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David Baxter PhD

Late Founder
Challenges in diagnosing and treating maternal depression
Wednesday, 9 May 2007

Depression among pregnant women and new mothers is underdiagnosed and undertreated, according to leading obstetrician-gynecologists speaking at a news briefing today during the 55th Annual Clinical Meeting of The American College of Obstetricians and Gynecologists (ACOG).

Addressing gaps in information about the signs of depression, screening practices, and treatment options is critical in ensuring that women with maternal depression receive adequate and proper medical care at a time when they are most vulnerable.

Women in their childbearing years account for the largest population of Americans with depression. Depression is one of the most common complications during pregnancy and the No. 1 risk factor for postnatal depression; approximately 1 in 10 women will have major or minor depression sometime during pregnancy and the postpartum period.

"[W]omen are twice as likely to suffer from depression as men are and that women have a 20% risk of developing depression during their lifetime, with that risk peaking during childbearing years," said Stanley Zinberg, MD, MS, ACOG deputy executive vice president and vice president for practice activities. "As ob-gyns, we need to look at the bigger picture and understand that good prenatal and postpartum care involves focusing not just on our patients' physical health but also on their emotional and psychological health," he added.

Depression is often overlooked because it is incorrectly assumed that pregnancy protects women from depression and that postnatal depression is within a woman's control, according to Sharon T. Phelan, MD, a professor of obstetrics and gynecology at the University of New Mexico School of Medicine in Albuquerque. "These are unrealistic expectations and only add to the stigma associated with depression," she noted.

Moreover, some of the symptoms of depression and the normal signs of pregnancy and new motherhood overlap, making depression hard to diagnose. As a result, many women and their doctors may ignore or underestimate the significance of their symptoms. "Half the battle lies in distinguishing between an exhausted and overwhelmed pregnant woman or new mom versus one suffering from an episode of depression," explained Paul A. Gluck, MD, an associate clinical professor of obstetrics and gynecology at the University of Miami School of Medicine in Florida.

The signs of pregnancy-related depression are often similar to those of postnatal depression and include crying, sleep problems, fatigue, appetite changes, disinterest in daily activities, difficulty concentrating, irritability, apathy or heightened anxiety, obsessive thoughts or worries, and feelings of guilt or hopelessness. When these symptoms limit a woman's ability to function on a day-to-day basis, last for at least two weeks and intensify, it is time to seek medical advice, experts say.

While the causes of depression during pregnancy and postpartum are unknown, researchers believe that the levels and fluctuations of hormones likely play a big role. "Women need to understand that depression is a chemical imbalance. While most women adjust successfully to all the changes associated with pregnancy and new motherhood, there are about 20% of women who are overwhelmed by a prenatal or postpartum mood disorder and require professional help," added Dr. Phelan.

According to Dr. Gluck, obstetrician-gynecologists are the front-line physicians that most pregnant women and new mothers turn to, but many ob-gyns may not feel qualified to diagnose or treat depression because of their limited training in this area.

"Ob-gyns' uncertainty about making a diagnosis of depression should not prevent them from screening their patients," said Dr. Gluck. "There are several formal, self-administered tools to assist with the screening process that are both effective and easy to implement. Once depression is accurately diagnosed, ob-gyns can refer the patient to mental health specialists who can best manage her depression," he explained. In addition to screening, it is advised that physicians initially rule out other health problems.

Screening for pregnancy-related depression is critical. Untreated depression during pregnancy has been linked to higher rates of miscarriage, stillbirths, premature deliveries, intrauterine growth restriction, and low birth weight babies. "It's widely observed that depressed pregnant women may be delinquent about prenatal care, eat and sleep poorly, and are more likely to self-medicate with alcohol, cigarettes, and drugs, all of which have serious health implications for mom and baby," noted Dr. Phelan.

If left untreated, postnatal depression can last up to a year and a half or longer. Studies have shown that women with untreated postnatal depression sometimes don't bond with their infants, leading to emotional, social, and cognitive problems in their children later on. Furthermore, women who have suffered from postnatal depression in the past have a heightened risk of recurrence, from about one-in-three to one-in-four.

Though depression in women is a common problem, it is treatable with counseling and/or medication. For mild or moderate depression, experts suggest psychotherapy alone may be enough. In moderate to severe cases, treatment may include counseling as well as short-term use of antidepressant medications to improve the underlying abnormality of the chemical messengers in the brain, called neurotransmitters-serotonin, dopamine, and norepinephrine.

Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed class of antidepressants because they are effective, well tolerated, and have adverse effects that are less severe than those of older antidepressants. However, recent studies have indicated that exposure to SSRIs late in pregnancy has been associated with short-term complications in newborns, including mild respiratory distress, irritability, feeding problems, jitteriness, and seizures. Individuals taking SSRIs may experience other side effects, including nausea, drowsiness or fatigue, decreased sex drive, headaches, weight gain or loss, and agitation.

"Uncertainty about the possible side effects on the newborn and the possible risk to the mother of relapsing if she stops her antidepressant medications during pregnancy makes decisions about the treatment of depression in pregnant women especially challenging for physicians and patients," said Dr. Phelan. "But one thing is for certain, women who are pregnant or thinking about becoming pregnant should not stop any antidepressants without first consulting their physician," she added. Most experts believe that the risks of antidepressants are small compared with the negative impact of untreated depression on women and their babies.

According to ACOG, the use of SSRIs for the treatment of depression during pregnancy should be individualized based on their respective risks and benefits. ACOG also advises that paroxetine (Paxil?), be avoided when possible by pregnant women or women planning to become pregnant due to the potential risk of fetal heart defects, newborn persistent pulmonary hypertension, and other negative effects.
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