Editorial

Depression during pregnancy

Donna Stewart, MD, FRCPC

D
epression is common, disabling, and treat- be at risk of harming themselves or even commit-
able. As many international studies have ting suicide. The biologic correlates of depression,
shown, depression is a leading cause of dis- including high cortisol levels and perturbed hypo-
ability among women aged 18 to 44.1 The 12-month thalamic-pituitary-adrenal axis and beta endor-
prevalence rate of depression in the Canadian phins, can result in harmful effects on a developing
Community Health Survey is approximately 4.5% fetus, including prematurity, lower birth weight,
among all Canadians older than 12 years.2 This rate and slower fetal activity and development. Infants
is much higher among women during their repro- of depressed mothers sometimes receive subopti-
ductive years.3 One of the curious, but consistently mal physical and psychological care. Older children
documented, findings of epidemiologic studies is that and spouses can also suffer from the secondary
rates of depression in boys and girls are roughly equal effects of maternal depression.8
until puberty, when adolescent girls’ rates suddenly Symptoms of depression during pregnancy and
increase to twice those of boys. These doubled rates the postpartum period are similar to those at other
of depression among women remain constant until times of life, but can be more difficult to disen-
menopause; then they gradually decline until death.4 tangle from physical symptoms related to preg-
Reasons for this sex differential are controversial nancy or infant care, such as poor sleep, low energy,
but are likely multifactorial, comprising biologic, and weight changes. Not surprisingly, depressive
psychologic, and sociocultural factors. Recent stud- thoughts often focus on pregnancy, labour, infant
ies show that adverse events in childhood, such as feeding, bathing, health, and safety. The one excep-
abuse and neglect, loom large among later risks tion is postpartum psychosis, which is rare, sud-
for depression, especially for women already at den, and severe, with thoughts that are out of touch
increased genetic risk.5 with reality.
Given that rates of depression are highest Depression and anxiety often go hand in hand,
among women aged 18 to 44, it is unsurprising and this is true during pregnancy as well. A
that depression is frequently seen in pregnant and recent community study of 8323 pregnant women
recently pregnant women. Whether prevalence of in England found 11% had anxiety and 13% had
depression is increased by pregnancy, however, is depression during pregnancy, and 13% had anxiety
debatable; if it is increased, rates are probably only and 13% had depression postpartum. Most post-
slightly higher than among non-pregnant women partum depression and anxiety was preceded by
of comparable age and socioeconomic status. 6 antenatal depression and anxiety. Antenatal anxiety
What makes depression during and after pregnancy also predicted postpartum depression, even after
special is the context in which it occurs and the controlling for antenatal depression.9 In most stud-
effects it can have on women, fetuses, infants, and ies, depression during pregnancy is the strongest
families.7 Depressed pregnant women are less likely predictor of postpartum depression.10
to eat and sleep well and more likely to neglect per-
sonal hygiene and to smoke and drink alcohol. They
are less likely to seek prenatal care or to adhere Identifying and treating depression
to medical recommendations. In addition to per- As depression during pregnancy is a major threat
sonal suffering and disability, these women might to maternal health, and increasing evidence

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Editorials

indicates it also harms fetuses and infants, how can Physician by Ryan et al (page 1087) attempts to do
we best identify and treat it in busy clinical prac- this, but appears to conclude that antidepressants
tices? A brief, valid, reliable instrument with good are safe and neonates do not show short-term or
sensitivity and a low false-positive rate is needed. long-term adverse effects. Both of these assurances
The Edinburgh Postnatal Depression Scale11 has need caveats, as there is much we do not know.
been used in prenatal care, as have the Antenatal The Canadian Task Force on Preventive Health
Psychosocial Health Assessment form (ALPHA)12 Care19 grades recommendations based on the qual-
and instruments developed by Austin 13 and ity of published evidence and places greatest weight
Matthey et al.14 All of these questionnaires, how- on study design and analysis. The strongest evidence
ever, might be too long for many prenatal environ- comes from well designed studies with appropriate
ments. More recently, one to five probe questions follow up, such as randomized controlled trials. An
from the Mental Health Inventory,15 Patient Health underpowered or poorly designed randomized con-
Questionnaire,16 or ALPHA have been introduced, trolled trial, however, might be of less value than a
sometimes without rigorous evaluations. For exam- well designed large cohort study. Consequently, the
ple, the Ontario Antenatal Record has incorporated Canadian Task Force on Preventive Health Care has
five topics from ALPHA for discussion during pre- suggested that an internal validity rating of “good,”
natal care, and although the full ALPHA performs “fair,” or “poor” also be assigned to inform ranking
well in practice, evaluation of this abbreviated ver- for grade A recommendations (good evidence to
sion is still needed. Most promising are two probe support) to grade E recommendations (good evi-
questions recommended by the United States and dence to exclude) the intervention. Unfortunately,
Canadian task forces on preventive health care and most studies of antidepressant use in pregnancy
common to many of the above instruments: “Over have serious flaws in power, design, and follow up;
the past 2 weeks have you felt down, depressed, or many medical interventions share the same leaky
hopeless?” and “Over the past 2 weeks have you felt boat, and the Canadian Task Force on Preventive
little interest or pleasure in doing things?” These Health Care has recently added another classifica-
two questions are almost as effective as longer tion—grade I—for interventions for which there
instruments.17-19 is “insufficient evidence (in quality and quantity)
Once depression is diagnosed in pregnant to make a recommendation; however, other fac-
women, how should it be managed? Women, their tors may influence decision making.”19 Grade I is
families, and health care providers are understand- clearly where antidepressant use during pregnancy
ably wary of antidepressants—especially in the cur- belongs. There are no sufficiently powered, double-
rent context of black-box warnings; unsuspected blind, randomized controlled trials with sufficient
adverse events; drug recalls; and increasing rev- follow up on these drugs, and recently there have
elations of the effects of pharmaceutical company been some worrying withdrawal and toxicity find-
funding on published clinical trials, prescriptions ings in pediatric neurophysiologic studies.23,24
written, and opinions of experts. Clearly part- The bottom line is that we do not know the
ner, social, and environmental support and cogni- effects of antidepressants (all of which affect the
tive and interpersonal psychotherapy are first-line neurotransmitter system) on immature and rapidly
approaches, but they do not work for everyone, developing fetal and neonatal brains. Might they
especially if depression is severe. Before psychotro- lead to later perturbations in mood or cognition? A
pic drugs are prescribed, an individual risk-benefit more cautious and honest approach is to admit to
decision must be made in collaboration with the ourselves and our patients that definitive answers
woman and, if appropriate, her family.20,21 on the safety of antidepressants during pregnancy
But how do clinicians evaluate the benefits are not yet available, but untreated depression also
and harms of antidepressant drugs for pregnant poses some risks to mothers, fetuses, and infants.24
women? The article in this issue of Canadian Family While the advantages of antidepressants are clear

1062 Canadian Family Physician • Le Médecin de famille canadien d VOL 5: AUGUST • AOÛT 2005
 Editorials

for severely depressed pregnant women, the risk- Correspondence to: Dr Donna Stewart, Women’s Health
benefit decisions are much less obvious for mildly Program, University Health Network, 200 Elizabeth St,
depressed and anxious women, for whom nonphar- EN 7-229A, Toronto, ON M5G 2C4; telephone (416) 340-
macologic treatments should be first line. 4800; e-mail donna.stewart@uhn.on.ca
I often prescribe or continue antidepressants
for severely depressed women after discussing the The opinions expressed in editorials are those of the
risks of untreated depression compared with the authors and do not imply endorsement by the College of
known risks of antidepressants. Family physicians Family Physicians of Canada.
who are familiar with these drugs and aware of the
evolving literature should feel comfortable doing References
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ALPHA form in practice to assess antenatal psychosocial health. CMAJ 1998;159(6):677-84.
women are in frequent contact with health care 13. Austin MP. Antenatal screening and early intervention for “perinatal” distress, depression
and anxiety: where to from here? Arch Women Ment Health 2004;7(1):1-6.
providers. It offers an unparalleled opportunity for 14. Matthey S, White T, Panasetis P, Hopper U, Larkin M, Glossop T, et al. Evaluation of the
routine psychosocial assessment at Liverpool Hospital antenatal clinic. June 2002. Sydney,
education about depression and for identifying and Australia: Infant, Child and Adolescent Mental Health Service, South Western Sydney Area

treating it. We need broader use of screening tools Health Service; 2002.
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to identify depression in antenatal care, but identi- lations. J Consult Clin Psychol 1983;51(5):730-42.
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fication is useless without timely, easily accessible, PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders.
Patient Health Questionnaire. JAMA 1999;282(18):1737-44.
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to ensure that, as clinicians, we are aware of best nale. Ann Intern Med 2002;136(10):760-4.
18. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depres-
practices (both nonpharmacologic and pharmaco- sion. Two questions are as good as many. J Gen Intern Med 1997;12(7):439-45.
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Dr Stewart is Chair of Women’s Health at the University 23. Zeskind PS, Stephens LE. Maternal selective serotonin reuptake inhibitor use during
pregnancy and newborn neurobehaviour. Pediatrics 2004;113(2):368-75.
Health Network and a University Professor at the 24. Hallberg P, Sjoblom V. The use of selective serotonin reuptake inhibitors during
pregnancy and breast-feeding: a review and clinical aspects. J Clin Psychopharmacol
University of Toronto in Ontario. 2005;25(1):59-73.

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