Recommendation
Insufficient evidence to determine if psychological
therapies (psychosocial and
psychological interventions) are effective treatment for antenatal
depression. Study limitations include the lack of a control group and small
number of subjects (I C)
Background
Mental illness is a
major public health concern. According to the World Health Organization, by the
year 2020 depression will be second disease in disability experienced
worldwide. Although pregnancy is a time of emotional well-being for many women,
conferring 'protection' against psychiatric disorders, a recent meta-analysis
of 21 studies suggests that the mean prevalence rate of depression across the
antenatal period is 10.7%, ranging from 7.4% in the first trimester to a high
of 12.8% in the second trimester. There is no clear evidence to suggest that
differences in prevalence rates exist between developed and developing
countries (Danis 2008).
Although 10% of pregnant women meet criteria for
major or minor depression, they often remain undiagnosed because the symptoms
of depression are similar to somatic complaints of pregnancy. Making it
important for women to pay careful attention to the changes taking place during
pregnancy and note any prolonged symptoms of depression. Some signs of
antenatal depression include: feelings of isolation, lack of energy, moodiness/
irritability, feeling foggy-headed/inability to concentrate, sadness, feeling
unexcited or anxious about impending motherhood/ new baby, anxiety, withdrawal
from other people, fatigue or poor sleep habits (insomnia), headaches, thoughts
of harming oneself. While some of these feelings may be within the normal range
of emotions and symptoms for some, a pregnant woman experiencing these warning
signs about the possibility of depression.
Predisposing factors
to antepartum depression are personal or family history of depression, marital
dysfunction, young age, minimal education, and larger number of children.
Antenatal depression
affects 10%–20% of pregnant women. Pregnant women who are depressed are at risk
for anorexia, use of nicotine, drugs, and alcohol, and failure to obtain
adequate prenatal care. It is associated with a greater risk of negative pregnancy
outcomes, such as prematurity, fetal distress, neonatal behavioral differences,
and a greater risk of postpartum depression. Recent data emphasize that relapse
rates for depression are high during pregnancy. Cohen and colleagues found that
43% of a sample of pregnant women with a history of major depression
experienced a major depressive episode during pregnancy (Freemann, 2007, Spinelli,1997)
Other negative
effects to the newborn have been linked to antenatal depression including an
"increased risk for irritability, less activity and attentiveness, and
fewer facial expressions compared with those born to mothers without
depression," according to a recent study conducted through a joint effort
between The American College of Obstetricians and Gynecologists (ACOG) and the
American Psychiatric Association (APA) (Dennis and
Allen, 2008)
The selection of
treatment for depression in a pregnant woman must take into account the
well-being of both mother and baby. Due to maternal treatment preferences and
potential concerns about fetal and infant health outcomes, non-pharmacological
treatment options are needed (Dennis, Ross and Grigoriadis, 2007)
Treatment decisions
should be collaborative, involving the mother, the baby’s father when
appropriate, and health care providers. The risks and benefits of treatment are
complex, and the weight given to the factors involved varies among individuals.
Treatment decisions
should take into account the severity of symptoms, past history of depression
and treatment response, and patient preferences. In cases of mild depression,
non pharmacological treatments may be considered first. For pregnant women with
moderate to severe depression, antidepressants are a reasonable part of a
treatment plan. A history of previous postpartum depression or recurrent major
depression is a risk factor for perinatal depression and may support the
decision to use antidepressants during pregnancy.
In 5% of women,
antenatal depression predicts postnatal depression. Since antenatal depression
is a risk factor for postpartum depression, the safety of treatment during
breastfeeding should also be considered. Despite a few case reports of possible
adverse effects in infants breastfed by mothers taking antidepressants, most
data on antidepressant levels in breast milk and infant serum suggest a low
level of infant exposure to antidepressants via breastfeeding (Freemann 2007)
Supporting Evidence
Depression is a
treatable illness but caution must be taken in pregnancy. Non-pharmacological
interventions, such as enhanced social support and/or a psychological
intervention should be considered before antidepressant treatment, especially
if symptoms are mild or in early pregnancy (first trimester). Due to concerns
about the safety of antidepressants in pregnancy, many mothers may prefer to
trial psychological therapies before an antidepressant.
Among those are:
• psychosocial interventions, such as diverse supportive interactions
including support groups;
• psychological interventions, such as cognitive behavioral therapy (a
treatment that assists the individual in identifying and correcting erroneous
beliefs and systematic distortions in information processing with the hopes of
reducing distress and enhancing coping efforts); and
• interpersonal psychotherapy (a treatment where the connection between
depressive symptomatology onset and interpersonal problems is used as a focus).
A 16-week open pilot trial was conducted with 13 pregnant women who met
DSMIII-R criteria for major depression. The women’s mean depression ratings
decreased significantly from week 0 to week 16 of the treatment program. In
this study interpersonal psychotherapy for antepartum depression appears to be
an effective alternative to pharmacotherapy in pregnancy (Spinelli,1997).
Other trial was
incorporating 38 outpatient antenatal women who met Diagnostic and Statistical
Manual for Mental Disorders-IV criteria for major depression. Interpersonal
psychotherapy, compared to a parenting education program, was associated with a
reduction in the risk of depressive symptomatology immediately post-treatment
using the Clinical Global Impression Scale (one trial, n = 38; relative risk
(RR) 0.46, 95% confidence interval (CI) 0.26 to 0.83) and the Hamilton Rating
Scale for Depression (one trial, n = 38; RR 0.82, 95% CI 0.65 to 1.03).
Conclusion
In small studies psychological therapies (psychosocial and psychological interventions)
appears to be efficacious for antenatal depression and prevention of postpartum
depression in women at risk .Psychotherapy can be given in a variety of formats
including individual sessions, group therapy, family therapy or marital/couple
therapy. Within these formats there are also different psychotherapy approaches
that a mental health practitioner may utilise.
References
Dennis CL and Allen K.
2008 Interventions (other than pharmacological, psychosocial or psychological)
for treating antenatal depression. Cochrane Database of Systematic Reviews,
Issue 4. Art. No.: CD006795.
Dennis C-L, Ross LE and Grigoriadis S. 2007, Psychosocial and
psychological interventions for treating antenatal depression. Cochrane
Database of Systematic Reviews, Issue 3. Art. No.: CD006309.
Freeman MP,2007. Antenatal Depression:
Navigating the Treatment Dilemmas Am
J Psychiatry, 164:8.
Spinelli, M.G., 1997. Interpersonal
Psychotherapy for Depressed Antepartum Women: A Pilot Study, Am J Psychiatry, 154:7
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