emotional illnesses may occur. The blues are not considered a
mental illness. Postpartum blues occur within the first 2-3 weeks after birth,
occur in up to 70% of women worldwide and cross-culturally. There are symptoms
of mood lability, anxiety, tearfulness, irritability, insomnia (even when the
baby is asleep) and fatigue. The causes are thought due to the marked fall in
estrogen and progesterone, in addition to any illnesses or personal crises that
may be occurring then. No treatment is indicated.
Postpartum depression is
Major Depression defined in the Diagnostic and Statistical Manual of the
American Psychiatric Association and has symptoms similar to depressions
occurring at other times of life. There is a disturbance of mood lasting more
than 2 weeks, a lack of pleasure in anything (anhedonia) accompanied by changes
in sleep, appetite, thinking, libido, possibly obsessive-compulsive ideas (of
harming self or baby) and sometimes suicidal ideas. There may be feelings of
guilt. It usually occurs during the pregnancy but more likely in the first three
months after delivery. It affects about 10-20% of women giving birth. In nursing
mothers, there may be onset about the time of weaning. The best predictors of
this condition are a past history of depression or anxiety disorders, a family
history of such conditions, premenstrual syndrome, lack of social supports,
adverse life events occurring during the pregnancy such as death of a close
person. Milder symptoms may not reach diagnostic levels but need evaluation,
which also must include a very thorough physical exam, appropriate laboratory
tests and thyroid function levels. A great help in diagnosis has been the use of
psychological tests such as the Edinburgh Postnatal Depression Scale or other
similar scales for depression and anxiety. Treatment includes use of
medications, psychotherapy, group treatments, support groups, and involvement of
family for emotional supports. The antidepressant medications have been an
invaluable addition. Among these, the first line treatments have been the
selective serotonin reuptake inhibitors, which include fluoxetine, sertraline,
paroxetine, citalopram, and fluvoxamine. These have been studied more in
pregnancy and postpartum period including nursing mothers. Estrogen has also
been used with some success in the treatment. Interpersonal psychotherapy has
been useful. Having mental health professionals available in the offices and
clinics which offer obstetrical and pediatrics services to pregnant women and
new mothers has been a way of identifying and treating women who may be
reluctant to go to mental health settings. It is also quite interesting that
postpartum depression may affect fathers, grandparents and adoptive parents,
which may give some increasing support for non-hormonal factors causing these
conditions. The effects of depression on pregnancy include women taking more
risk-taking behaviors like smoking and use of drugs and alcohol. Prematurity may
be more common in depressed mothers, but more data is needed.
Psychosis in pregnancy or
the postpartum period is the most serious and severe form of mental illness and
occurs in about 1% of women. It is characterized by a loss of reality testing,
the presence of hallucinations and delusions, possible agitation or severe
withdrawal. The recent very tragic case of Andrea Yates, a 36-year old mother
and nurse who drowned her five children, delusionally believing that they would
be better off in another world, is an example of the extreme danger that this
severe illness can bring. The psychoses are usually bipolar disease, psychotic
depression, schizophrenia, or organic disorders, which can be induced by
metabolic disruption or drugs. These women require immediate hospitalization
after evaluation by a mental health professional, treatment with medications and
psychotherapy, and are never to be left alone until they are definitely better.
Medications include antipsychotic drugs, mood-stabilizing drugs, and possibly
for treatment refractory conditions, electroconvulsive therapy. Infanticide is
rare, but may occur with psychosis.
Anxiety disorders may occur
with depression or independently. Obsessive-compulsive disorders, panic,
posttraumatic stress disorders may start during or after pregnancy. All are
treatable. Perinatal losses or the occurrence of fetal anomalies or severe
illnesses in baby or mother may be precipitating causes. Domestic violence
increases in pregnancy and often with a new baby in the household. This needs
further research.
The Edinburgh Postpartum Depression Scale is a very useful tool used to measure depression in pregnancy
and postpartum. It was chosen after a careful reading of the instruments used in
recent studies and discussion with some of the researchers in this field
(Wisner, Appleby, Murray, Schaper, Yonkers, Glaze, and Zelkowitz). Other
instruments include Prime-MD, Beck Depression Inventory, Center for
Epidemiologic Studies Depression Scale (CES-D) and Psychiatric Sympton Index.