Review
The obstetrician and depression during pregnancy

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Abstract

The objective of this article is to review the literature as to the presence of depression during and after pregnancy and some of its clinical implications; and to present a simple statistical aide for screening purposes. Clinical depression affects at least one in five women of childbearing age. During pregnancy, this figure does not diminish and not only signals problems for the pregnant woman but also for the child, measurably so into adolescence. Postpartum depression, but even more so antepartum depression, are medical conditions that negatively affect mother and child, and need to be detected as early as possible to avoid or limit the use of pharmacological treatments with possible side effects. The obstetrician should regularly test for depression from the very first moments of planning for a child, and use the test results for a “pregnancy mood profile”. This profile requires only a few minutes and is very simple to complex. It could serve for early control of depression during pregnancy as well as determine the risk for postpartum depression and thus serve as a pre-alert for postpartum suicide.

Introduction

When the World Health Organization (WHO) estimates that 22% of women of childbearing age suffer from depression at one time or another, this should be taken as a very cautious estimate. The tendency in Europe and the United States, but also increasingly in other parts of the industrialized world, is that clinical depression affects more adults, more adolescents and more children every year. If other related mood disorders are included, the numbers increase dramatically. Thus, depression has become the primary cause of incapacity in the world, according to the WHO.

Pregnancy is a time when women are specially vulnerable to the negative consequences of depression. The hormonal changes in their bodies can aggravate the condition, or make it more difficult to control. There is also the concern for the wellbeing of the child. Recent longitudinal and large-number investigations are showing that this concern is justified. Depression can have negative consequences by itself, but anti-depressant medication too can have negative consequences for the child, in the short and in the long-term. Not treating depression adequately with proper medication may result in loss of life, because the risk of suicide in postpartum depression is all too real.

In May 2002 the US authorities, through the US Preventive Services Task Force, Agency for Healthcare Research and Quality, made public a rather dramatic change in the official recommendations for screening for depression. Before this date the official standpoint considered insufficient evidence available to support a recommendation to use standardized screening tests to detect depression in primary care patients. This evidence now is considered to exist, and routine screening for depression in all adults is recommended [1].

Special risk-groups such as women between 20 and 50 should be screened for depression, and because of the prevailing clinical evidence that the consequences of depression for mother and child can amount to changes in fetal development, miscarriage, and suicide, screening for depression during pregnancy should become a matter or priority.

Depression, like anxiety and stress, is a psychopathological condition that even at subclinical levels affects many aspects of pregnancy, both in the mother and in the fetus, both in the short and in the long-term [2], [3], [4], [5].

Many physicians, however, underestimate the severity of the effects of depression on health and well-being, and obstetricians are no exception to this rule [6].

Section snippets

Antepartum depression

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association specifies a number of mood disorders, together commonly called depression, and specifically refers to postpartum onset, within 4 weeks postpartum [7]. There is no similar reference to the depression that manifests itself just before or during pregnancy. However, clinical data indicate that both the interaction of depression and pregnancy and the interaction of depression and infertility,

Postpartum depression: screening for suicidal tendencies?

About half of all women suffer from a postpartum depression period that can vary from a few days to several months [37], and that qualifies as a mood disorder in between 10 (overall) and 22% (inner city) [42] of cases. Hormonal changes and psychosocial factors combine to produce mood changes in the mother and, to a much lesser extent, in the father. Mood disorders at moderate to severe levels are not infrequent and at least two of every 1000 new mothers suffer from major postpartum depression

Discussion

Depression and pregnancy are a dangerous combination. The pregnant or puerperal woman is at considerable risk of this all-too-underestimated pathology. Depression has direct negative consequences on mother and child, and indirectly causes possible side effects through medication. Depression during pregnancy and in nursing mothers is therefore more complicated to (effectively and safely) treat, thus making early detection imperative in order to apply early and adequate multi-disciplinary

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