Depression During Pregnancy

1. Depression During Pregnancy Kathleen S. Peindl, M.S., Ph.D. Associate Professor in Psychiatry Thomas Jefferson University Philadelphia, PA 19107

2. Over the past 18 years, my interest in prenatal depression grew for two reasons. First, it has become increasingly clear that prenatal depression is a risk factor for recurrent depression throughout the female life cycle. Second, both prenatal and postpartum depression adversely affect child development. Breaking the cycle of depression through identification, education and treatment is one of my goals.

3. Depression During Pregnancy Learning Objectives • To understand what prenatal depression is • To learn about a tool for depression screening • To understand some consequences of the illness • To learn about treatments of depression during pregnancy

4. Performance ObjectivesDepression During Pregnancy • To be able to recognize depression during pregnancy • To know the risk factors for depression during pregnancy • To know some cost of the illness to the mother and infant • To understand treatments for the disease

5. Depression Onset in Young Adult Women • Depression in females is 2 times higher than the rate found in males • Change in rates occurs during puberty and the onset of menses

6. Young Women and Depression • Women, aged 22, with major depressive disorder had first onset of illness in adolescence • 44% had their first episode of major depression during pregnancy

7. What is Depression During Pregnancy • Diagnosis • Symptoms • Difficulty with Diagnosis • Prevalence Rates of Detection of Illness

8. Diagnosis of Depression • Most Mental Health Professionals use DSM-IV criteria as the standard to diagnose Psychiatric Disorders • The Prime-MD is used in general clinical settings to diagnose common psychiatric disorders and will code the disease using DSM-IV Criteria

9. Depression Sadness Loss of interest Sleep disturbances Weight loss/gain Guilt/Worthlessness Thoughts of death Appetite disturbances Fatigue Pregnancy Sleep Disturbances Weight Gain Appetite Disturbances Fatigue Symptoms of Depression and of Normal Pregnancy

10. Difficulty with Diagnosis of Illness • 50% of women have undiagnosed depression in an obstetric/gynecology clinic* • The rate of detection may be as low as 0.8% among pregnant women**

11. Prevalence of Depression During Pregnancy • Assessments method for determining prevalence rates of depression during pregnancy fall into three categories: • Self-reported symptoms • Distress • Structured psychiatric interviews using Standard Diagnostic Criteria • Real Prevalence worldwide is around 10% in pregnant adult women

12. Valid Tool for Screening for depression during pregnancy • A Tool for screening must access only affective and cognitive symptoms • Edinburgh Postnatal Depression Scale

13. Recognition of Depression During Pregnancy • Awareness of depression during pregnancy starts with screening. On the Edinburgh Postnatal Depression Scale, the score would be >10.

14. Risk Factors for Depression During Pregnancy • Race and Ethnicity: increased rates among African-American and Hispanic populations • Adolescents • Single status • Low Socio-economic status (world-wide risk factor) • Uninsured status • Personal History of Depression • Family History of Depression

15. Consequences of Depression During Pregnancy • Two sets of consequences need to be identified for depression during pregnancy • A. Those affecting the mother • B. Those affecting the fetus

16. Depression and the Mother Women with Prenatal Depression have: • Poor prenatal care and health behaviors • Poor weight gain and nutrition • Fatigue and loss of functioning • Disturbed sleep • Use of drugs including cigarettes and illicit drugs

17. Prenatal Depressive Symptoms and Fetal Development • Increase in Preterm Delivery • Mean gestational age: 29.5 weeks • Reduction in birth weight of 9.1 grams for every one point increase in a self-report measure of depression in low-SES group • 4-fold increase in low birth weight babies in an African-American population

18. More Childhood Outcomes • At birth: the risk of unconsolability is 2.64 • High Scores on the Childhood Behavioral Checklist for Externalizing for children whose mothers had prenatal depression

19. Treatment of Depression During Pregnancy Experts differ on optimal treatment

20. Risk Benefit Ratio • Discontinuation of treatment before conception • Continuation of Treatment until conception • Treatment if illness severe: maintain through pregnancy

21. Exposure of Psychotropic Medication to Fetal Brain • Morphological teratogenesis • Behavioral teratogenesis

22. Morphological Teratogenesis • Embryonic Period: weeks 2-8 • Fetal Period (months 4-9)

23. Behavioral Teratogenesis • Little is known about effects of medication treatment for prenatal depression • Depressive symptoms do adversely effect behavioral outcomes in offspring

24. FDA Classification for Antidepressants use during pregnancy Antidepressant medication used to treat depression

25. FDA Category A • Controlled studies show no risk • No Antidepressants are Category A

26. FDA Category B • Inadequate number of human studies, animal findings are negative • Animal studies show risk but human studies do not show risk • Bupropion is category B

27. FDA Category C • Risk cannot be ruled out. Human studies are lacking. • Animal studies show risk or there are few animal studies completed. • Following list are category C

28. FDA Category D • Negative risk to the fetus • No Antidepressants in this category

29. FDA Category X • Contraindication for Pregnancy • Fetal Risk outweighs benefits

30. Successful Treatment • Successful Treatment also found with Therapy: Interpersonal Psychotherapy • No risk of exposure to the fetus