Unexpected depression

Clinical depression in pregnancy can be equally detrimental for both mother and baby with higher risks of poor attendance at antenatal clinics, substance misuse, low birth weight and pre-term delivery, writes JUNE SHANNON

UP TO 10 per cent of pregnant women in Ireland may suffer from anxiety and or depression and while a lot has been written about postnatal depression, antenatal or depression during pregnancy has, for the most part, been ignored.

As a result, there is a dearth of information on the numbers of Irish women who, on top of struggling with the many physical demands of a difficult pregnancy, may also be battling the crippling effects of clinical depression.

Concerns about the risks of some antidepressants in pregnancy may lead some women who are on treatment for depression to discontinue it immediately on discovering they are pregnant. Worryingly for a number of women, this can have grave consequences.

Left untreated, clinical depression in pregnancy can be equally detrimental for both mother and baby with depressed mood during pregnancy being associated with poor attendance at antenatal clinics, substance misuse, low birth weight and pre-term delivery. In some severe cases there is also an increased risk of self-harm and suicide.

A study by researchers at the University of Bristol examined depressed mood throughout pregnancy and after childbirth in a cohort of 14,000 women in the UK with an expected date of delivery between April 1st, 1991 and December 31st, 1992. This study concluded that symptoms of depression were “not more common or severe after childbirth than during pregnancy”.

In fact, the Bristol study revealed that depression scores were higher at 32 weeks of pregnancy than eight weeks after childbirth with 13.5 per cent of women scoring above the threshold for probable depression at 32 weeks.

According to the researchers, “although there are concerns about the widespread use of antidepressants during pregnancy, the benefits may outweigh the risks for women with severe depression. Non-pharmacological interventions that have been found effective in mild to moderate depression could be evaluated for treating depression during pregnancy.

“Our results show depression during pregnancy is more common than postnatal depression. Offering treatment may be important for both the mother and the future wellbeing of the child and family.”

Moreover, recent studies from the US indicate that 10-15 per cent of women experience clinically significant depressive symptoms during pregnancy with the majority not receiving adequate treatment.

Dr Anthony McCarthy is a consultant psychiatrist at the National Maternity Hospital (NMH) in Holles Street in Dublin with a special interest in perinatal psychiatry.

“There is a myth out there that all women go through pregnancy perfectly happy and then there is this peak of depression only after pregnancy called post-natal depression,” he says.

“The reality of course is that there are an awful lot of women who are really struggling during pregnancy. The reality is that some women are really happy and have very easy pregnancies and some have very hard pregnancies.

“Pregnancy can be tough in all sorts of ways. Some women don’t want to be pregnant. For others, rather than blissful happy hormones there is nausea, vomiting, body changes, getting up at night to visit the toilet, kidney infections, restless legs, itchiness, pelvic pain, etc and that is just the physical side.”

Then there is the emotional side. “How does she feel about it? Some women love it, some hate it, perhaps they spend their lives trying to be thin and suddenly they are big, people looking at you . . . strangers touching you . . . invading your space.”

According to McCarthy, there is no evidence to suggest that pregnancy causes an increase in depression, psychosis or anxiety. However, he adds that despite the happy hormone myth, pregnancy does not result in a reduction of these disorders either.

McCarthy says approximately 5-10 per cent of pregnant women in Ireland suffer from significant anxiety and or depression. One of the risk factors would be women who have had a history of recurring depression and are no longer on treatment, and are having a difficult pregnancy.

A 2004 study from the American College of Obstetricians and Gynaecologists on the prevalence of depression during pregnancy revealed that rates of depression were substantial especially during the second and third trimesters.

McCarthy says this is due to a significant number of women who are being treated for depression immediately discontinuing their medication on discovering they are pregnant. “Therefore you are going to see the peak of depression two or three months down the road,” he explains.

Suddenly discontinuing antidepressants is not advised without first getting advice from a doctor and in pregnancy that decision should be weighed up for each individual person.

According to McCarthy, “If a woman is significantly clinically depressed in pregnancy not only is she suffering but she is more likely to have a premature delivery, a smaller baby and she is more likely to self-harm. There is also a risk of suicide, which is one of the more common causes of maternal death. She is also more likely not to attend prenatal appointments, to be smoking, drinking and not eating well.”

McCarthy also points out that depression in pregnancy could also have wider effects on other children in the home and on the woman’s partner.

“The other key thing is that if a woman has depression in pregnancy and it is not treated, she is guaranteed to get it worse afterwards. Some people have this myth that she will be fine once the baby is born and that is extremely rare . . . in the majority of cases if a woman is depressed in pregnancy, she is likely to get much more depressed afterwards.”

Depression is a very complex condition and each case has to be assessed on an individual basis. However, McCarthy says that if a woman presents with the clinical symptoms of depression and is unlikely to respond to psychological techniques alone, such as counselling and psychotherapy then the next course of action would be to prescribe medication.

Like all decisions relating to medication in pregnancy for any condition, the benefit to the mother must be balanced with the potential risk to the unborn child and, with antidepressants, the main risks to be assessed are congenital malformations.

According to McCarthy, all the evidence strongly suggests that there is no significant increased risk of any congenital malformations from any antidepressants with the exception of Seroxat – which he doesn’t prescribe in pregnancy.

“It is a very small risk but there is an increased risk with Seroxat . . . nothing has come through with the other antidepressants. Some antidepressants have been around for longer and have been used more so we can say that those are probably safer, but there is no evidence that any of the other ones cause any increased risk of congenital malformations.”

Coupled with the risk of congenital problems, a number of women also worry about the long-term effects of antidepressants on their child’s social and behavioural development. However, according to McCarthy, there is no evidence to suggest that this is the case.

Conversely, McCarthy says that this is very different from children of mothers who have significant and untreated postnatal depression.

“If a mother has persistent and severe postnatal depression, there is a significant risk that her baby may have speech difficulties, behavioural problems and social developmental problems compared to children of similar socio-economic backgrounds, which makes sense.

“If the woman is profoundly depressed, she is not relating to her child, not looking at it, verbalising, smiling . . . if you are depressed you don’t do that.”

McCarthy emphasises that the risks of untreated antenatal depression are “much worse” than treating the condition. He adds that there are concerns with antidepressants towards the end of pregnancy, however, he says, these are easily manageable.

“In some children there is a very small risk of minor withdrawal symptoms which can last anything from a day to a couple of days and have no long-term negative effects that we know of. They are very transient but we try to avoid them if possible by reducing the dose of antidepressants in the last weeks of pregnancy.”

He also says there is one study that suggests that Seroxat may cause persistent pulmonary hypertension in newborn babies. However, he says this is almost certainly transient, occurring in less than 1 per cent of cases and is shown in only one study. “But it is something we are looking out for,” McCarthy states.

The dearth of research on the prevalence of Irish women taking antidepressants in pregnancy is something McCarthy is hoping to address. Together with his colleagues in the National Maternity Hospital in Holles Street, he hopes to establish Ireland’s first database on the use of psychotropic medication in pregnancy.

McCarthy advises women on antidepressants who are thinking of becoming pregnant to contact their GP for advice and says women who are currently pregnant and on medication for depression should speak to their midwife or doctor. He also recommends the website www.womensmentalhealth.org which he says is a very good resource for mental health issues and pregnancy.

“Depression is a label and the advice that each woman will get will be very much tailored to her story and her own circumstances . . . for the majority of women having a baby can be the most rewarding and meaningful thing they do in their lives, we just want to make sure it isn’t ruined by depression,” he concludes.

Helpful contacts

The Aware Helpline is a non-directive listening service for people who experience depression and concerned family and friends. The helpline offers a non-judgmental listening ear to people who may be distressed or worried, or just need someone to talk to. The Aware loCall Helpline is available on: 1890 303 302.

The Samaritans provides confidential, non-judgmental, emotional support, 24 hours a day for people who are experiencing feelings of distress or despair, including those which could lead to suicide.

The Samaritans can be contacted at tel: 1850 60 90 90 or e-mail: jo@samaritans.org