Depression in the United States is a hidden epidemic: roughly 9% of U.S. adults meet the criteria for depression,[1],and the same appears to hold true for pregnant women (8.5-11%), and women during the postpartum period (6.5-12.9%).[2] It is ironic that while obstetric care providers have gotten better at managing postpartum hemorrhage and infection – two major causes of maternal death in the past – maternal suicide has become a significant cause of maternal mortality.
Depression may be divided into the following categories:
- major depression
- dysthymic disorder
- adjustment disorder with depressed mood
- minor/mild depression
Diagnostic signs of depression include a loss in interest in things that previously provided pleasure/enjoyment, poor concentration, irritability, insomnia, hypersomnia, a sense of guilt or low self worth, and thoughts of suicide.
It is also important to consider whether the signs of depression are related to underlying medical issues (such as thyroid disease) or a stressful event in your life.
Depression is particularly significant during pregnancy because it can cause, or be related to, a host of issues that influence fetal development and the mother’s health, including poor weight gain, anxiety, limited prenatal care, and use of tobacco, alcohol, or drugs.
My approach to screening for depression when I see patients in the office isn’t sophisticated, but I find it works well: “How is your day?” I ask, and then I wait for a response, and make sure to listen carefully. In my experience patients may be reluctant to share their concerns about mood unless given permission.
My advice to women with a history of depression who are pregnant or considering pregnancy is to speak to their physician or midwife. Although it is extremely important to review all medications with your care provider, most common medications used to treat depression appear to be well tolerated in pregnancy. In general, if you are unable to perform your activities of daily living without medication, the medication should be continued at the lowest effective dose.
Many pregnant women on a medication to treat depression tell me that they want to stop treatment for fear that the medication will harm their child. Although it is important to review the rare side effects that common (and uncommon) antidepressant medications can have during pregnancy and during the newborn period, long-term effects are extraordinarily rare. Just make sure to discuss these medications with your obstetrician or midwife and then with your baby’s pediatrician.
Many patients may benefit from psychotherapy either alone, or in conjunction with medications. Psychotherapy may include structured sessions with family members to identify and address stressors.
And don’t forget that exercise has been shown to improve mood in patients with mild depression.
The rapid change in the hormone levels seen around the time of delivery creates a permissive environment for depression. For patients with a history of depression, this is a time of particular risk. Such patients should plan close follow-up during this period, and put plans in place in case postpartum depression strikes.
Key points
- Depression is a serious condition and medication should not be withheld from patients simply because of pregnancy
- Most medications used to treat depression appear to be safe in pregnancy
- Depression may be multifactorial – discuss your concerns with your care providers and seek-out resources to promote wellbeing for your mental health as well as your pregnancy.
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Boston MFM is a group of board-certified maternal-fetal medicine specialists dedicated to the health of our patients. Boston MFM physicians see patients at over a dozen sites in the Greater Boston Area, Central and Western MA, and on Cape Cod. We are affiliated with Harvard Medical School and collectively have over a century of experience practicing maternal-fetal medicine. Our physicians lecture nationally, are engaged in clinical research, have received NIH funding, and participate in the training of residents, fellows and medical students.
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