Depression in pregnancy

Depression refers to a spectrum of mental health problems characterised by the absence of positive affect (loss of interest and enjoyment in ordinary things and experiences), low mood, and additional emotional, cognitive, physical, and behavioural symptoms. Women who are pregnant or postnatal can develop or have the same mental health problems as other adults.¹

Perinatal depression can occur during pregnancy (prenatally), the year following birth (postpartum), or both.²

How common is depression in pregnancy? (Epidemiology)

Depression is under-recognised during pregnancy and postnatally. In pregnancy, depression and anxiety are the most common mental health problems, with depression affecting around 12% and anxiety affecting 13% of women.¹

Risk factors

Women experiencing social or economic adversity are most likely to experience antenatal depression. Risk factors include:^{1 3 4}

• History of mood and anxiety disorders.

• History of postnatal depression.

• History of premenstrual dysphoric disorder.

• Family history of perinatal psychiatric illness.

• Maternal anxiety.

• History of childhood abuse.

• Low income.

• Poor social support.

• Life stress.

• Unplanned pregnancy.

• Single motherhood.

• Large number of existing children.

• Domestic violence.

• Relationship factors.

• Young age.

A Cochrane review concluded that there was insufficient evidence to suggest that the use of psychosocial risk assessments improves perinatal mental health outcomes.⁵

Symptoms of depression in pregnancy (presentation)

The signs and symptoms of antenatal depression are as for depression in general. See separate Depression article.

However, if one focuses on somatic symptoms (eg, fatigue, insomnia, appetite changes), pregnancy symptoms may mask those of depression, particularly in the first trimester. Thus, the psychological symptoms (eg, anhedonia, hopelessness, guilt) may be more reliable during pregnancy.

Screening for depression in pregnancy^{1 6}

At a woman's first contact with primary care, or at her booking visit, and early in the postnatal period, discuss her mental health and wellbeing and consider asking two questions to identify possible depression:

• During the past month, have you often been bothered by feeling down, depressed, or hopeless?

• During the past month, have you often been bothered by having little interest or pleasure in doing things?

Regularly ask women about their current mental health during pregnancy and the postpartum period.

If depression is suspected from a positive answer to either of the depression identification questions, the woman is at risk of developing a mental health problem, or there is clinical concern, assess further, including the severity of any depression, using the Patient Health Questionnaire (PHQ-9) as part of a full assessment or, if a severe mental health problem is suspected, refer to a mental health professional.

To help to assess and diagnose a suspected mental health problem in pregnancy, ask about:

• History of any mental health problem (particularly depression, postpartum psychosis, or bipolar disorder), including in pregnancy or the postnatal period, treatment received, and response; family history of mental health problems in a first-degree relative.

• Any worries or preoccupations.

• Attitude towards the pregnancy (including denial of pregnancy), her experience of pregnancy, and any problems encountered by her, the fetus or the baby.

• Physical wellbeing (including weight, smoking, nutrition and activity level) and any physical health problems.

• Social factors, including social networks, living conditions, employment, economic and immigration status, domestic violence and abuse, sexual abuse, trauma or childhood maltreatment, whether caring for other children and young people or other adults, alcohol and drug misuse.

Assess the woman's risk of self neglect, self harm or suicide. If there is a risk of self harm or suicide, assess whether the woman has adequate social support and is aware of sources of help, arrange help appropriate to the level of risk, and advise the woman, and her partner, family or carer, to seek further help if the situation deteriorates.

Exclude differential diagnoses, eg, bipolar disorder.

Investigations may be needed to exclude other physical causes of symptoms, eg, full blood count and thyroid function if predominant fatigue.

Management of depression in pregnancy ^{1 6}

There have been increasing concerns about the effects on fetal development of antidepressants taken during pregnancy. The threshold for use of non-medication options such as psychological treatments is much lower at this time but the availability of such options has obvious implications.

Each case has to be taken on its own merits. A discussion should be held with each patient and, if appropriate, with her family, which should address:

• Non-medication options.

• The risks associated with any normal pregnancy.

• The risks and benefits of antidepressants - the possibility of overdose, abrupt cessation of medication, and safer choices for breast-feeding.

Having had this discussion, the patient's view should then be obtained. Other considerations will include the stage of pregnancy, the severity of the depression, any previous treatment (if applicable) and the need for referral (see below).

Watchful waiting

Where an individual has had mild depression treated with antidepressants and is pregnant/intends to become pregnant, withdraw the drugs gradually and monitor regularly.

Self-help

This is suggested where intervention is required for mild-to-moderate depression without a previous history of depression. Possibilities include:

• Guided self-help.

• Computerised cognitive behavioural therapy (C-CBT).

Alternatives, where available, would be nondirective counselling ('listening visits') or brief psychological treatment - usually 4-6 sessions of CBT or interpersonal psychotherapy (IPT).³

The evidence is inconclusive for depression-specific acupuncture, maternal massage, bright light therapy, and omega-3 fatty acids for the treatment of antenatal depression.⁷

One study reported that aerobic exercise improved depressive symptoms in nulliparous patients with mild-to-moderate depression.⁸

Psychological treatments may be considered for moderate or severe depression where a woman opts for this in preference to drug treatment or in combination with antidepressant medication. They should also be considered with mild depression with episodes of more severe depression in the past.

IPT and CBT

These therapies (also known as structured psychological treatments) are useful for moderate- to-severe depression. They should also be considered with mild depression with episodes of more severe depression in the past. They are sometimes combined with antidepressant medication.

Antidepressants

No antidepressant is considered completely safe in pregnancy, if for no other reason that marketing trials on pregnant women are eschewed by pharmaceutical companies on ethical grounds. The information base is therefore limited.

Moreover, a recent meta-analysis found that antidepressants may significantly increase the risk for preterm birth and low birth weight.⁹ However, this has to be balanced against the risks of untreated depression. Psychiatric illness during pregnancy is in itself an independent risk factor for preterm delivery and perinatal mortality, as well as congenital malformations,

NICE recommends antidepressant medication for a woman with moderate-to-severe depression who:

• Has not responded to high intensity psychological treatment (eg, CBT).

• Declines psychological treatment.

• Has expressed a preference for medication.

• Understands the risks and benefits of the proposed medication.

Before starting antidepressant treatment during pregnancy, consider seeking advice from the UK Teratology Information Service (UKTIS) on 0844 892 0909; a specialist perinatal mental health team, where available; or from secondary psychiatric care.

Inevitably, there is more safety information about older antidepressants than newer medication. On this basis, tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs) and in some circumstances serotonin-norepinephrine reuptake inhibitors (SNRIs) are considered the safest options. Even then, the following should be borne in mind:

• TCAs - amitriptyline has the most supportive information and suggests no risks of congenital abnormalities or adverse fetal outcome. Similarly, the literature that is available has supported the use of trazadone and dosulepin, but there are fewer data available.

• SSRIs - there is an increased risk of congenital malformations in the first trimester, most consistently reported with paroxetine. After 20 weeks, SSRIs have been associated with persistent pulmonary hypertension of the newborn (PPHN). Serotonin withdrawal syndrome is a self-limiting condition with usual neonatal symptoms including hypotonia, irritability, excessive crying, sleeping difficulties and mild respiratory distress. It is more likely to occur with paroxetine. Some centres try to prevent it by gradually discontinuing medication in the third trimester but this carries a high risk of relapse. NB: serotonin toxicity may give very similar symptoms to its withdrawal syndrome.¹⁰

• SNRIs - they are not routinely used as there is even less safety information available than other options but are useful in some circumstances on specialist advice.

• Avoid St John's wort and monoamine-oxidase inhibitors (MAOIs) in pregnancy.

• All antidepressants carry the risk of withdrawal or toxicity in the neonate. Normally this is mild and self-limiting.¹¹

For patients who become pregnant whilst taking antidepressants:

• Consider seeking specialist advice before stopping or switching medication.

• Avoid abrupt withdrawal.

• Cover all the relevant issues that would be discussed with a patient who was taking an antidepressant for the first time.

• Consider (with specialist advice) the range of options available and discuss with the patient. This may include gradual withdrawal of medication, instituting psychological therapy and/or switching to a drug with fewer adverse effects.

Electroconvulsive therapy (ECT)

Electroconvulsive therapy (ECT) should be considered for pregnant women with severe depression, severe mixed affective states or mania, or catatonia, whose physical health or that of the fetus is at serious risk.

Referral

Urgently refer to a secondary mental health team (ideally with a special interest in perinatal mental health) if:

• Severely depressed and presents a considerable immediate risk of harm to herself or other people; admission may be required if clinically indicated.

• Evidence of severe self-neglect.

• Possible diagnosis of bipolar disorder.

• History of severe mental illness, including postnatal depression, puerperal psychosis, or bipolar disorder (during pregnancy or the postnatal period or at any other time).

Refer to a specialist substance misuse service if, in addition to depression, the woman has harmful or dependent drug or alcohol misuse in pregnancy or the postnatal period.

Refer or seek specialist advice if:

• Considering continuing, starting, stopping, or switching antidepressant treatment during pregnancy.

• Considering reducing the dose of, or discontinuing, antidepressant treatment close to delivery.

• The woman is not responding to treatment appropriate to the severity of her depression.

Specialist advice may be sought ideally from a specialist perinatal mental health team where available, or from a secondary mental health service or the UK Teratology Information Service (UKTIS) on 0344 892 0909.

Other factors to be taken into account when deciding whether to refer include:

• The woman's preference.

• The woman's past history and response to treatment.

• The degree of functional impairment.

• The presence of significant comorbidities or specific symptoms.

Complications of depression in pregnancy¹

Severe depression is associated with an increase in:

• Obstetric complications.

• Sudden infant death syndrome.

• Low birthweight and premature infants.

• Self harm and suicide attempts (suicide is a more common cause of death in the peripartum period than hypertensive disorders or postpartum haemorrhage and is now a leading cause of maternal death in the first year postpartum, although it is still rare.

If depression is untreated during pregnancy, women have a seven-fold increased risk of postpartum depression compared with women with no antenatal depressive symptoms.

Antenatal depression is also associated with:

• Increased pregnancy symptoms, pain relief in labour and worse obstetric outcome.¹²

• Higher incidence of lower birth weight, caesarean section but not infant mortality.¹³

• Relationship and family break-up.

Depression in pregnancy, particularly if not treated, may affect the cognitive, emotional, social, educational, behavioural, and physical development of the infant, although a minority of children are affected.

Peripartum depression is associated with failure to thrive, attachment disorder, and developmental delay at a year old.

Prognosis

Early detection of depression during pregnancy and its adequate treatment are critical to avoid its persistence into the postpartum period and sequelae such as impaired mother-infant attachments and the consequences this has for children.

There is a lack of evidence to suggest that the prognosis of mental health problems developing during pregnancy or the postnatal period is different from those occurring at other times of life. However, the risk of subsequent relapse is high, affecting around 1 in 4 women.¹

Whilst women are at generally low risk of suicide during pregnancy, it is a significant cause of maternal death in the year following birth in the UK. Improving awareness of perinatal mental health problems, in all their diversity, is important.

Prevention of depression in pregnancy

Women with pre-existing affective disorder

• All women with affective disorders, of reproductive age and potential, should have family planning discussed as part of their routine care. Where women with a past history of severe or resistant depression are planning to become pregnant, referral to specialist psychiatric services for preconceptual advice is appropriate.

• The decision to stop or continue medication should be an informed decision made by the woman, with access to available evidence and risk assessment.

Women with depressive symptoms⁶

Where a woman experiences depressive symptoms that do not meet diagnostic criteria but do significantly interfere with her personal or social functioning:

• If she has not had a previous episode of depression, consider increasing social support during pregnancy and the postnatal period with regular informal individual or group-based sessions.

• If she has had a previous episode of depression, consider offering brief psychological treatment (4-6 sessions) such as IPT or CBT.

Vigorous exercise (3-5 times a week, raising the heart rate to 70-80% of maximum) may have a protective effect.¹⁴