Samantha Meltzer-Brody MD, MPH

Moody and Blue

Depression

Depression During Pregnancy Requires Detection and Treatment

Treatment of depression during pregnancy is critical: Stop the stigma

Posted Jun 04, 2015

A recent piece in the New York Times Magazine by Andrew Solomon, “The Secret Sadness of Pregnancy with Depression,” eloquently describes the anguish that depressed mothers experience and the stigma associated with taking antidepressant medication during pregnancy.

In fact, here is a remarkable statistic: Depression affects women twice as often as men and the female reproductive lifecycle is believed to be a major reason for this.

The perinatal period (during pregnancy and following childbirth) is a particularly vulnerable time for women to experience mood and anxiety symptoms. Depression and anxiety impacts up to 1 in 8 women during pregnancy and postpartum, making childbirth one of the strongest triggers for depression in women.

The perinatal period is also a time when women have regular contact with health care providers.  Ideally, women and their providers should be able to have an open and honest conversation about the common mental health concerns that arise during pregnancy. However, many women are reluctant to discuss mental health issues and may feel shame or embarrassment about sharing their symptoms of depression during pregnancy or postpartum(1).

Moreover, healthcare providers may also be reluctant to discuss mental health concerns and therefore may not adequately screen women for depression during pregnancy or postpartum, making it even more difficult for the women suffering with a mental health concern to talk to her provider. 

Untreated depression during pregnancy has been associated with many serious adverse effects to both mother and fetus including increased risk of preterm birth(2), preeclampsia (or high blood pressure and blood in urine)(3) and risk for postpartum depression(4).  Untreated depression in pregnancy has also been associated with toxic fetal stress, which confers long-term developmental consequences on the infant(5). Additionally, depression during pregnancy is the single greatest risk factor for postpartum depression.  And most importantly, maternal depression is the most significant risk factor for maternal death due to suicide(6). 

Despite this robust evidence, many women are reluctant to seek treatment during this vulnerable time.  Depression is a medical condition that requires treatment and is not something to be ignored.  Unfortunately, depression during pregnancy, is too often seen as something that women should “shake off” and consequently the stigma associated with seeking necessary medication treatment becomes both very real and quite painful. 

This underdiagnosed condition is why my colleagues and I led a collaborative effort at the University of North Carolina School of Medicine to open the first Maternal-Baby Psychiatric Inpatient Unit in the U.S. This allows us to meet the needs of women experiencing severe perinatal mental illness in a safe, specialized and stigma free setting at this most vulnerable time.

When a woman is depressed during pregnancy, treatment decisions must take into account the risk-benefit ratio to both mother and fetus.  Both psychotherapy and psychotropic medications have a strong evidence base for efficacy.  Ultimately, the individual patient and her provider must work together to develop a treatment plan that considers past history, past response to treatment, current severity of symptoms, and the type of treatment that will be most acceptable to the patient.

The goal is to ensure best outcomes for both mother and infant, while adequately treating the maternal depression. Maternal mental health is critical for the mental health of children and families.

It’s a topic we need to destigmatize and discuss freely and openly.

References

1.         Meltzer-Brody S. Treating perinatal depression: risks and stigma. Obstet Gynecol. 2014;124(4):653-4.

2.         Grote NK, Bridge JA, Gavin AR, Melville JL, Iyengar S, Katon WJ. A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Arch Gen Psychiatry. 2010;67(10):1012-24.

3.         Hoedjes M, Berks D, Vogel I, Franx A, Bangma M, Darlington AS, et al. Postpartum depression after mild and severe preeclampsia. J Womens Health (Larchmt). 2011;20(10):1535-42.

4.         O'Hara MW, McCabe JE. Postpartum depression: current status and future directions. Annu Rev Clin Psychol. 2013;9:379-407.

5.         Shonkoff JP, Garner AS, Committee on Psychosocial Aspects of C, Family H, Committee on Early Childhood A, Dependent C, et al. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232-46.

6.         Chesney E, Goodwin GM, Fazel S. Risks of all-cause and suicide mortality in mental disorders: a meta-review. World psychiatry : official journal of the World Psychiatric Association. 2014;13(2):153-60.