Chapter 24: Depression in Pregnancy

INTRODUCTION

Approximately 10% to 13% of pregnant women suffer from pregnancy-associated depressive episodes,^1,2 and about 5% to 6% develop major depression during pregnancy.² Maternal suicide accounts for 20% of postnatal deaths among depressed women.³ One in five women will experience a major depression episode during the course of her lifetime. Upon diagnosis of pregnancy, most women will discontinue their antidepressants owing to the concern of adverse effects on the fetus. Pregnancy, however, does not protect against the development of an episode of depression, making it more likely that these patients will need behavioral and pharmacologic treatments. Yet this aspect continues to be the most neglected part of a woman’s obstetric care.

Pregnancy-associated depression is associated with fetal and neonatal complications.^4,5 The latter range from low birth weight to adverse neurodevelopmental and psychopathological outcomes. Interventions to maintain euthymic mood in the mother may have a significant positive impact on mother-infant interaction and the child’s cognitive function.⁶

CLINICAL PRESENTATION

Major Depression

Though uncommon, major depression may present for the first time during pregnancy. The depressive episode is the central feature, although it can have a psychotic variant. The relapse risk of unipolar or bipolar depression is increased during the latter part of pregnancy because some women discontinue their psychopharmacologic treatment when they become pregnant. There are conflicting reports on whether the relapses increase postpartum or the women seek treatment more often after delivery than during pregnancy.^7,8,9 Symptoms must be present for a minimum of 2 weeks in order to establish the diagnosis.

Bipolar Disorder

Bipolar disorder may include depressive episodes or episodes with mixed depressive and manic symptoms. Psychotic symptoms may occur.

Minor Depressive Disorder

Depressive episode is the main feature. It does not have a psychotic variant. The woman is depressed for most of the day, nearly every day, for at least 2 weeks. Prevalence is 5% to 9%.

Dysthymic Disorder

Dysthymic disorder is a state of chronic depressive symptoms.

Schizoaffective Disorder and Schizophrenia

These disorders may have depressive episodes, but the central features are the psychotic symptoms.

Postpartum Blues

The prevalence is 40% to 80%. Symptoms consist of mild, rapid mood swings from elation to sadness, irritability, anxiety, decreased concentration, insomnia, tearfulness, and crying spells. It occurs within 2 to 3 days of delivery and resolves within 2 weeks.

For major depression, bipolar disorder, and schizoaffective disorder or schizophrenia, immediate consultation or transfer to psychiatric facility should be sought.

RISK FACTORS

The birth of a baby brings both ...