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Overview
CE credits: 1
Learning objectives:
After reading this article, CE candidates will be able to:
- Describe the factors that contribute to depression among pregnant women.
- Describe how maternal depression harms mothers and babies.
- Discuss the treatments for antenatal depression.
One patient stands out for psychologist Ellen L. Poleshuck, PhD. When the woman came to see her, she already had three children by two fathers and was pregnant with a fourth. She felt ambivalent about the pregnancy, uncertain about her ability to manage and very depressed.
With Poleshuck's help, the woman not only got over her depression but found ways to be excited about becoming a mother again. She made regular prenatal care visits. She also stabilized her housing situation, negotiated how much involvement the baby's father would have and reached out to relatives for help. As a result, says Poleshuck, the pregnancy and transition to having another baby went smoothly.
"It's enormously important that the field start thinking about assessing and treating depression during pregnancy, not just postpartum," says Poleshuck, an associate professor of psychiatry and obstetrics and gynecology (OB/GYN) at the University of Rochester School of Medicine and Dentistry, who directs the Women's Behavioral Health Service at the university's medical center. "It's a time when women are already more likely to be engaged in health care, so we have better access to them and an opportunity to engage them in mental health care."
Several factors are helping to expand the focus from postpartum care to care during pregnancy. New guidelines from the U.S. Preventive Services Task Forceopens in new window, for example, now include pregnant women and new mothers in depression screening recommendations. And with both the American Congress of Obstetricians and Gynecologists and the American Psychiatric Association discouraging pharmacological treatment of depression in pregnant women, psychologists are increasingly providing psychotherapeutic interventions to this population, for the good of both expectant mothers and their babies.
"It's difficult for women who are suffering from untreated depression to come to their appointments," says Ellen J. Tourtelot, MD, an assistant professor of OB/GYN at Rochester and director of the Women's Health Practice at the university's medical center. "Establishing successful breastfeeding after delivery is also much more difficult if the depression isn't treated before the baby's birth, since women often give up a few days after birth if breastfeeding isn't going well."
Having psychologists and other mental health professionals as part of an OB/GYN team makes it easier for physicians to use their limited time with patients to discuss all the issues they have to cover, says Tourtelot. Plus, she says, it helps combat stigma when patients can see a psychologist just down the hall from their OB/GYN. "The office is kind of like their home," she says.
Protecting moms and children
A growing body of evidence shows that maternal depression harms babies, too. A new study of more than 7,000 pregnant women found that depression was associated with an 82 percent increased risk of extremely premature birth and a 28 percent increased risk of low birth weight, for instance (Venkatesh et al., Obstetrics and Gynecology opens in new window, 2016).
Yet many pregnant women are reluctant to take antidepressants—for good reason. Although research findings have been mixed, the U.S. Preventive Services Task Force evidence review suggests that antidepressant use during pregnancy could be associated with a small increase in the risk of serious harm to children, including premature birth, seizures, major malformations and death (O'Connor et al., Journal of the American Medical Association opens in new window, 2016).
Newer research not included in that review suggests that the effects of antenatal antidepressant use can linger long term. A study of almost 65,000 women—one of the few to track children long term—examined data from a national registry in Finland and found that children whose mothers took antidepressants during pregnancy were more than four times as likely to be depressed themselves by age 15 than children whose mothers also had psychiatric disorders but didn't take the drugs (Malm et al., Journal of the American Academy of Child & Adolescent Psychiatry opens in new window, 2016), for example. In an effort to control for the severity of the mothers' problems, the researchers excluded mothers on multiple psychiatric medications and took into account previous suicidal behavior.
While some cases of antenatal depression are so severe that antidepressants are a must, therapy is also effective, the U.S. Preventive Services Task Force found. In the review of the evidence, psychologist Elizabeth O'Connor, PhD, an investigator at Kaiser Permanente's Center for Health Research, and her co-authors found that treating depression in pregnant and postpartum women who screen positive for depression at a medical visit effectively reduces depression (O'Connor et al., Journal of the American Medical Association opens in new window, 2016). Cognitive-behavioral therapy has the strongest evidence showing that it is helpful in increasing the likelihood of remission, the authors found.
Interpersonal psychotherapy—a brief, highly structured form of therapy that focuses on fixing relationship problems and reducing symptoms—is another effective, well-validated treatment option, says Poleshuck. "It has been studied quite extensively among perinatal women specifically," she says.
In one study, she points out, an interpersonal psychotherapy intervention especially adapted for pregnant women was found to be markedly more effective than a parenting education program among pregnant women with moderate depression (Spinelli et al., Journal of Clinical Psychiatry opens in new window, 2016). An earlier analysis of the data that included women with mild depression found no difference between the two interventions (Spinelli et al., Journal of Clinical Psychiatry opens in new window, 2013).
"Mild depression tends to respond to all kinds of interventions," says Jean Endicott, PhD, one of the paper's co-authors and a professor of clinical psychology at the Columbia University Medical Center. "The current finding helps emphasize that the baseline of the severity of the depression is quite important."
Treating antenatal depression
Cultural norms insist that pregnancy is a blissfully happy time. Yet according to evidence cited by the task force, 9 percent of pregnant women—and 10 percent of postpartum women—meet criteria for major depression. "There was a time when we thought of pregnancy as a buffer against depression," says Malina Spirito, PsyD, a psychologist at the Center for Women's Emotional Wellness at Christiana Care Health System in Newark, Delaware.
More recent research shows that pregnancy can prompt or exacerbate depression, says Spirito, adding that this goes beyond the hormonally driven changes in mood that can occur early in the first trimester and immediately after delivery.
"Emotional reactions to hormonal shifts tend to be relatively mild and transient," says Spirito. While hormones can contribute to depressive symptoms during pregnancy, she says, they're likely not the only source of distress.
The mismatch between reality and social norms can make women feel even worse, says Spirito.
For one patient, for example, depression was rooted in an intense dislike of the experience of pregnancy itself. "She was being overwhelmed with feelings of tremendous discomfort, almost feeling like she didn't have control or ownership of her body anymore," says Spirito.
Even though she wanted another child, she didn't feel bonded with her developing baby or the idea of another child, felt guilt and shame about her lack of excitement and was afraid she would wish the baby away. Therapy—and antidepressants begun just before delivery—helped her accept that even though her experience wasn't the norm, she could still be the mother she wanted to be. She went on to have a positive delivery and postpartum experience, says Spirito. These preventive interventions also helped the woman avoid the postpartum depression she had experienced after her first pregnancy, she says.
Some women, especially first-time mothers, may get depressed as they struggle with issues of identity, says Spirito. "It's about forging a new identity of being a mother while figuring out how to hold on to and continue to nurture other aspects of identity," she says. Other women have past trauma, such as trauma or even post-traumatic stress disorder brought on by difficult previous deliveries, that can make pregnancy or the transition to parenthood especially difficult. Spirito will accompany women into the delivery room if they have extreme anxiety, histories of trauma or inadequate family support.
If pregnant women need antidepressants, Spirito refers them to the psychiatric advanced practice nurse on her team, who can help them weigh the pros and cons and prescribe medication if necessary. "The research supports the notion that nothing beats a calm mom," says Spirito. "When we can achieve that through psychotherapy alone that's awesome, but that's not the case for all women. Sometimes we need all the resources in our toolbox, including psychotropics."
Because the mental health team is embedded in Christiana's OB/GYN department, clinicians can coordinate care and triage patients who need psychological care immediately. And women can see their obstetrician, get ultrasounds and bloodwork done, obtain medications and have therapy in back-to-back appointments. "We get lots of positive feedback about this, as it is very difficult for pregnant women, especially those with other small children or those who are working, to juggle so many different medical appointments through pregnancy," says Spirito.
Encouraging mindfulness
Contemplative practices, such as meditation and yoga, are also gaining ground, says Sona Dimidjian, PhD, an associate professor of psychology and neuroscience at the University of Colorado at Boulder. Dimidjian's research shows that mindfulness helps prevent depression during pregnancy and also teaches women skills they can use as they transition into parenthood and beyond.
She has tested an eight-week mindfulness-based cognitive therapy program that also includes loving kindness meditation practice designed to enhance a woman's connection to her baby and her commitment to caring for herself and her baby. The program also includes homework assignments in which women practice asking for help and saying no to requests.
In a pilot study, Dimidjian and her co-authors found that the mindfulness-based cognitive therapy program prevented relapses in pregnant women with histories of depression (Dimidjian et al., Journal of Consulting and Clinical Psychology opens in new window, 2016). Only 18 percent of the women assigned to receive the mindfulness intervention had relapses, compared with 50 percent of the women who received treatment as usual.
For Dimidjian, the goal is to teach pregnant and postpartum women the skills they need to care for themselves in ways that prevent depression and promote well-being.
"It's so important that we as a culture talk about how common — and preventable — the experience of depression during pregnancy is because it opens the door for women to reach out for help," she says.
