An update on Perinatal depression: Risk Factors, Diagnosis and Treatment for "Baby Blues"

Pregnancy and Labour are very overwhelming times for women. Women go through various bodily and mental changes over a very short period of time. Most women are able to accept these changes and cope. However, a small percentage are unable to quickly adapt to these changes especially the ones with preexisting mental illnesses. Generally one in ten persons suffers from anxiety and depression in India. The incidence of perinatal depression varies from 5 – 20 percent.

Perinatal depression is defined as an episode of major depressive disorder (MDD) occurring either during pregnancy or within the first 12 months postpartum. It is important to screen all antenatal women at least once in pregnancy and once in the postpartum period for depressive symptoms. It is very important to screen early as perinatal depression is prone for lot of adverse outcomes for both the mother and baby. Also, suicide and infanticide are closely associated with psychiatric illness especially depression. So early identification & intervention can prevent such debilitating effects. Many women with depression never get diagnosed. It is very important that to screen them and remove the stigma around mental illness, so more women will come forward and report symptoms.

The risk factors for depression need to be understood. Obstetricians need to be aware and pick up these risk factors in the history. Most of these mothers also have co-morbid anxiety. So, on identifying risk factors for depression, obstetrician needs to evaluate these women further, because only screening helps in picking up these women and helping them with some form of intervention.

Women with anxiety during pregnancy are more prone to develop antenatal and post-partum depression. They are three times more likely to develop depression during pregnancy. Women with previous history of treatment for anxiety or depression and previous history of post-partum depression form well established risk factors for developing perinatal depression. A history of childhood abuse is also a strong factor for developing anxiety and depression in pregnancy. Also substance abuse, smoking and alcohol dependence worsen the symptoms.

Social support is multidimensional. Poor relationship with partner, problematic partner and lack of partner are all known risk factors for depression in pregnancy and postpartum. Intimate partner violence is yet another undisputed factor in the development of depression.

Young age, unemployment, low socioeconomic background and poor educational status all predispose to perinatal depression. Adverse life events like losing a close one, loss of employment, an assault or rape etc can trigger an episode of depression or anxiety during pregnancy.

Having an unintended or an unplanned pregnancy can be stressful. A negative birth experience like delivering a still birth, ending up with a bad perineal laceration all can predispose to anxiety and depression in the current pregnancy. Also, women carrying pregnancies conceived by assisted reproductive methods suffer from low self-esteem, severe anxiety and depression.

Personality factors such as pessimism, nervousness, low self-esteem, poor efficiency are factors associated with the development of anxiety and depression in pregnancy. Poor eating habits, lack of regular exercise, sedentary life style also predispose to perinatal depression.

The pathophysiology is not well understood. The role of reproductive hormones on behaviour suggests a neuroendocrine pathophysiology. The female hormones estrogen and progesterone, apart from their reproductive functions, also exhibit neuroregulatory effects on mood and cognition. Abnormality in the functioning of hypothalamopituitary-adrenal (HPA) axis has been proposed as a major etiological factor in the development of major depressive disorder and perinatal depression. Among susceptible women, estrogen and progesterone have profound interactions with HPA axis and trigger abnormal behaviour. The trigger for HPA is genetically determined however, life events can also contribute to the abnormal behaviour.

Perinatal depression impairs maternal and child bonding and this happens at crucial time of brain development. This impairs the morphology and the physiology of the child's brain leading to behavioural and neurocognitive abnormalities extending into adult life.

A detailed history taking will give an insight into the cause or trigger of the present episode of depression. Past, personal and family history of depression and suicide should also be obtained. History of substance abuse, alcohol dependence, over the counter medications should also be obtained. The ACOG recommends that the obstetrician/gynaecologist or obstetric care provider to screen all women at-least once during their perinatal period for symptoms using a validated tool. Screening alone provides an opportunity to identify and initiate care.

The commonly used tools in general are Whooley's and Edinburgh postnatal depression scale. The Edinburgh postnatal depression scale although engineered for postpartum, can be used antenatally also. The Hamilton rating scale for depression (HAM-D), Beck's depression inventory (BDI) and Patient health questionnaire are used to grade the severity of depression.

The diagnosis of depression remains the same, presence of five depressive symptoms over two weeks. Postpartum depression is considered when a patient has a major depressive episode along with the peripartum-onset, and it is not mentioned as a separate disease. By definition, it is defined as a major depressive episode with the onset of pregnancy or within 4 weeks of delivery. The diagnosis should include either persistent low mood or loss of interest (anhedonia), in addition to the five symptoms to be diagnosed. An episode of depression can be classified as mild, moderate or severe depending on the severity and the number of symptoms.

A variety of treatment options are available which can be used in combinations also. Mild to moderate symptoms can be treated with psychotherapy and antidepressant medication. Usage of medication during pregnancy and postpartum may be perceived as problem by women as it may cross the placenta or breast milk and affect the baby. The various psychotherapies available are cognitive behavioural therapy (CBT), psychodynamic therapy, interpersonal therapy and counselling. A metaanalysis had shown that, CBT is a better therapy than other psychological interventions. The study showed that CBT significantly improved stress, anxiety and depressive symptoms. Also it was cost effective.

Antidepressants can be started with or without CBT in mild to moderate cases of depression. The decision to use antidepressant therapy should be done after, clearly weighing the risk benefit ratio. Selective serotonin receptor inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs) have replaced Tricyclic antidepressants (TCAs) as first line drugs. Fetus gets exposed to these drugs through the placenta.

The absolute risk of congenital malformations is low. Low birth weight, prematurity and low APGAR scores have been documented with SSRI usage. In the newborn, neuro-behavioural syndrome or neonatal abstinence syndrome is observed in a small proportion of babies exposed to antidepressants in the third trimester. There is an increased risk of developing primary pulmonary hypertension with antidepressant use after twenty weeks of pregnancy.

Patients not responding to SSRIs may be shifted to SNRIs or a combination therapy can be tried and observed for improvement of symptoms. Transcranial Magnetic stimulation (TMS) is used to stimulate the nerve cells, which are usually underactive in people with severe depression. Some with severe depression may not respond to various drug trials. These are the women who may be given electroconvulsive therapy (ECT). ECT may be an easier option in postpartum women, but antenatal depression may warrant some more drug trials. Women declining ECT may be given brexanolone infusion, the only approved drug for postpartum depression, but it is not freely available.

Untreated perinatal depression can have devastating consequences on the mother, her children and family. The mother child bonding will be impaired. Their parenting style may be cold and harsh. Children feel insecure and do not develop healthy childhood habits. This may extend into adulthood, forming a vicious cycle. Women who are depressed postnatally can fail to bond well with their baby and this can persist for a year. Early identification and intervention for poor bonding is indicated.

The relationship between breastfeeding and postpartum depression was thought to be unidirectional, with postpartum depression resulting in lower rates of breastfeeding initiation and early cessation. However, recent reports suggest that, while postpartum depression may reduce rates of breastfeeding, not engaging in breastfeeding may increase the risk of postpartum depression. Also, there is some evidence that breastfeeding may protect against postpartum depression or assist in a swifter recovery from symptoms.

Source: Coumary A et al. / Indian Journal of Obstetrics and Gynecology Research 2021;8(2):142–145

DOI: https://doi.org/10.18231/j.ijogr.2021.031