Point prevalence
Major and minor depression (%)
Major depression (%)
First trimester
11.0
3.8
Second trimester
8.5
4.9
Third trimester
8.5
3.1
1 month postpartum
9.7
3.8
3 months postpartum
12.9
4.7
6 months postpartum
10,6
5.6
12 months postpartum
6.5
3.9
3.5 Etiology and Pathogenesis
3.5.1 What Is the Pathogenesis of Perinatal Depression?
The pathogenesis of perinatal depression is largely unknown. As is true for depression in general, the causes of perinatal depression are likely to be a combination of biological, psychological, and environmental factors.
3.5.2 What Are Risk Factors for Perinatal Depression?
Psychological and environmental risk factors for perinatal depression that are reported in separate studies are [3]:
- 1.
Past history of psychiatric disorders
- 2.
Depression/anxiety during current pregnancy
- 3.
Maternity blues
- 4.
Recent adverse life events
- 5.
Low socioeconomic status
- 6.
Insufficient emotional/social support
- 7.
Poor marital relationship
- 8.
Unplanned pregnancy
- 9.
Immigration/pre-migration stress
- 10.
Personality traits
- 11.
Unfavorable obstetric/pregnancy outcomes
- 12.
Unfavorable neonatal outcomes
- 13.
Chronic/current physical illness
- 14.
History of Premenstrual Mood Disorder (PMD)
- 15.
History of physical/sexual abuse
- 16.
Multiple births
- 17.
Domestic violence
- 18.
Childcare stress/infant temperament
Table 3.2 shows the effect sizes of risk factors associated with depression during pregnancy and postpartum, based on systematic reviews [4, 5]. In summary, there are many risk factors or indicators for depression.
Table 3.2
Risk factors for perinatal depression and their effect sizes
Risk factor | Depression during pregnancy | Postpartum depression |
|---|---|---|
History of depression | +++ | ++++ |
Anxiety | ++++ | ++++ |
Life stress/events | +++ | ++++ |
Neuroticism | ? | +++ |
Lack of support | ++++ | ++++ |
Poor partner relationship | +++ | +++ |
Domestic violence | + | ? |
Unintended pregnancy | +++ | ? |
Obstetric factors | − | + |
Smoking | + | ? |
Socioeconomic status | − | + |
3.5.3 Do Hormonal Factors Play a Role in the Pathogenesis?
Since levels of the reproductive hormones estrogen and progesterone increase during pregnancy and fall rapidly after delivery, perinatal depression is often hypothesized to be related to hormonal fluctuations. However, clinical studies investigating the effect of hormonal interventions to prevent or reduce perinatal depression are limited and inconclusive [6].
More evidence exists for hypothalamic-pituitary-adrenal (HPA) axis dysfunction in women with perinatal depression. Patients with depression, both during and outside the perinatal period, have higher baseline levels of cortisol and a hyperactivity in reaction to stress. For example, a double-blinded study in which the rapid withdrawal of reproductive hormones after delivery was simulated in euthymic, nondepressed women outside the puerperal period with and without a history of postpartum depression showed that women with a history of perinatal depression were at much higher risk to develop significant mood symptoms in the withdrawal period [7]. Also, some studies found an association between lower levels of serum free triiodothyronine (FT3) and free thyroxine (FT4) and an increased incidence of mood disturbances in the postpartum period [8, 9]. However, these studies do not give evidence and/or indications for prevention or treatment of perinatal depression. Therefore, hormone substitution in women with—or at risk for—perinatal depression should be avoided until more evidence is available.
3.6 Specific Diagnostic Aspects
Early detection and diagnosis of perinatal depression can be complicated by the shame and burden most women feel at presenting with depressive symptoms to their healthcare professional in a period that is traditionally considered cheerful. Therefore, one should be particularly aware of the emotional and social isolation that women with depressive feelings often experience. Even if women do not appear depressed, they could significantly suffer from their symptoms. Another difficulty in identifying women with perinatal depression is that depressive symptoms could mimic pregnancy-related symptoms, such as altered weight, insomnia or hypersomnia, fatigue or loss of energy, and problems with concentration. In contrast to women with only pregnancy-related symptoms, women with perinatal depression also suffer from one of the core symptoms: depressed mood and/or loss of interest/pleasure (anhedonia).
3.6.1 How Can Women at Risk for Perinatal Depression Be Screened?
As recommended by the National Institute for Health and Care Excellence (NICE) guidelines in the UK, healthcare professionals (including midwives, obstetricians, health visitors, and GPs) should ask two questions at a woman’s first contact with primary care, at her booking visit, and postnatally (usually at 4–6 weeks and 3–4 months) to identify a possible depression:
- 1.
During the past month, have you often been bothered by feeling down, depressed, or hopeless?
- 2.
During the past month, have you often been bothered by having little interest or pleasure in doing things?
If the woman answers “yes” to either of the above, then a third question should be asked:
- 3.
Is this something you feel you need or want help with?
For further assessment of perinatal depression, the most widely accepted Edinburgh Postnatal Depression Scale (EPDS) could be used, which takes 2–5 min to complete [10]. In this validated 10-item self-report questionnaire, the somatic symptoms are excluded because they do not differentiate well between depressed and nondepressed pregnant and postpartum women. This questionnaire is also validated for use during pregnancy [11]. A cutoff score of ≥10 is indicative for clinically relevant depressive symptoms. Women who score above this threshold should be referred to a general practitioner or psychologist for further evaluation and eventual treatment of perinatal depression.
Case History: Continued
When the midwife asks Nadia whether she felt depressed or has been bothered by having little interest or pleasure in doing things during the past month, Nadia answers “yes” to both questions. Further assessment of the severity of depressive symptoms by means of the EPDS reveals a score of 15, which is above the cutoff score for clinically relevant depressive symptoms. The midwife, who closely collaborates with a perinatal psychologist, arranges a consultation in the next week.
3.7 Specific Therapeutic Aspects
3.7.1 What Are Evidence-Based Treatments for Perinatal Depression?
There is growing notice of the importance of screening for depression during pregnancy. However, evidence-based treatment algorithms for depression during pregnancy are limited. In general there is no reason to assume that evidence-based treatments for “normal” depression would not be as effective in the perinatal period.
However, in decisions about treating perinatal depression, the risks and benefits to the unborn child must also be taken into account. Leaving depression untreated may be hazardous to the unborn child. At present, it is well known that children of women who suffered from depression during pregnancy have an increased risk of adverse perinatal health outcomes and behavioral, emotional, cognitive, and motor problems in early childhood [12, 13].
An important first step in treating perinatal depression is explaining to the woman and her partner that depression is a frequently occurring condition that can effectively be treated. Second, it is important to discuss ideas about the disorder, including stigma and feelings of guilt and shame, and expectations about treatment. If possible, also the partner, family, and other nearby people should be actively involved in the decisions about treatment and their role in supporting the woman.
3.7.1.1 Non-pharmacological Treatment
Pregnant women express a strong preference for non-pharmacological depression treatment over antidepressant medication, because of the possible harm to their child [14]. In pregnancy and in the postpartum period, the efficacy of psychotherapy is empirically supported. Interpersonal psychotherapy (IPT) and cognitive behavioral therapy (CBT) have been shown to be effective for perinatal depression across the spectrum from mild to severe depression [15]. The results of the latter study stress the importance of implementing preventive CBT as a first-choice treatment for relapse of depression/anxiety during pregnancy.
IPT is a time-limited psychotherapy that targets reduction of depressive symptoms, improved interpersonal functioning, and increased social support. The underlying theory is that changes in interpersonal relationships trigger depression in sensitive women [16]. Especially in the perinatal period, relationships with the partner, employer, and the woman’s own parents are changing and often stressful. The first phase in IPT is identifying the major loss or losses that are related to the interpersonal role changes that occur during pregnancy or after childbirth. For example, a woman who used to have an active social life before becoming pregnant has to give up going out during nights as frequently as before pregnancy. First she could be helped with realizing and accepting that life will never be like before pregnancy again and that this is a major loss that may cause feelings of mourning. After discussing the loss and feeling the grief, the therapist will help this woman to identify possibilities to adjust to the new situation of pregnancy. For example, she could discuss with her partner to find other distractions that are more compatible with her pregnancy or aim at ways of getting to know other pregnant women with whom she could meet during the day and share feelings that are typically related to pregnancy and becoming a mother.
CBT has mainly been studied, and shown to be effective, in the prevention and treatment of postpartum depression [15]. CBT addresses dysfunctional thoughts and beliefs, e.g., “I will never be a good mother” or “other women do much better than I.” These often automatically generated negative thoughts will first be identified and secondly challenged and replaced with alternative more helpful thoughts and activities. Registration of thoughts and feelings during the day and goal-oriented exercises provide women with insight and tools to change their maladaptive behaviors.
Other non-pharmacological treatments that might be considered are summarized in Table 3.3 [16–22]. These effect sizes are mainly based on randomized controlled trials (RCTs). However, a placebo response could not be ruled out because in most non-pharmacological treatments, blinding is not possible, except for bright light therapy.
Table 3.3
Non-pharmacological treatments for perinatal depression and their effect sizes
Treatment | Effect size |
|---|---|
Interpersonal psychotherapy [16] | ++++ |
Cognitive behavioral therapy [17] | ++++ |
Relational therapy [18] | ++
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