Depression in Pregnancy

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Depression in Pregnancy

• Angela Bowen, RN PhD (Cand.)
• Community Health and Epidemiology
• Assistant Professor, College of Nursing
• Strategic Training Fellow
• Community Population Health Research Program
• Nazeem Muhajarine, PhD
• Associate Professor
• Community Health and Epidemiology
• University of Saskatchewan
• Funding CUISR, CPHR-SPHERU, CIHR

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Depression

• World Health Organization
• 2020
• depression will be 2nd greatest cause of
  premature death and disability worldwide in both
  sexes
• Already
• number one cause of disease burden in women
• Canada
• Prevalence 7, lifetime prevalence 12.3
  (Stewart, 2003)

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• Why mothers die?
• Confidential Enquiries into Maternal Deaths
  (1997-9 UK)
• 12 of maternal deaths attributed to psychiatric
  illness (death during pregnancy and in the first
  year post delivery)
• 10 suicide
• 1 cause of death (gtdeep vein thrombosis etc.)
• Those with early onset of illness died early
• others did die later often didnt appear to be
  suffering PPD
• Less associated with low income and other risk
  factors
• More violent methods of suicide
• Few by overdose
  (Oates, 2003)

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Depression is Depression

• Major Depressive Disorder
• Having 5 of these symptoms for 2 or more weeks
• Minor Depressive Disorder
• Having 2 of these symptoms for 2 or more weeks

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• Depressed mood most of the day
• Anhedonia (severely diminished interest or
  pleasure in activities)
• Weight changes-secondary to appetite changes
• Insomnia or hypersomnia
• Psychomotor restless, agitated, slowed
• Diminished energy level
• Feelings of worthlessness or excessive guilt
• Decreased concentration and increased
  indecisiveness
• Recurrent thoughts of death or suicide

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Women express depression differently

• increased anxiety
• somatization
• physical symptoms for no reason
• feelings of sadness
• excessive guilt and worthlessness
• ? weight
• hypersomnia
• too much sleep
• anger and hostility
• ? suicidal attempts

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Postpartum Blues

• Normal transient, emotional response
• up to 85 of women, peak day 3-5
• Depressed in the 1st week after delivery
• 20-40 ? major depression in the 1st year pp
• Significant increase risk for PPD at 4-8weeks
  (Teissèdre Chabral, 2004)
• Present in father (day 1-2)
• co-morbidity in parents
• Impaired bonding associated with blues
• I feel trapped, my baby cries too much, I wish my
  baby would somehow go away, I feel happy when my
  baby smiles and laughs, my baby irritates me, I
  resent my baby, my baby is the most beautiful
  baby in the world (Edborg, 2005)

awareness, early identification intervention
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Postpartum Depression-PPD

• Major depression
• Psychosis, infanticide, homicide
• 60 women experience their 1st major depression
  PP
• Idealization of birth motherhood
• Feeling inadequate, lack of social support,
  primipgt30 (Beck, 2001 Fergerson, 2002)
• Hormones, thyroid, cholesterol, anemia, stress

(Eberhard-Gran et al. 2002Oates, 2003) Depression Psychosis
General 10-15 0.1-0.2
Teens 26
High-risk gt35 8 suicidal
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• Depression in pregnancy does
• not
• predict Postpartum depression
• in individual women
• but
• Up to 66 of women depressed in pregnancy go on
  to have PPD
• and
• Is a disease unto itself

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Depression in Pregnancy--Antenatal Depression -
AD

• Melancholia in pregnancy
• documented in the 1840s
• as recently as the 1970s pregnancy
• thought to be protective for depression
• Hospitalization rates
• Hormones
• less psychosis suicide (Brockington, 1996)
• Effects to mother, baby, and family

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Systematic Review Antenatal Depression (Bennett, et al., 2004) Systematic Review Antenatal Depression (Bennett, et al., 2004) Systematic Review Antenatal Depression (Bennett, et al., 2004) Systematic Review Antenatal Depression (Bennett, et al., 2004)
Prevalence 1st Trimester 2nd Trimester 3rd Trimester
General population 7.4 - 24.6 9.1 - 48.9 8.8 - 51.4
Low-socioeconomic NA 28 - 47 25 39

• longitudinal studies
• Equal or greater than postpartum
• more common than medical conditions routinely
  screened for
• diabetes
  (Austin, 2003 Spinelli, 2001)
• Some protection for suicide but not morbidity
• 40 of depressed women had suicidal thoughts
  (Levey, 2004)
• Pilot study confirmed this

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Somatic complaints

• Physical complaints are considered normal in
  pregnancy and postpartum
• Other times in life would be flag for depression
• Aches and pains-- GI, headache, nausea
• Sleep
• Appetite, weight changes
• excessive physical complaints can alert to
  potential depression
• Significantly more physical complaints
• 23 - primary care setting depressed
• Depression/anxiety most significant predictor of
  increased somatic complaints
• 47 of depressed reported more than 6 physical
  symptoms
• (Kelly, 2003)

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Somatic symptom Depression/anxiety Yes N43 No N143
Nausea 93 66
Back pain 88 78
Stomach pain 79 50
Headaches 71 42
Short of breath 71 42
GI symptoms 68 45
Arm, Leg, joint pain 64 57
Heart pounding 58 36
Dizziness 54 32
intercourse-pain 41 22
Chest pain 21 14
Fainting 10 6
Plt 0.05, Plt 0.01, Plt0.001 Plt 0.05, Plt 0.01, Plt0.001 Plt 0.05, Plt 0.01, Plt0.001
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Risk factors-general

• Female
• Single or living with parents
• Partner discord
• Lack of social support
• Stress -- Often precedes first episode
• Substance Abuse
• Previous Hx of Depression
• Moods up/down
• Low income -- Food security
• Low education
• Ethnic minority -- new immigrant Aboriginal

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Obstetrical

• Parity
• Age
• teen vs. older primip
• Complications
• Diabetes, Bedrest
• Family violence
• Often starts in pregnancy
• Ambivalence about pregnancy
• Attempted abortion
• Anxiety about fetus
• Infertility
• Depression precedes infertility
• Discontinuation of Anti-Depressants

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Depressed pregnant women

• deteriorating social function, emotional
  withdrawal
• worry excessively about pregnancy ability to
  parent
• less likely to attend regular obstetric visits
• less likely to comply with prenatal advice
• take prenatal vitamins less often
• know less about the benefits of folic acid
• Fetal abuse
• punch abdomen
• lack of care
• substance abuse
• Poor self-care poorer obstetrical
  outcomes
• (Bonari, 2004 Kent, 1997 Zuckerman,
  1989)

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Effects on Pregnancy, mother, baby

• Depression not well studied or understood
• Stress Anxiety Depression
• Stress- anxiety
• often considered normal in pregnancy
• Timing of stressor in pregnancy
• No consensus
• Earthquake only affected preterm in 1st trimester
  
• Early stressor affects organ development
• 28-32 weeks affects neurobehavioral (Wadwa,
  2005)
• Real or perceived stress

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• Depression is associated with higher rates of
  tobacco, alcohol, and other substance use
• Smoking is associated with drinking/drugs
• Smoking increases with parity
• Quitting smoking can trigger depressive symptoms
  (Kahn, 2002)

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Alcohol Depression

• Chronic alcohol use associated with depression
• Both are harmful to mother and fetus
• Exacerbate each other increased acuity
• More likely to relapse
• More resistant to treatment
• More likely to suicide (Homish et
  al 2004)

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• Fetus
• Cortisol the stress hormone
• Fetal and maternal endocrine levels are
  correlated
• Hypercortisolaemia affects gluccocorticoid
  receptors in fetal brain
• ? CHR, ACTH
• FHR 35 wks
• ? variability ? rate / contradicted in one study
• Habituation and dishabituation decreased, delayed
  in depressed
• Uterine irritability
• ?resistance in blood vessels to the uterus
• ? blood flow to the baby- IUGR
• ? pre-term delivery
• 
  (Austin, 2005 Okeane,
  2005Teixeira,1999 Zuckerman, 1990)

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• Hypothalamic-pituitary-adrenal (HPA) axis
• Chronic dysregulation affects neural function
• Estrogen/HPA are intertwined
• ?depression ?fertility
• HPA-placental neuroendocrine axis
• Maternal stress affects fetal development
• Sustained HPA dysregulation and stress reaction
• Neuronal death abnormal development of fetal
  brain
• Altered performance on neuromotor tests, ability
  to cope
• monkeys, rats no reason to expect different in
  humans (Austin, 2005 Okeane Scott, 2005
  Glover et al, 2002)

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Effects of depression on Mother

• Increases and worsens with parity
• Increased risk for further depressions
• Increase in severity if left untreated
• Complications in the pregnancy
• Hypertension,? Epidural operative deliveries
  (Andersson, 2004 Chung, 2001)
• PPD - emergency c/s vs planned (Kurki, 2000)

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mother

• ? physical problems
• ?gastric secretions, Irritable Bowel Syndrome
  (Solmaz, 2003)
• Nausea, constipation
• Sleep problems
• ?General wellbeing
• ? Decision making, irritability, perception of
  events
• Associated with ?substance use, worries,
  loneliness, anxiety
• PP Depression/psychosis (Hiscock, 2001 Sharma,
  2004)

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• Cortisol
• prolonged increases can lead to changes in mood
• cycle continues and worsens
• Chronic depression
• changes in the adult brain
• shrinking hippocampus
• memory and cognitive impairment
• ? risk for depressions (MacQueen, 2003)
• Less responsive to babys cues
• Attachment problems begin
• Less attentive to stimulating baby, safety issues
  (Spinelli, 2001)

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Effects on Newborn

• ? risk of preterm delivery
• ?NICU admission
• Effects of depression and/or antidepressants
• Lower Apgar scores
• Lower birth weight/IUGR
• ? weight gain
• ? NBAS
• Less breastfeeding
• PPDSG
• ? Failure to thrive
• Smaller head circumference (Chung, 2001 Murray,
  2003)

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Effects on babies

• Less developed motor tone
• ? activity levels
• More withdrawn
• Cry excessively, irritable, less consolable
• ? expressivity and imitative behavior
• Negative expression
• ? SIDS
• Effects of lifestyle
• alcohol ?FASD, smoking, poor diet etc.
  (Murray, 2003 Zuckerman, 1989)

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Effects in Children

• Behavior problems in children
• anxiety in pregnancy ?ADHD in boys
• Direct effect of antenatal anxiety on fetal brain
  development
• ? Depression
• Patterns of stress
• Withdrawn
• Social and school difficulties
• Autism
• Criminality (Austin, 2005 Maki, 2003
  Murray,2003 OConnor, 2002 Weinstock, 2005
  Wilkerson, 2002)

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Family

• Up to 50? paternal depression in PPD
• No reason to expect it will be any less than for
  antenatally depressed families (Goodman, 2004)
• Non-depressed fathers important to child
  development
• Intergenerational problems continue
• Usually magnify if not treated (Murray, 2003)

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• Depressed pregnant women
• are underdiagnosed
• and undertreated
• (American Psychiatric Association Meeting, 2004)

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• Pregnancy is a time of
• increased contact with
• health services
• Chance for the early identification and
  intervention of depression

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Depression Screening

• Decreases clinical morbidity
• British Columbia - 2007
• 22-26 weeks, postpartum X 2
• Calgary
• all women 6 weeks postpartum
• Edmonton
• at immunization visits
• Ontario
• Healthy Babies Healthy Children
• Hamilton
• antenatal and postnatal in doctors offices
• Saskatchewan
• Feelings in pregnancy and motherhood Study
  underway in Saskatoon Health Region

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Edinburgh PostNatal Depression Scale - EPDS

• Most widely used perinatal depression screening
  tool - 1987
• Takes out physical and emotional symptoms common
  in the perinatal period
• Irritability, sleep disturbance, tiredness,
  bowel, appetite, and weight changes
  (Cox,
  2003)
• GPs diagnose 25-50 of ppd (Fergerson, 2002)
• EPDS and clinical assessment82 (Buist, 2002)

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EPDS

• Reflects the mood over the past 7 days
• Short - 10 items
• Self-report
• Free
• Easy to complete, score
• gt10 minor depression, population prevalence
• gt13 major depression
• Acceptable to women and caregivers
• Valid and Reliable
• antenatal and postnatal
• Many languages and dialects
• Sensitivity 100, specificity 80 (Cox, 2003)

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EPDS

• Opens door for communication
• Can also pick up anxiety (2 items)
• Rapid identification of suicidal ideation (item
  10)
• Asking -- prevents not provokes suicide
• Family drs pick up 12 of suicidal thoughts
  (Smith et al, 2004)
• Screen for depressive symptoms
• does NOT Diagnose depression
• Clinical interview needed to confirm depression

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• Interventions
• Psychotherapy
• Cognitive Behavioral Therapy - CBT
• Interpersonal Therapy-IT
• Significantly more than just education (Spinelli,
  2003)
• Groups
• Support, psycho education, self-care
• Supportive, listening visits
• Prevent PPD -- Unknown in antenatal (Clement,
  1995)
• Educate family
• Support, help with chores
• Aware and report worsening symptoms
• Suspiciousness, social isolation, no improvement
  despite intervention, sudden lightening of
  symptoms or elation

Lifetime effects
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• Self Care
• Nutrition - food mood
• Monitor quit drinking, quit smoking
• Exercise - walk outside, swimming
• Electroconvulsive Therapy ECT (Rabheru K, 2001)
• Bright Light therapy
• Pilot studies positive (Epperson et al, 2004)
• Alternate treatments
• Limited information
• Food and supplements folic acid, omega 6,
• Acupuncture
• Massage (Chui, 2003 Simon et al, 2002
  Spinelli, 2001)

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9. Medication

• 80 of women who become pregnant
• 35 are taking psychotropic medications
• 50 are unplanned
• 1st month most critical
• teratogenesis, organogenesis
• most women dont know pregnant
• First thought is to come off
• up to 50 will relapse (Cohen, 2006)
• If start medication during pregnancy
• Not likely to start until after first few weeks
  which is the time of greatest teratogenocity

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• Fluoxetine (Prozac)
• 1st Line of Treatment (CanMat)
• longest, most studied SSRI, no evidence of
  teratogenicity
• Not all women tolerate Fluoxetine
• Citalopram (Celexa) (SSRI)
• 4-fold increase of neonatal adaptation syndrome
  requiring adm. to NICU-transient-48hrs,
  manageable (Sivojelezova, 2005)
• Health Canada - advisories
• 2004 SSRIs
• Neonatal withdrawal-transient jitteriness,
  sleepiness, ?pain response
• Dec 2005 - Paroxetine (Paxil) (SSRI)
• 2-fold risk of cardiac malformations
• March 2006 - SSRIs
• PPHN potentially fatal
• Venlaflaxine (Effexor) SNRI
• No known teratogenetic effects or toxicity
  (Einarson, 2001)

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• Dosing
• Always aim for the lowest dose
• effective for alleviating symptoms
• Taper dose close to delivery to lessen the
  potential withdrawal or toxicity effects to
  newborn
• But then must monitor woman closely
• Depressive symptoms tend to increase as delivery
  approaches
• if woman has decreased or discontinued medication
  
• closely monitor (Misri, 2005).

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• Antidepressants
• Neonatal toxicity
• transient
• Heart malformations
• PPHN
• 0.01 (10 fatal)
• UNKNOWNS
• No known long term effects to IQ or developmental
  milestones SSRIs on market for 25yrs now

• Untreated Depression
• Operative deliveries
• Preterm birth
• IUGR
• Failure to thrive
• SIDS
• Poorer prenatal care
• Developmental delays
• Social, behavioral, psychological difficulties
• UNKNOWNS

From what we know at this timeeveryday new
information
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• Challenges
• Problem occurs in obstetrical clients but the
  clinical expertise, consultant diagnosis,
  treatment etc realm of psychiatry
• Family Practitioners and Nurses
• Good position to monitor throughout
• Pre-conception counseling to those at risk (prev
  depressions)
• Throughout pregnancy
• Postpartum year
• Lack of resources, interest, expertise
• Team of reproductive mental health, psychiatric,
  obstetrical practitioners available for
  consultation and treatment
• Keeping up with research
• Lack of public policy for screening and education
• Research is difficult in pregnant women
• RCTs, longitudinal, recruitment

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• Thank you
• Women and Staff
• Healthy Mother Healthy Baby,
• Community and Westside Clinic,
• Postpartum Depression Support Program,
• Saskatoon. SK, Canada