MOOD DISORDERS AND PREGNANCY
From Sleep, Sleep Disorders, and Depression, and Current Issues in Perinatal Mood Disorders, presented by the
University of Michigan Medical School, Department of Psychiatry and Depression Center, the Michigan Psychiatric
Society, and the Depression and Bipolar Alliance
| MOOD DISORDERS DURING AND AFTER PREGNANCY —Heather A. Flynn, PhD, Assistant Professor, Department
of Psychiatry, University of Michigan Medical School, Ann Arbor
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| Introduction: depression about twice as common in women as in men, but reason unknown; peak periods of prevalence
in women associated with times of hormonal and life-stress transition, ie, puberty, perinatal period, and perimenopause
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| Prevalence of mood disorders during and after pregnancy: postpartum “blues”—common, up to 75% reported
cross-culturally (speaker posits that “blues” is misnomer; condition characterized more by mood lability and tearfulness,
but tears can be tears of joy as well as of sadness); typically arises and resolves within 14 days of delivery and
usually resolves spontaneously; no treatment required, but it should be monitored because of some indication in literature
that it may be risk factor for postpartum depression; postpartum psychosis—rare; prevalence 1 to 2 per 1000,
and this rate stable across cultures; most cases have rapid onset immediately after delivery; characteristics mostly cognitive,
which leads many researchers to conclude that it is psychosis of bipolar spectrum rather than of schizophrenia
(only ≈5% of women with postpartum psychosis end up with diagnosis of schizophrenia)
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| Postpartum depression: prevalence ≈13% cross-culturally (not significantly different from that of depression in age-
matched controls who are not pregnant); rates fluctuate from study to study, and higher when self-reported through
instrument, eg, Beck Depression Inventory, than when reported through structured diagnostic or clinician-administered
interview; diagnostic criteria same as for depression at any other point, except for requirement that it begin
within 4 wk of delivery (however, speaker states that postpartum depression can emerge up to 1 yr postpartum)
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 | Features: symptoms same as those of any depression, but include prominent anxiety features; difficult to differentiate
whether sleep disturbance due to depression or pregnancy; asking if patient able to sleep when her infant sleeps may
help to clarify cause
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| Validated screening tools: help to detect depression during and after pregnancy; many available, but Edinburgh Postnatal
Depression Scale (EPDS) most common; has 10 items, easy to score, and clearly defined cutoffs (score of 9 to
10 indicates increased risk for depression); widely available; translated into many languages and used internationally
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| Prevention through early detection: prenatal period presents key opportunity to screen for depression because up to
95% of women seek care at some point during pregnancy (whereas only ≈15% seek specialty care such as psychiatry,
social work, or psychology); moreover, women may be more open to making changes in health behavior during pregnancy;
may be possible to prevent negative outcomes for “the passenger” by intervening fully in mother’s depression;
risk factors for depression during or after pregnancy include history of mood disorder, inadequate social support (variously
defined), socioeconomic disadvantage, and high levels of stress or anxiety during pregnancy
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| Getting parturient connected with mental health care: challenging; barriers exist to getting patient into mental health
treatment after depression or risk for depression identified; many obstetric and primary care clinics do not have
mental health providers on site
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| Speaker’s survey: up to 30% of women screened for depression during pregnancy at risk, but 78% of them did not receive
any treatment for depression; of women with current clinician-diagnosed major depressive disorder, only
≈50% received treatment for depression; of those who did receive treatment, it was adequate (as defined by American
Psychiatric Association guidelines) in only 13%; study concluded that about 1 in 4 women who seek prenatal
care at risk for depression, most did not receive any treatment for it, and most of those treated did not receive adequate
treatment
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| Barriers to connecting patients with treatment: system-level barriers—constraints on clinician time and reimbursement;
clinician lack of training in screening for depression; identifying available local outlets for mental health
treatment; patients’ ability to pay; practical barriers—parturient’s lack of energy; lack of child care; limitations on
parturient’s mobility; psychologic barriers—social stigma associated with mental disorder; “the nature of depression
may preclude the ability to seek help”; interpersonal issues—parturient may worry about what family or
friends will think if she seeks care for depression; woman’s belief that seeking care for herself is selfish; feelings of
guilt about seeking care for herself
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| Solving the problem: screening necessary but not sufficient to affect depression outcomes; clinician’s staff must be dedicated
to supporting patients and to providing education about depression; standardized follow-up protocol necessary;
timely and coordinated referral to specialty care essential; more research needed to identify and overcome barriers to
care; adequate treatment of mother may help prevent negative outcomes for child; important to treat mother to full remission
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| PHARMACOLOGIC TREATMENT OF DEPRESSION DURING AND AFTER PREGNANCY —Meir Steiner, MD,
PhD, Professor of Psychiatry and Behavioural Neurosciences and Obstetrics and Gynecology, McMaster University; Director
of Research, Department of Psychiatry; and Founding Director, Women’s Health Concerns Clinic, St. Joseph’s
Healthcare, Hamilton, Ontario
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| Introduction: perinatal psychiatric disorders leading cause of maternal morbidity and mortality; parental mental illness
may pose first adverse life event for child; depression transmits across generations; myth that depression does not occur
during pregnancy; new mothers expect to have period of adjustment and may not recognize that their feelings
might be due to depression; mother who does recognize that depression unhealthy may be unwilling to seek treatment
for fear infant will be taken away; many parents unprepared for emotional challenges of parenthood, and their expectations
may be unmet once child goes home with them; in attempt to reassure new mother, health care provider may
try to downplay mother’s distress by declaring it to be normal part of pregnancy or postpartum period; access to mental
health care often limited by system barriers
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| Before pregnancy: woman’s personality and habits already developed and may create unrealistic expectations; woman
may have low self-esteem and respond inappropriately to difficulties in pregnancy or parenting; woman who has had
negative life events, eg, miscarriage, stillbirth, death of parent, may bring much anxiety to current pregnancy; woman
who is single mother or in poor marital relationship may lack social support
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| Postnatal depression inventory: developed in Canada to provide simple screen for depression in pregnancy; takes <1
min to administer and asks 4 key questions: 1) do you get sleep when baby is asleep? 2) can you fall back to sleep completely
after feeding baby? 3) are you eating at all? what are you eating? 4) are you getting out at all? speaker also asks
about unusual thoughts, such as obsessive-compulsive thinking
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| Screening tools: EPDS works in community because it takes <2 min to administer and can be administered and scored
by any staff member (eg, receptionist, nurse, clerk) who has scoring sheet; if score between 12 and 16 points, help patient
make appointment with mental health provider; if >16 points, send to mental health provider immediately (however,
beware of occasional false-positive results due to, eg, borderline personality disorder; “if they score 30 out of 30,
you know that can’t be”); other screening tools too cumbersome, take too long to administer
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| If depression during pregnancy not treated: woman “guaranteed to have postpartum depression”; she may shop
around for subspecialists and alternative medicine providers, exposing herself and fetus to “other meds that they’re
not supposed to have for all kinds of aches and pains”; in urban areas, women seek illegal drugs and alcohol and increase
tobacco use; women not treated for depression have more complications, eg, preeclampsia; failure of mother
to bond with baby during pregnancy and/or suicidal thoughts are warning signs
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| What happens to baby if mother not treated during pregnancy? more miscarriages and preterm deliveries occur; more
babies admitted to neonatal intensive care unit (NICU); more babies small for gestational age and have smaller head
circumference, lower Apgar scores, more congenital anomalies, and more neurodevelopmental delays; studies show
child’s problems can extend into adulthood
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| Differentiating between pregnancy and depression: mother in first trimester complains of nausea and lack of
appetite—signs of pregnancy or depression? mother in last trimester complains of insomnia—sign of pregnancy or
depression? signs and symptoms must be taken in context; if signs and symptoms accompanied by lack of bonding
with fetus, suicidal ideation, anhedonia, and/or cognitive attitude (eg, “when this baby is born, I’m going to give it up
for adoption; it was a mistake”), diagnosis is depression
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| Postpartum psychosis: <5% of cases due to schizophrenia, 95% due to bipolar disorder, schizoaffective disorder, or
manic disorder; most of these women have history of bipolar disorder or postpartum psychosis; lithium only safe
mood stabilizer (but lithium not recommended for woman who is breast-feeding)
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| Prevention of Sleep Deprivation Program: conceived and tested by speaker’s group; they identify women during
pregnancy at risk for postpartum episode of depression; risk factors include history of depression, previous postpartum
episode, and family history of depression; in last 4 to 6 wk of pregnancy, women do not sleep well, so they enter labor
already sleep-deprived, and labor and delivery exacerbate fatigue; in Canada, speaker’s group negotiated with Ministry
of Health to allow women at risk for depression to stay in hospital for 5 days and 5 nights to recover from sleep
deprivation; patient gets private room, and infant removed from mother’s room between 10 and 11 pm to allow mother
to sleep; nurses care for baby, including bottle feeding if necessary, until 6 or 7 am; no harm to infant from 1 bottle
feeding per day, and data indicate that these mothers continue to breast-feed for average of 6 mo (longer than control
populations); mothers in hospital can have sleeping pill on as-needed basis, and speaker’s group follows them at 6 and
12 wk postpartum; data show that EPDS scores lower after discharge than before delivery; this program not randomized
control trial, but results so favorable that Ontario Mental Health Foundation now funding randomized control trial
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| Antidepressants: all antidepressants fall into pregnancy class C, so speaker requires 100% indication before prescribing
antidepressants during pregnancy and breast-feeding; consider what is happening in patient’s life and whether psychopharmacologic
intervention will help; final choice should always be mother’s, unless she is psychotic; ask if patient
planning on breast-feeding and if so, select agent that can be continued after delivery
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| Safety: at least 2 major institutions now working on changing classification system for teratogenicity; mental health
clinician must discuss known risks with mother and inform her that, to date, no antidepressants identified with damage
to specific organs in infants; older antipsychotics “not the safest thing for the first trimester”; preliminary data
on newer antipsychotics suggest they may be safe; mood stabilizers and antiepileptics known to be unsafe;
monoamine oxidase inhibitors (MAOIs) “are a no-no”
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| Antidepressants: large database indicates antidepressants do not appear to be teratogenic, but database contains only
treatment-based case series, so must be taken with grain of salt; weakness includes both underreporting and overreporting
of negative events; speaker disagrees with Food and Drug Administration advice to taper dosage of antidepressant
in last trimester so fetus receives no drug for at least 7 to 10 days before delivery because tricky to guess
exactly when baby will be born, and last month or so of pregnancy most vulnerable period for mother
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| Infants: symptoms described in literature mild and transient; management limited to supportive care; at speaker’s institution,
no cases of jittery baby reported, and no cases consistent with discontinuation syndrome or toxic serotonergic
syndrome; speaker’s institution found small but statistically significant changes in Apgar scores at 1 and 5
min, but all reverted to normal by 10 min; they also saw some babies with respiratory distress, but unclear if infant’s
respiratory distress connected to mother’s ingestion of antidepressant (however, antidepressants appear to be protective
against neonatal jaundice)
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| Breast-feeding: uncertain how to calculate dose of antidepressant infant gets through breast milk; several models exist,
and most promising right now is measuring plasma 5-hydroxytryptamine (5-HT) responses; speaker recommends
having 100% indication before prescribing antidepressant to breast-feeding mother and staying with monotherapy
as much as possible
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Educational Objectives
| The goal of this program is to educate the listener about diagnosing and treating mood disorders during and after pregnancy.
After hearing and assimilating this program, the clinician will be better able to:
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| 1. Select validated screening tools for detecting depression during and after pregnancy.
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| 2. Recognize the barriers to getting the depressed parturient connected with mental health care.
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| 3. Discuss the risk factors for depression during and after pregnancy.
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| 4. State the risks to mother and infant if the mother’s perinatal depression is not treated.
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| 5. Determine whether it is appropriate to administer antidepressants during pregnancy and breast-feeding.
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Suggested Reading
Birnbaum CS et al: Serum concentrations of antidepressants and benzodiazepines in nursing infants: A case series. Pediatrics
104:e11, 1999; Bloch M et al: Risk factors for early postpartum depressive symptoms. Gen Hosp Psychiatry
28:3, 2006; Bonari L et al: Perinatal risks of untreated depression during pregnancy. Can J Psychiatry 49:726, 2004;
Cardone IA et al: Psychosocial assessment by phone for high-scoring patients taking the Edinburgh Postnatal Depression
Scale: communication pathways and strategies. Arch Women Ment Health 2005 Nov 15; [Epub ahead of print]; Cohen
LS et al: Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant
treatment. JAMA 295:499, 2006; Flynn HA et al: Rates of maternal depression in pediatric emergency department and
relationship to child service utilization. Gen Hosp Psychiatry 26:316, 2004; Freeman MP et al: Postpartum depression
assessments at well-baby visits: screening feasibility, prevalence, and risk factors. J Womens Health (Larchmt) 14:929,
2005; Gentile S: The safety of newer antidepressants in pregnancy and breastfeeding. Drug Saf 28:137, 2005; Gordon
TE et al: Universal perinatal depression screening in an academic medical center. Obstet Gynecol 107:342, 2006; Mallikarjun
PK, Oyebode F: Prevention of postnatal depression. J R Soc Health 125:221, 2005; Marcus SM et al: A
screening study of antidepressant treatment rates and mood symptoms in pregnancy. Arch Women Ment Health 8:25,
2005; Marcus SM, Flynn HA et al: Depressive symptoms among pregnant women screened in obstetrics settings. J
Womens Health (Larchmt) 12:373, 2003; Marcus SM, Flynn HA et al: Treatment guidelines for depression in pregnancy.
Int J Gynaecol Obstet 72:61, 2001; Mastorakos G, Ilias I: Maternal and fetal hypothalamic-pituitary-adrenal
axes during pregnancy and postpartum. Ann N Y Acad Sci 997:136, 2003; McEwen BS: Early life influences on life-
long patterns of behavior and health. Ment Retard Dev Disabil Res Rev 9:149, 2003; Mian AI: Depression in pregnancy
and the postpartum period: balancing adverse effects of untreated illness with treatment risks. J Psychiatr Pract 11:389,
2005; Morris-Rush JK, Freda MC, Bernstein PS: Screening for postpartum depression in an inner-city population.
Am J Obstet Gynecol 188:1217, 2003; Mosack V, Shore ER: Screening for depression among pregnant and postpartum
women. J Community Health Nurs 23:37, 2006; Moses-Kolko EL, Roth EK: Antepartum and postpartum depression:
healthy mom, healthy baby. J Am Med Womens Assoc 59:181, 2004; Peindl KS, Wisner KL, Hanusa BH: Identifying
depression in the first postpartum year: guidelines for office-based screening and referral. J Affect Disord 80:37, 2004;
Springate BA, Chaudron LH: Mental health providers’ self-reported expertise and treatment of perinatal depression.
Arch Women Ment Health 9:60, 2006; Stewart DE: Perinatal depression. Gen Hosp Psychiatry 28:1, 2006; Stowe ZN
et al: The pharmacokinetics of sertraline excretion into human breast milk: determinants of infant serum concentrations.
J Clin Psychiatry 64:73, 2003; Suri R et al: Estimates of nursing infant daily dose of fluoxetine through breast milk.
Biol Psychiatry 52:446, 2002.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the
faculty reported nothing to disclose.
Drs. Flynn and Steiner were recorded at Sleep, Sleep Disorders, and Depression, and Current Issues in Perinatal Depression,
held November 10-11, 2005, in Ann Arbor, Michigan, and sponsored by the University of Michigan Medical
School, Department of Psychiatry and Depression Center, the Michigan Psychiatric Society, and the Depression
and Bipolar Alliance. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the
production of this program.
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