Up to 20% of all pregnant and postpartum women will suffer from depression during the perinatal period, including the period up to 1 year postpartum. Although perinatal depression is more common than hypertensive disorders in pregnancy (2%-8%) and gestational diabetes (7%), many women with it go untreated for lack of diagnosis and/or intervention.1,2 There are several reasons that perinatal depression may not be identified and subsequently treated, but the two most common are non-disclosure from patients and inadequate screening of pregnant and postpartum women. Given the far-reaching effects of perinatal depression on mothers and their offspring, appropriate and timely diagnosis and treatment are imperative.
Making the diagnosis
A diagnosis of perinatal and/or postpartum depression is made when symptoms of depression last longer than 14 days.3 Symptoms include changes in sleep and appetite, which may be considered “normal” for pregnancy and thus overlooked by both the patient and the clinician. In addition, patients may report decreased energy, concentration, and interest, as well as feelings of guilt. These symptoms interfere with a woman’s ability to perform normal activities of daily living and cause significant impairment. Patients who describe symptoms of depression should always be screened for thoughts of self-harm/suicide. If thoughts of self-harm are accompanied by a plan, intervention becomes acutely necessary. In addition, women should be screened for signs and symptoms of psychosis as this may be associated with the rare diagnosis of postpartum psychosis, which is considered a psychiatric emergency because it puts women at risk of suicide and infanticide.
Patients who suffer from perinatal depression may have concomitant anxiety disorders, such as generalized anxiety disorder, which affects approximately 10% of pregnant and postpartum women.4 Diagnosis may be delayed or overlooked due to the overlap of anxiety and depression symptoms. Symptoms of generalized anxiety disorder (GAD) include excessive worry, inability to focus/concentrate, irritability, restlessness, fatigue and muscle tension.3 Another associated anxiety disorder seen in perinatal women is obsessive-compulsive disorder (OCD). Perinatal and postpartum OCD is believed to affect approximately 3% of pregnant and postpartum women. Approximately 50% of women with perinatal OCD also have a diagnosis of perinatal depression. Symptoms include obsessions related to fears of harm or death of the infant, contamination fears, and, compulsions such as frequent checking and cleaning behaviors.
Women are at risk of developing perinatal depression when they have been diagnosed with a depressive disorder previously, have a history of postpartum depression in a prior pregnancy, or have a family member with a diagnosis of depression or anxiety. In addition, women who are young, of lower socioeconomic status, and who have limited resources and limited social support are at higher risk.5 Interestingly, women who have a history of premenstrual dysphoric disorder are also at risk for perinatal depression. Research shows that hormone fluctuations, and not specific levels of estrogen and progesterone, may be related to onset or exacerbation of symptoms.6,7 In fact, women are at increased risk of depression during specific times in their lives, including onset of menses, pregnancy, and the perimenopausal period, all times in which there is noted fluctuation in hormone levels.8
Screening women for depression during pregnancy and in the postpartum period is recommended.5 Several self-report screening tools have been validated for use in the perinatal period. Two commonly used screening tools for use in pregnant and postpartum women are the PHQ-9 and the Edinburgh Postnatal Depression Scale (EPDS). The EPDS is available in 50 languages including Spanish. The PHQ-9 is available in English and Spanish. Patients who have a positive screening result (a 12 or greater for EPDS, a 10 or greater for PHQ9) should be further evaluated to determine whether they require intervention.
It is important to remember that when a self-report questionnaire is given to a patient for completion, the findings should be reviewed. The screening tools previously mentioned both include a question related to self-harm. Thus, it is imperative that the clinician review the responses before the patient leaves the office. Some patients may not feel comfortable speaking the words “I have thoughts of hurting myself” but they will indicate this feeling by circling a response.
The author reports no potential conflicts of interest with regard to this article.
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