Depression in Pregnancy Often Goes Untreated

Although pregnancy can be a time of joyful anticipation, research at the University of Michigan shows that 1 out of 5 expectant mothers experience symptoms of depression, and few are receiving help.

“We know that there are risks to the mother and infant that are associated with a failure to treat depression in pregnancy,” said Sheila Marcus, M.D., principal investigator on the study and lead author of the article, “Depressive Symptoms Among Pregnant Women Screened in Obstetrics Settings,” in the May 22 Journal of Women’s Health.

Marcus is a clinical assistant professor of psychiatry at the University of Michigan Medical School and director of the Women’s Mood Disorders Program at the University of Michigan Depression Center.

She and her colleagues screened 3,472 pregnant women at 10 obstetrics clinics in southeastern Michigan from 1999 to 2002. The researchers queried the women about history of depression, treatment for depression, use of alcohol, and employment status, for example.

To measure subjects’ depressive symptoms, they used the Center for Epidemiologic Studies Depression Scale (CES-D), a standardized 20-item questionnaire.

After screening the women, the researchers found the following:

• Twenty percent of the sample, 689 women, screened positive for elevated depressive symptoms as measured by the CES-D.

• When researchers reinterviewed the women with elevated CES-D scores using the Structured Clinical Interview for DSM-IV-TR, they found most had minor depression or dysthymia, and about 20 percent met diagnostic criteria for major depressive disorder.

• Of the 689, just 13.8 percent, or 91, were receiving psychotherapy and/or medications for their depression.

• Twenty-eight percent of the total sample reported a lifetime history of major depression. Of this group, 42.6 percent had current symptoms of depression.

• Women who reported a history of major depression (958) were 4.9 times more likely than other subjects to have elevated CES-D scores during pregnancy.

• Risk factors associated with depressive symptoms during pregnancy include being unmarried, unemployed, and in poor overall health.

• Eighty-eight percent of those with a history of major depression had not received any treatment for their depression in the months before the study.

Marcus told Psychiatric News that significant changes in a pregnant woman’s hormone levels can affect her levels of mood-regulating neurotransmitters, which may in turn result in depressive symptoms.

But mounting evidence shows that life’s circumstances may also play an important role.

“Unemployment and the resulting financial circumstances or the lack of a family support system for an expectant mother may worsen the problem,” she said.

It’s difficult to know whether rates of depression among pregnant women are on the rise in America, Marcus added. One reason is that studies measuring depression in pregnant women over the past 10 to 20 years use different scales to measure different degrees of depression.

In general, rates of minor depression or depressive symptoms among pregnant women are usually higher than those of major depression.

It is possible, she acknowledged, that as certain risk factors for depression during pregnancy increase—being unmarried and poor, for example—the prevalence of pregnant women experiencing depressive symptoms will also increase.

One reason that screening pregnant women for symptoms of depression during pregnancy is so important, Marcus said, is that it may prevent future bouts with depression. “We know depression is recurrent,” she said, and studies have found that “women with symptoms of depression during pregnancy are probably more likely to have full-blown postpartum depression.”

Marcus and her colleagues are now following their cohort of pregnant women in Michigan to track the occurrence of postpartum depression in the sample.

Once a pregnant woman screens positive for depressive symptoms or major depression, then what?

“Assuming that the woman has only minor symptoms with a history that is relatively benign,” Marcus said, “psychotherapy would probably be the best option.”

Many physicians may be reluctant to prescribe antidepressants for major depression, said Marcus, because they fear that the medications will harm the fetus.

Although some drugs, such as lithium, have been associated with birth defects, the bulk of evidence, she said, “would suggest that there is no link between selective serotonin reuptake inhibitors (SSRIs) and tricyclic agents and congenital defects in newborns.”

“We know there are risks associated with not treating depression in pregnancy, however,” she said.

Nada Stotland, M.D., M.P.H., a professor of psychiatry and obstetrics and gynecology at Rush University in Chicago and APA representative to the American College of Obstetricians and Gynecologists, agreed.

“Few physicians are aware of the deleterious impact depression has on the progress and outcome of the pregnancy, a woman’s ability to mother, and the well-being of her child after it is born,” she said.

Although “no one can say for certain that any medication is safe during pregnancy and lactation,” Stotland said, there is a growing body of literature on the impact of SSRIs on the fetus and nursing baby, research she called “quite reassuring.”

Marcus said the more well-established risks associated with not treating depression in expectant mothers include premature delivery, low birth weight, and pre-eclampsia in the mother.

The article “Depressive Symptoms Among Pregnant Women Screened in Obstetrics Settings” is posted on the Web at www.liebertpub.com/jwh/default1.asp. ▪