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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

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Depression in pregnancy

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


Depression in pregnancy


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


    • Prevalence 7%, lifetime prevalence 12.3%(Stewart, 2003)

Depression in pregnancy

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 (>deep vein thrombosis etc.)

  • Those with early onset of illness died early

    • others did die later ~ often didn’t appear to be suffering PPD

  • Less associated with low income and other risk factors

  • More violent methods of suicide

    • Few by overdose(Oates, 2003)

Depression is depression
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

Depression in pregnancy

  • 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

Women express depression differently
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

Postpartum blues
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

    Postpartum depression ppd
    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, primip>30 (Beck, 2001; Fergerson, 2002)

    • Hormones, thyroid, cholesterol, anemia, stress

    Depression in pregnancy

    Depression in pregnancy does


    predict Postpartum depression

    in individual women


    Up to 66% of women depressed in pregnancy go on to have PPD


    Is a disease unto itself

    Depression in pregnancy antenatal depression ad
    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

  • Depression in pregnancy

    • 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

  • Somatic complaints
    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)

    Risk factors general
    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




    teen vs. older primip


    Diabetes, Bedrest

    Family violence

    Often starts in pregnancy

    Ambivalence about pregnancy

    Attempted abortion

    Anxiety about fetus


    Depression precedes infertility

    Discontinuation of Anti-Depressants


    Depressed pregnant women
    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)

    Effects on pregnancy mother baby
    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

    Depression in pregnancy

    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)

    Alcohol depression
    Alcohol & Depression alcohol, and other substance use

    • 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)

    Depression in pregnancy

    Fetus alcohol, and other substance use

    Cortisol “the stress hormone”

    • Fetal and maternal endocrine levels are correlated

      • Hypercortisolaemia affects gluccocorticoid receptors in fetal brain

      •  CHR, ACTH

    • FHR35 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; O’keane, 2005;Teixeira,1999; Zuckerman, 1990)

    Depression in pregnancy

    Stress alcohol, and other substance use

    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; O’keane & Scott, 2005; Glover et al, 2002)

    Effects of depression on mother
    Effects of depression on Mother alcohol, and other substance use

    • 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)

    mother… alcohol, and other substance use

    ↑ 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)

    Depression in pregnancy

    Cortisol alcohol, and other substance use

    • 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 baby’s cues

      • Attachment problems begin

      • Less attentive to stimulating baby, safety issues (Spinelli, 2001)

    Effects on newborn
    Effects on Newborn alcohol, and other substance use

    • ↑ 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)

    Effects on babies
    Effects on babies… alcohol, and other substance use

    • 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)

    Effects in children
    Effects in Children alcohol, and other substance use

    • 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; O’Connor;, 2002; Weinstock, 2005; Wilkerson, 2002)

    Family alcohol, and other substance use

    • 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)

    Depression in pregnancy

    Depressed pregnant women alcohol, and other substance use

    are underdiagnosed

    and undertreated

    (American Psychiatric Association Meeting, 2004)

    Depression in pregnancy

    Pregnancy is a time of alcohol, and other substance use

    increased contact with

    health services

    Chance for the early identification and intervention of depression

    Depression screening

    Decreases clinical morbidity alcohol, and other substance use

    British Columbia - 2007

    22-26 weeks, postpartum X 2


    all women 6 weeks postpartum


    at immunization visits


    Healthy Babies Healthy Children


    antenatal and postnatal in doctor’s offices


    Feelings in pregnancy and motherhood Study underway in Saskatoon Health Region

    Depression Screening

    Edinburgh postnatal depression scale epds
    Edinburgh PostNatal Depression Scale alcohol, and other substance use- 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 assessment=82% (Buist, 2002)

    Depression in pregnancy
    EPDS… alcohol, and other substance use

    • Reflects the mood over the past 7 days

      • Short - 10 items

      • Self-report

      • Free

      • Easy to complete, score

        • >10 minor depression, population prevalence

        • >13 major depression

      • Acceptable to women and caregivers

      • Valid and Reliable

        • antenatal and postnatal

        • Many languages and dialects

          • Sensitivity 100%, specificity 80% (Cox, 2003)

    Depression in pregnancy
    EPDS… alcohol, and other substance use

    • 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 NOTDiagnose depression

    • Clinical interview needed to confirm depression

    Depression in pregnancy

    Interventions alcohol, and other substance use

    • Psychotherapy

      • Cognitive Behavioral Therapy - CBT

      • Interpersonal Therapy-IT

        • Significantly more than just education (Spinelli, 2003)


      • 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

    Depression in pregnancy

    • Self Care alcohol, and other substance use

      • 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)

    9 medication
    9. alcohol, and other substance useMedication

    • 80% of women who become pregnant

      • 35% are taking psychotropic medications

      • 50% are unplanned

    • 1st month most critical

      • teratogenesis, organogenesis

      • most women don’t 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

    Depression in pregnancy

    Fluoxetine (Prozac) alcohol, and other substance use

    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)

    Depression in pregnancy

    • Dosing alcohol, and other substance use

      • 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).

    Depression in pregnancy

    Antidepressants alcohol, and other substance use

    Neonatal toxicity


    Heart malformations


    0.01% (10% fatal)


    No known long term effects to IQ or developmental milestones – SSRIs on market for 25yrs now

    Untreated Depression

    Operative deliveries

    Preterm birth


    Failure to thrive


    Poorer prenatal care

    Developmental delays

    Social, behavioral, psychological difficulties


    From what we know at this time…everyday new information

    Depression in pregnancy

    Challenges alcohol, and other substance use

    • 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

    Depression in pregnancy

    Thank you alcohol, and other substance use

    Women and Staff…

    Healthy Mother Healthy Baby,

    Community and Westside Clinic,

    Postpartum Depression Support Program,

    Saskatoon. SK, Canada