September 2007: Be vigilant for symptoms of perinatal depression
Who is at risk of perinatal depression?
How can it be recognised?
Which drugs are safe to use?
Who is at risk of perinatal depression?
How can it be recognised?
Which drugs are safe to use?
The perinatal period carries the greatest lifetime risk of mental illness for women, and psychiatric disorders are the leading cause of maternal deaths in the UK (see table 1, attached).1,2
Postnatal depression is the most common mental health problem associated with childbirth and is known to have a detrimental effect on the mother, baby and the family. Antenatal depression is also important and GPs have a role in managing depression throughout this key period.
Women have considerable contact with health professionals before, during and after childbirth. Midwives and GPs are encouraged to use this to identify mental health problems as early as possible in antenatal care and monitor or treat those with symptoms or risk of illness.
Infants of mothers with postnatal depression, especially boys, have poorer emotional, behavioural and cognitive development. Infants of women with antenatal anxiety and depression also have altered stress responses, which persist after birth,6 and are more likely to be born preterm and have a low birth weight.
Mothers with depression lose confidence, may struggle with child rearing and are at risk of further episodes of depression. Personal and social relationships can be strained and disrupted, and these women are at a increased risk of domestic violence.
Generally, women have a high rate of anxiety and depression symptoms (twice as high as men).7 Approximately 10% of women conceive while depressed or recovering from depression.7
Patients may be taking antidepressants, though will often stop as soon as they realise that they are pregnant. Women need to be informed of the consequences of continuing on medication, alternative strategies and the risk of relapse.
About 10-15% of women develop a new depressive episode in pregnancy or after childbirth. Such depression can persist for many months and tends to recur.8,9
The best predictor of depression around childbirth is a personal history of depression or anxiety, especially previous postnatal depression. A family history of serious mental illness is also predictive. The NICE guideline5 recommends that all women are asked about a personal or family history of serious mental illness, the treatment received and any psychotropic medication taken recently.
Women with bipolar disorder, especially those with a history of puerperal psychosis, are at highest risk. These patients have a 25-50% risk of relapse in the first month after childbirth and such depressive episodes are often severe, psychotic and associated with suicide and infanticide.
Women with bipolar disorder should be referred to specialist care, whether or not they are ill in pregnancy, and a management plan should be prepared as early as possible.5
The NICE guideline recommends that midwives and GPs should ask pregnant women two key questions about mood at the first consultation (see table 2, attached). A positive response to the third question should prompt assessment.
Midwives should be trained to refer women to the GP, secondary or specialist mental health services according to locally agreed protocols, and should always keep the patient's GP informed.
Assessment of a woman's mental health needs includes diagnosis and a management plan. Midwives may have direct access to perinatal specialist advice and assessment, but nevertheless GPs are pivotal in providing the long-term perspective on a woman's situation, information about past consultations and access to a range of interventions.
Most cases of mild to moderate depression can be managed within primary care and only more serious or complex conditions require referral to secondary mental health services. Specialist perinatal professionals may be involved if available.
GPs should always consider a woman's mental wellbeing and ask about mood and coping each time she is seen during pregnancy and after childbirth.
In many areas the tool used for detecting puerperal depression is the Edinburgh Postnatal Depression Scale (EPDS), see table 3, attached. This scale is used in primary care, mainly by health visitors, as part of a screening and intervention strategy for postnatal depression.
Recent research suggests that the EPDS is less acceptable to women than first thought.11 It is now recommended as part of an assessment for depression and for monitoring outcomes rather than for screening.
The puerperal depressive disorders most often encountered in primary care are non-psychotic and mild to moderate in severity. Depression is diagnosed when low mood persists and is accompanied by other symptoms that impair function.
• Loss of interest and pleasure
• Negative thoughts
• Hopelessness and/or anxiety about the future.
Sleep and appetite may be disturbed and exhaustion is common but difficult to interpret around childbirth.
A woman who is depressed may slow down, take to her bed or become agitated. Such patients should be asked about suicidal ideas and thoughts of harming their baby.
A mother who is depressed may feel guilty and a failure but pretend to be cheerful in case she is judged unable to care for her baby; thus some depressed women present frequently with worry or non-specific somatic symptoms. Others present their baby or other children with minor ailments or difficulties with feeding.
Severity is judged by the high-risk nature of certain symptoms, including suicidal or infanticidal plans, neglect of self or the baby or delusions prompting risky behaviour; the level of impairment of functioning and the degree of distress. In very severe cases psychotic symptoms may be present and a mother may have delusional beliefs about herself or the baby. These are usually negative and laden with guilt.
The threshold for psychological treatment in pregnancy and the puerperium is lower than at other times because of the risk of harm to the infant or fetus posed by untreated illness and the use of medication.
Women requiring psychological therapy should receive treatment within one month and no later than three months from referral. Patients with existing depressive illness should be considered for psychological therapy instead of their antidepressant medication depending on the severity of their condition. The lower cut-off for psychological therapy is mild depression with significant life stressors and impairment of functioning; the upper cut-off is severe depression with pervasive and intense negative thoughts or agitation, or difficulty considering a psychological model.
The following options are effective in a new episode of mild/moderate depression or anxiety:
• Self-help strategies (such as guided self-help, computerised cognitive behaviour therapy [C-CBT] and exercise12)
• Counselling by health visitors (listening visits)13
• Brief CBT (4-6 sessions)14
• Antidepressant medication, if the woman prefers this to psychological treatment.
Mild depression may be managed by support and encouragement and a booked review appointment (watchful waiting).15
Secondary care assessment should be sought for women with moderate and severe depression, those whose condition deteriorates and those with complex problems to assist the planning and implementation of appropriate care.
Medication in pregnancy and breastfeeding
Information on the risks to the baby of exposure to psychotropic drugs in pregnancy and breastfeeding is limited. The evidence suggests that antidepressants are as effective in pregnancy and postnatally as the negative effects of untreated depression are significant.
Monotherapy is preferred to combination treatment and the lowest effective dose should be used. The woman's past response to treatment and her views, wishes and fears should also inform the choice of medication.
Tricyclic antidepressants and selective serotonin re-uptake inhibitors (SSRIs) have not been associated with teratogenesis, except for paroxetine (cardiac defects), see box 1, attached.
SSRIs are well tolerated in pregnancy but are associated with spontaneous abortion, low birth weight and preterm birth. The neonate may have symptoms of withdrawal and toxicity but these are mild and self-limiting. Use of SSRIs after 20 weeks' gestation may cause persistent pulmonary hypertension in the neonate.
Tricyclic antidepressants are not known to cause specific problems in pregnancy but their anticholinergic side-effects may limit tolerability.
They are toxic in overdose for both the mother and the baby, except for lofepramine, which is also less sedating than other tricyclics.
Sertraline, nortriptyline and imipramine are preferred in breastfeeding because little drug passes into the milk. Lofepramine can also be continued during breastfeeding but fluoxetine and citalopram pass into the breastmilk in large amounts. Serotonin and noradrenaline re-uptake inhibitors and other antidepressants should only be used with specialist advice.
The lowest dose possible should be used to control symptoms and restore function.
Typical antipsychotics have the longest track record with little evidence of direct toxicity/teratogenicity. Trifluoperazine and chlorpromazine, then haloperidol, appear to be the safest during both pregnancy and lactation.
Olanzapine and clozapine are not favoured because of the risk of gestational diabetes and weight gain, and clozapine passes into breastmilk. Other atypicals have some negative effects and/or there are no data.
Mental health, maternity and primary care services are being asked to develop care pathways for women with mental health problems both during pregnancy and after childbirth.
Women with a personal or family history of serious mental illness, or current symptoms, should be identified and assessed by the GP or specialist perinatal professional according to an agreed protocol for the area. The severity of illness suitable for referral will depend on local services, but the GP will be the best judge of the needs of a woman in her particular context.
Midwives, GPs, health visitors and others must communicate concerns and plan care together to cover the needs of the patient, including the provision of secondary or specialist services for women with severe or high-risk problems. These can be integrated with any existing postnatal depression strategy that health visitors and GPs administer.
The NICE guideline recommends that each local area develop perinatal managed care networks of professionals that enable disciplines to liaise and plan the care of pregnant and postnatal women who have mental health needs (see table 4, p32). It recommends that they identify services, develop specialist teams, arrange training and create protocols that will allow good liaison between primary, secondary and specialist services, as well as integrate non-statutory services such as Sure Start. When a mother needs admission to hospital, this group will have agreed which mother and baby unit can be offered and how admission is arranged.
Detection and treatment of antenatal and postnatal depression can limit or avoid the negative consequences of these conditions. Most patients will be managed in primary care.
The GP has a particular role in assessment, diagnosis and treatment, and also in facilitating access to secondary care and other resources. The GP can explore the use of medication in pregnancy and lactation and also has a role in supporting other members of the family.Author
Dr Fiona Blake
consultant psychiatrist for acute general adult services, Cambridge University Hospitals NHS Foundation Trust