Depression in pregnant women

Authors Shaila Misri, MD, FRCPC Shari I Lusskin,

MD, FAPA
Section Editors Charles J Lockwood, MD Peter P
Ro!"rne, MD
Deputy Editor Da#id
Solomon, MD
INTRODUCTION
Pregnanc is generall considered a period o$ emotional well!%eing $or the woman and her
$amil& 'owe#er, $or man women, pregnanc and motherhood are times o$ increased
#ulnera%ilit to pschiatric conditions& Longitudinal studies ha#e shown that pregnanc does
not protect against the de#elopment o$ new onset ma(or depression or relapse o$ e)isting
ma(or depressi#e illness *+,& -omen who discontinue or reduce their doses o$
antidepressants are at particularl high risk&
.pidemiological sur#es indicate that the li$etime pre#alence o$ ma(or depression is two
times higher in adult women than in men */,& 0here$ore, it is not surprising that depression
is one o$ the most $re1uentl encountered medical complications during pregnanc and
postpartum *2,& In spite o$ the high risk o$ this illness in women, man clinicians $ail to
recogni3e, diagnose, and o$$er appropriate treatment $or depression during pregnanc& 0his
ma %e due, in part, to the $act that somatic smptoms o$ depression during pregnanc,
such as changes in sleep and appetite, ma %e attri%uted to normal pregnanc!related
changes in maternal phsiolog *4,& .#en when women at risk $or depression are identi$ied,
studies ha#e shown that #er $ew recei#e treatment *5,&
Depression during pregnanc will %e discussed here& Postpartum depression is re#iewed
separatel& 6See 7Postpartum %lues and depression7&8
PREVALENCE
Although man women report e)periencing negati#e mood smptoms during their
pregnancies, the num%er o$ pregnant women who actuall $ul$ill the diagnostic criteria $or
ma(or depression is much smaller *5!++,& 0he %est estimate o$ pre#alence o$ perinatal
depression was reported % the Agenc $or 'ealthcare Research and 9ualit *+/,:
Point pre#alence 6ie, the measure o$ a condition in a
population at a gi#en point in time8 o$ ma(or depression alone
ranged $rom 2&+ to 4&; percent at di$$erent times during
pregnanc and +&< to 5&; percent at di$$erent times during the
$irst postpartum ear&
Point pre#alence $or ma(or and minor depression ranged
$rom =&5 to ++&< percent during pregnanc and >&5 to +/&;
percent during the $irst ear postpartum&
0he period pre#alence 6ie, the measure o$ a condition in
a population o#er a period o$ time? a com%ination o$ point
pre#alence and incidence8 o$ depression at an time $rom
conception to %irth was +4 to /2 percent? the period pre#alence
at an time $rom %irth to three months postpartum was ++ to 2/
percent&
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Re'erences
0op
+& Cohen, LS, Altshuler, LL, 'arlow, "L, et al& Relapse o$ ma(or
depression during pregnanc in women who maintain or
discontinue antidepressant treatment& JAMA /<<>? /;5:4;;&
/& -eissman, BM, Cl$son, M& Depression in woman: implications
$or health care research& Science +;;5? />;:D;;&
2& 'endrick, E, Altshuler, L& Management o$ ma(or depression
during pregnanc& Am J Pschiatr /<</? +5;:+>>D&
4& Altshuler, LL, 'endrick, E, Cohen, LS& Course o$ mood and
an)iet disorders during pregnanc and the postpartum
period& J Clin Pschiatr +;;=? 5; Suppl /:/;&
5& Marcus, SM, Flnn, 'A, "low, FC, "arr, FL& Depressi#e
Smptoms among Pregnant -omen Screened in C%stetrics
Settings& J -omens 'ealth 6Larchmt8 /<<2? +/:2D2&
>& Llewelln, AM, Stowe, GB, Bemero$$, C"& Depression during
pregnanc and the puerperium& J Clin Pschiatr +;;D? 5=
Suppl +5:/>&
D& -atson, JP, .lliott, SA, Rugg, AJ, "rough, DI& Pschiatric
disorder in pregnanc and the $irst postnatal ear& "r J
Pschiatr +;=4? +44:452&
=& CH'ara, M-& Social support, li$e e#ents, and depression
during pregnanc and the puerperium& Arch Ien Pschiatr
+;=>? 42:5>;&
;& Fumar, R, Ro%son, FM& A prospecti#e stud o$ emotional
disorders in child%earing women& "r J Pschiatr +;=4?
+44:25&
+<& .#ans, J, 'eron, J, Francom%, ', et al& Cohort stud o$
depressed mood during pregnanc and a$ter child%irth& "MJ
/<<+? 2/2:/5D&
++& "ennett, 'A, .inarson, A, 0addio, A, et al& Pre#alence o$
depression during pregnanc: sstematic re#iew& C%stet
Inecol /<<4? +<2:>;=&
+/& Ianes, "B, Ia#in, B, Melt3er!"rod, S, et al& Perinatal
depression: pre#alence, screening accurac, and screening
outcomes& .#id Rep 0echnol Assess 6Summ8 /<<5? :+&
+2& Lancaster, CA, Iold, FJ, Flnn, 'A, et al& Risk $actors $or
depressi#e smptoms during pregnanc: a sstematic re#iew&
Am J C%stet Inecol /<+<: /</:5&
+4& Jose$sson, A, "erg, I, Bordin, C, Sds(o, I& Pre#alence o$
depressi#e smptoms in late pregnanc and postpartum& Acta
C%stet Inecol Scand /<<+? =<:/5+&
+5& "eck, C0& A meta!analsis o$ predictors o$ postpartum
depression& Burs Res +;;>? 45:/;D&
+>& CH'ara, M-, Swain, AM& Rates and risk o$ postpartum
depressionJa meta!analsis& Int Re# Pschiatr +;;>? =:2D&
+D& "uist, A, Condon, J, "rooks, J, et al& Accepta%ilit o$ routine
screening $or perinatal depression& J A$$ect Disord /<<>?
;2:/22&
+=& Spit3er, RL, -illiams, J", Froenke, F, et al& Ealidit and utilit
o$ the PRIM.!MD patient health 1uestionnaire in assessment
o$ 2<<< o%stetric!gnecologic patients: the PRIM.!MD Patient
'ealth 9uestionnaire C%stetrics!Inecolog Stud& Am J
C%stet Inecol /<<<? +=2:D5;&
+;& Fell, R, Gat3ick, D, Anders, 0& 0he detection and treatment o$
pschiatric disorders and su%stance use among pregnant
women cared $or in o%stetrics& Am J Pschiatr /<<+?
+5=:/+2&
/<& Konkers, FA, Ramin, SM, Rush, AJ, et al& Cnset and
persistence o$ postpartum depression in an inner!cit
maternal health clinic sstem& Am J Pschiatr /<<+?
+5=:+=5>&
/+& Larsson, C, Sds(o, I, Jose$sson, A& 'ealth, sociodemographic
data, and pregnanc outcome in women with antepartum
depressi#e smptoms& C%stet Inecol /<<4? +<4:45;&
//& "onari, L, Pinto, B, Ahn, ., et al& Perinatal risks o$ untreated
depression during pregnanc& Can J Pschiatr /<<4? 4;:D/>&
/2& Furki, 0, 'iilesmaa, E, Raitasalo, R, et al& Depression and
an)iet in earl pregnanc and risk $or preeclampsia& C%stet
Inecol /<<<? ;5:4=D&
/4& Cates, M& Suicide: the leading cause o$ maternal death& "r J
Pschiatr /<<2? +=2:/D;&
/5& Apple%, L& Suicide during pregnanc and in the $irst postnatal
ear& "MJ +;;+? 2</:+2D&
/>& Mar3uk, PM, 0ardi$$, F, Leon, AC, et al& Lower risk o$ suicide
during pregnanc& Am J Pschiatr +;;D?+54:+//&
/D& Cates, M& Perinatal pschiatric disorders: a leading cause o$
maternal mor%idit and mortalit& "r Med "ull /<<2? >D:/+;&
/=& Comtois, FA, Schi$$, MA, Irossman, DC& Pschiatric risk
$actors associated with postpartum suicide attempt in
-ashington State, +;;/!/<<+& Am J C%stet Inecol /<<=?
+;;:+/<&
/;& Iandhi, SI, Iil%ert, -M, Mc.l#, SS, et al& Maternal and
neonatal outcomes a$ter attempted suicide& C%stet Inecol
/<<>? +<D:;=4&
2<& Lusskin, S, Pundiak, 0, 'a%i%, S& Perinatal depression: hiding
in plain sight& Can J Pschiatr /<<D? 5/:4D;&
2+& 'emels, M., .inarson, A, Foren, I, et al& Antidepressant use
during pregnanc and the rates o$ spontaneous a%ortions: a
meta!analsis& Ann Pharmacother /<<5? 2;:=<2&
2/& Mian, AI& Depression in pregnanc and the postpartum
period: %alancing ad#erse e$$ects o$ untreated illness with
treatment risks& J Pschiatr Pract /<<5? ++:2=;&
22& Suri, R, Altshuler, L, et al& .$$ects o$ antenatal depression and
antidepressant treatment on gestational age at %irth and risk
o$ preterm %irth& Am J Pschiatr /<<D? +>4:+/<>&
24& 'o$$man, S, 'atch, MC& Depressi#e smptomatolog during
pregnanc: e#idence $or an association with decreased $etal
growth in pregnancies o$ lower social class women& 'ealth
Pschol /<<<? +;:525&
25& -isner, FL, Sit, DF, 'anusa, "', et al& Ma(or depression and
antidepressant treatment: impact on pregnanc and neonatal
outcomes& Am J Pschiatr /<<;? +>>:55D&
2>& Crr, S0, James, SA, "lackmore Prince, C& Maternal prenatal
depressi#e smptoms and spontaneous preterm %irths among
A$rican!American women in "altimore, Marland& Am J
.pidemiol /<</? +5>:D;D&
2D& -eissman, MM, -ickramaratne, P, Bomura, K, et al& C$$spring
o$ depressed parents: /< ears later& Am J Pschiatr /<<>?
+>2:+<<+&
2=& Fim!Cohen, J, Caspi, A, Rutter, M, et al& 0he caregi#ing
en#ironments pro#ided to children % depressed mothers with
or without an antisocial histor& Am J Pschiatr /<<>?
+>2:+<<;&
2;& Dea#e, 0, 'eron, J, .#ans, J, .mond, A& 0he impact o$
maternal depression in pregnanc on earl child de#elopment&
"JCI /<<=? ++5:+<42&
4<& Field, 0, Diego, M, 'ernande3!Rei$, M, et al& Pregnanc
an)iet and comor%id depression and anger: e$$ects on the
$etus and neonate& Depress An)iet /<<2? +D:+4<&
4+& Ean den, "ergh "R, Mulder, .J, Mennes, M, Ilo#er, E&
Antenatal maternal an)iet and stress and the
neuro%eha#ioural de#elopment o$ the $etus and child: links
and possi%le mechanisms& A re#iew& Beurosci "io%eha# Re#
/<<5? /;:/2D&
4/& Connor, 0I, 'eron, J, et al& Maternal antenatal an)iet and
childrenHs %eha#iouralLemotional pro%lems at 4 ears& Report
$rom the A#on Longitudinal Stud o$ Parents and Children&
"ritish Journal o$ Pschiatr /<</? =<: 5</&
42& CHConnor, 0I, 'eron, J, Iolding, J, Ilo#er, E& Maternal
antenatal an)iet and %eha#iouralLemotional pro%lems in
children: a test o$ a programming hpothesis& J Child Pschol
Pschiatr /<<2? 44:+</5&
44& Ean den, "ergh "R, Marcoen, A& 'igh antenatal maternal
an)iet is related to AD'D smptoms, e)ternali3ing pro%lems,
and an)iet in =! and ;!ear!olds& Child De# /<<4? D5:+<=5&
45& Ean den, "ergh "R, Mennes, M, Costerlaan, J, et al& 'igh
antenatal maternal an)iet is related to impulsi#it during
per$ormance on cogniti#e tasks in +4! and +5!ear!olds&
Beurosci "io%eha# Re# /<<5? /;:/5;&
4>& Federenko, IS, -adhwa, PD& -omenHs mental health during
pregnanc in$luences $etal and in$ant de#elopmental and
health outcomes& CBS Spectr /<<4? ;:+;=&
4D& Littleton, 'L, "reitkop$, CR, "erenson, A"& Correlates o$
an)iet smptoms during pregnanc and association with
perinatal outcomes: a meta!analsis& Am J C%stet Inecol
/<<D? +;>:4/4&
4=& McIu$$in, P, Marusic, A, Farmer, A& -hat can pschiatric
genetics o$$er suicidologM& Crisis /<<+? //:>+&
4;& Ran, D, Milis, L, Misri, B& Depression during pregnanc& Can
Fam Phsician /<<5? 5+:+<=D&
5<& Co), J, 'olden, J& Perinatal pschiatr& @se and misuse o$ the
.din%urgh Postnatal Depression Scale& Ilasgow: 0he Roal
College o$ Pschiatrists +;;4? /D5&
5+& Jesse, D., Iraham, M& Are ou o$ten sad and depressedM
"rie$ measures to identi$ women at risk $or depression in
pregnanc& MCB Am J Matern Child Burs /<<5? 2<:4<&
Re'erences
0op
+& Cohen, LS, Altshuler, LL, 'arlow, "L, et al& Relapse o$ ma(or
depression during pregnanc in women who maintain or
discontinue antidepressant treatment& JAMA /<<>? /;5:4;;&
/& -eissman, BM, Cl$son, M& Depression in woman: implications
$or health care research& Science +;;5? />;:D;;&
2& 'endrick, E, Altshuler, L& Management o$ ma(or depression
during pregnanc& Am J Pschiatr /<</? +5;:+>>D&
4& Altshuler, LL, 'endrick, E, Cohen, LS& Course o$ mood and
an)iet disorders during pregnanc and the postpartum
period& J Clin Pschiatr +;;=? 5; Suppl /:/;&
5& Marcus, SM, Flnn, 'A, "low, FC, "arr, FL& Depressi#e
Smptoms among Pregnant -omen Screened in C%stetrics
Settings& J -omens 'ealth 6Larchmt8 /<<2? +/:2D2&
>& Llewelln, AM, Stowe, GB, Bemero$$, C"& Depression during
pregnanc and the puerperium& J Clin Pschiatr +;;D? 5=
Suppl +5:/>&
D& -atson, JP, .lliott, SA, Rugg, AJ, "rough, DI& Pschiatric
disorder in pregnanc and the $irst postnatal ear& "r J
Pschiatr +;=4? +44:452&
=& CH'ara, M-& Social support, li$e e#ents, and depression
during pregnanc and the puerperium& Arch Ien Pschiatr
+;=>? 42:5>;&
;& Fumar, R, Ro%son, FM& A prospecti#e stud o$ emotional
disorders in child%earing women& "r J Pschiatr +;=4?
+44:25&
+<& .#ans, J, 'eron, J, Francom%, ', et al& Cohort stud o$
depressed mood during pregnanc and a$ter child%irth& "MJ
/<<+? 2/2:/5D&
++& "ennett, 'A, .inarson, A, 0addio, A, et al& Pre#alence o$
depression during pregnanc: sstematic re#iew& C%stet
Inecol /<<4? +<2:>;=&
+/& Ianes, "B, Ia#in, B, Melt3er!"rod, S, et al& Perinatal
depression: pre#alence, screening accurac, and screening
outcomes& .#id Rep 0echnol Assess 6Summ8 /<<5? :+&
+2& Lancaster, CA, Iold, FJ, Flnn, 'A, et al& Risk $actors $or
depressi#e smptoms during pregnanc: a sstematic re#iew&
Am J C%stet Inecol /<+<: /</:5&
+4& Jose$sson, A, "erg, I, Bordin, C, Sds(o, I& Pre#alence o$
depressi#e smptoms in late pregnanc and postpartum& Acta
C%stet Inecol Scand /<<+? =<:/5+&
+5& "eck, C0& A meta!analsis o$ predictors o$ postpartum
depression& Burs Res +;;>? 45:/;D&
+>& CH'ara, M-, Swain, AM& Rates and risk o$ postpartum
depressionJa meta!analsis& Int Re# Pschiatr +;;>? =:2D&
+D& "uist, A, Condon, J, "rooks, J, et al& Accepta%ilit o$ routine
screening $or perinatal depression& J A$$ect Disord /<<>?
;2:/22&
+=& Spit3er, RL, -illiams, J", Froenke, F, et al& Ealidit and utilit
o$ the PRIM.!MD patient health 1uestionnaire in assessment
o$ 2<<< o%stetric!gnecologic patients: the PRIM.!MD Patient
'ealth 9uestionnaire C%stetrics!Inecolog Stud& Am J
C%stet Inecol /<<<? +=2:D5;&
+;& Fell, R, Gat3ick, D, Anders, 0& 0he detection and treatment o$
pschiatric disorders and su%stance use among pregnant
women cared $or in o%stetrics& Am J Pschiatr /<<+?
+5=:/+2&
/<& Konkers, FA, Ramin, SM, Rush, AJ, et al& Cnset and
persistence o$ postpartum depression in an inner!cit
maternal health clinic sstem& Am J Pschiatr /<<+?
+5=:+=5>&
/+& Larsson, C, Sds(o, I, Jose$sson, A& 'ealth, sociodemographic
data, and pregnanc outcome in women with antepartum
depressi#e smptoms& C%stet Inecol /<<4? +<4:45;&
//& "onari, L, Pinto, B, Ahn, ., et al& Perinatal risks o$ untreated
depression during pregnanc& Can J Pschiatr /<<4? 4;:D/>&
/2& Furki, 0, 'iilesmaa, E, Raitasalo, R, et al& Depression and
an)iet in earl pregnanc and risk $or preeclampsia& C%stet
Inecol /<<<? ;5:4=D&
/4& Cates, M& Suicide: the leading cause o$ maternal death& "r J
Pschiatr /<<2? +=2:/D;&
/5& Apple%, L& Suicide during pregnanc and in the $irst postnatal
ear& "MJ +;;+? 2</:+2D&
/>& Mar3uk, PM, 0ardi$$, F, Leon, AC, et al& Lower risk o$ suicide
during pregnanc& Am J Pschiatr +;;D?+54:+//&
/D& Cates, M& Perinatal pschiatric disorders: a leading cause o$
maternal mor%idit and mortalit& "r Med "ull /<<2? >D:/+;&
/=& Comtois, FA, Schi$$, MA, Irossman, DC& Pschiatric risk
$actors associated with postpartum suicide attempt in
-ashington State, +;;/!/<<+& Am J C%stet Inecol /<<=?
+;;:+/<&
/;& Iandhi, SI, Iil%ert, -M, Mc.l#, SS, et al& Maternal and
neonatal outcomes a$ter attempted suicide& C%stet Inecol
/<<>? +<D:;=4&
2<& Lusskin, S, Pundiak, 0, 'a%i%, S& Perinatal depression: hiding
in plain sight& Can J Pschiatr /<<D? 5/:4D;&
2+& 'emels, M., .inarson, A, Foren, I, et al& Antidepressant use
during pregnanc and the rates o$ spontaneous a%ortions: a
meta!analsis& Ann Pharmacother /<<5? 2;:=<2&
2/& Mian, AI& Depression in pregnanc and the postpartum
period: %alancing ad#erse e$$ects o$ untreated illness with
treatment risks& J Pschiatr Pract /<<5? ++:2=;&
22& Suri, R, Altshuler, L, et al& .$$ects o$ antenatal depression and
antidepressant treatment on gestational age at %irth and risk
o$ preterm %irth& Am J Pschiatr /<<D? +>4:+/<>&
24& 'o$$man, S, 'atch, MC& Depressi#e smptomatolog during
pregnanc: e#idence $or an association with decreased $etal
growth in pregnancies o$ lower social class women& 'ealth
Pschol /<<<? +;:525&
25& -isner, FL, Sit, DF, 'anusa, "', et al& Ma(or depression and
antidepressant treatment: impact on pregnanc and neonatal
outcomes& Am J Pschiatr /<<;? +>>:55D&
2>& Crr, S0, James, SA, "lackmore Prince, C& Maternal prenatal
depressi#e smptoms and spontaneous preterm %irths among
A$rican!American women in "altimore, Marland& Am J
.pidemiol /<</? +5>:D;D&
2D& -eissman, MM, -ickramaratne, P, Bomura, K, et al& C$$spring
o$ depressed parents: /< ears later& Am J Pschiatr /<<>?
+>2:+<<+&
2=& Fim!Cohen, J, Caspi, A, Rutter, M, et al& 0he caregi#ing
en#ironments pro#ided to children % depressed mothers with
or without an antisocial histor& Am J Pschiatr /<<>?
+>2:+<<;&
2;& Dea#e, 0, 'eron, J, .#ans, J, .mond, A& 0he impact o$
maternal depression in pregnanc on earl child de#elopment&
"JCI /<<=? ++5:+<42&
4<& Field, 0, Diego, M, 'ernande3!Rei$, M, et al& Pregnanc
an)iet and comor%id depression and anger: e$$ects on the
$etus and neonate& Depress An)iet /<<2? +D:+4<&
4+& Ean den, "ergh "R, Mulder, .J, Mennes, M, Ilo#er, E&
Antenatal maternal an)iet and stress and the
neuro%eha#ioural de#elopment o$ the $etus and child: links
and possi%le mechanisms& A re#iew& Beurosci "io%eha# Re#
/<<5? /;:/2D&
4/& Connor, 0I, 'eron, J, et al& Maternal antenatal an)iet and
childrenHs %eha#iouralLemotional pro%lems at 4 ears& Report
$rom the A#on Longitudinal Stud o$ Parents and Children&
"ritish Journal o$ Pschiatr /<</? =<: 5</&
42& CHConnor, 0I, 'eron, J, Iolding, J, Ilo#er, E& Maternal
antenatal an)iet and %eha#iouralLemotional pro%lems in
children: a test o$ a programming hpothesis& J Child Pschol
Pschiatr /<<2? 44:+</5&
44& Ean den, "ergh "R, Marcoen, A& 'igh antenatal maternal
an)iet is related to AD'D smptoms, e)ternali3ing pro%lems,
and an)iet in =! and ;!ear!olds& Child De# /<<4? D5:+<=5&
45& Ean den, "ergh "R, Mennes, M, Costerlaan, J, et al& 'igh
antenatal maternal an)iet is related to impulsi#it during
per$ormance on cogniti#e tasks in +4! and +5!ear!olds&
Beurosci "io%eha# Re# /<<5? /;:/5;&
4>& Federenko, IS, -adhwa, PD& -omenHs mental health during
pregnanc in$luences $etal and in$ant de#elopmental and
health outcomes& CBS Spectr /<<4? ;:+;=&
4D& Littleton, 'L, "reitkop$, CR, "erenson, A"& Correlates o$
an)iet smptoms during pregnanc and association with
perinatal outcomes: a meta!analsis& Am J C%stet Inecol
/<<D? +;>:4/4&
4=& McIu$$in, P, Marusic, A, Farmer, A& -hat can pschiatric
genetics o$$er suicidologM& Crisis /<<+? //:>+&
4;& Ran, D, Milis, L, Misri, B& Depression during pregnanc& Can
Fam Phsician /<<5? 5+:+<=D&
5<& Co), J, 'olden, J& Perinatal pschiatr& @se and misuse o$ the
.din%urgh Postnatal Depression Scale& Ilasgow: 0he Roal
College o$ Pschiatrists +;;4? /D5&
5+& Jesse, D., Iraham, M& Are ou o$ten sad and depressedM
"rie$ measures to identi$ women at risk $or depression in
pregnanc& MCB Am J Matern Child Burs /<<5? 2<:4<&