Women With History of Depression Are at Higher Risk for Postpartum Depression
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Reviewed By Louise Chang, MD
Sept. 28, 2007 -- Depression and pregnancy may not seem to go together, but a new study shows that more than one in seven women are depressed in the nine months before pregnancy, during their pregnancy, or in the nine months after giving birth.
The new research expands on information already known about depression after childbirth. "People have known for quite a while that postpartum depression is a serious, sometimes devastating event," says researcher Evelyn Whitlock, MD, MPH, senior investigator at the Kaiser Permanente Center for Health Research in Portland, Ore. "One of the things we were able to do is look across the spectrum -- nine months before pregnancy, the nine months of pregnancy, and the nine months postpartum. I think this is the first study to do that."
The results also seem to confirm that women with a history of depression are at higher risk for postpartum depression. "I think it's important that women realize that postpartum depression doesn't just come out of the blue," Whitlock tells WebMD. "About 54% of women [in the study] identified as having postpartum depression had also been identified either before or during pregnancy as being depressed."
The study, with an accompanying editorial urging more research, is published in the October issue of the American Journal of Psychiatry.
Depression and Pregnancy
Whitlock and her colleagues evaluated 4,398 women, all members of the Kaiser Permanente HMO, who had given birth between 1998 and 2001.
Before pregnancy, 8.7% were identified as depressed by their health care providers; 6.9% were classified as depressed during the pregnancy, and 10.4% were depressed in the nine months after delivery. In all, 15.4%, or more than one in seven of the women, were depressed during at least one of the three periods.
About half of the women who had postpartum depression also were depressed before the pregnancy occurred or during pregnancy. More than half of those depressed before pregnancy became depressed during the pregnancy, suggesting the condition is not temporary or relieved by getting pregnant or by giving birth.
Whitlock also found that 93.4% of those with pregnancy-related depression had seen a mental health provider and/or gotten antidepressants. About 77% of women took an antidepressant before becoming pregnant, 67% during pregnancy, and 82% after giving birth. Since the study, reports of possible side effects of antidepressant use during pregnancy, including lung problems and heart problems in newborns, have been published. As a result, doctors emphasize that a careful evaluation of the risks and benefits is crucial before deciding on an antidepressant during pregnancy.
In the study, women most likely to be depressed were not married, had delivered three or more children before the current pregnancy, smoked cigarettes during the pregnancy, were white, and had Medicaid health coverage.
A woman's age or education did not seem to play a role in whether she got depressed; nor did the time at which she began prenatal care.
The percent of women depressed before, during, or after pregnancy didn't surprise Whitlock. "I think it is in line with what we could expect, from what we know about depression," she says. "In the general population, about 9% of adults are depressed in a 12-month period," she says, citing national statistics. Previous research has shown that one in 10 women is depressed during pregnancy or within the first year after childbirth.
Second Opinion on Pregnancy-Related Depression
Nor do the results about depression throughout the prepregnancy and postpartum period surprise another expert, Diana L. Dell, MD, assistant professor of psychiatry and obstetrics and gynecology at Duke University Medical Center in Durham, N.C.
"My sense has always been that pregnancy doesn't provide any protection [against depression]," she says, although the notion that it does is prevalent.
Another widespread notion, she says, is that hazards during pregnancy are all external -- such as drinking alcohol or smoking cigarettes. "Being depressed during pregnancy isn't a neutral impact," says Dell, who tells women that internal hazards, such as depression, can be as harmful as external ones.
When untreated, depression during pregnancy is associated with many problems, including higher rates of miscarriage, stillbirth, and low birth weight, according to the American College of Obstetricians and Gynecologists. If untreated, postpartum depression can make it difficult for women to bond with their infants. While the exact causes of depression during and after pregnancy aren't known, the fluctuation of hormones is thought to contribute.
Treating Pregnancy-Related Depression
Women who suffer depression before, during, or after pregnancy are not likely to acknowledge it, says Whitlock. "I think it can be difficult for women to admit to themselves they aren't feeling happy."
Dell agrees. "They see themselves as being bad mothers."
Whitlock urges women who feel they may suffer pregnancy-related depression to share the information with their doctor "and not try to be supermom."
Treatment can be very effective, agree Dell and Whitlock. "Cognitive therapies [talk therapy] have been proven to be helpful for mild to moderate depression," Dell says. "If it is severe, that person should be evaluated for medication."
The use of one antidepressant, Paxil, should be avoided during pregnancy, ACOG advises, due to potential health risks to the baby.
SOURCES: Evelyn Whitlock, MD, MPH, senior investigator, Kaiser Permanente Center for Health Research, Portland, Ore. Diana L. Dell, MD, director, Maternal Wellness Program; assistant professor of psychiatry and obstetrics-gynecology, Duke University Medical Center, Durham, N.C. Dietz, P. American Journal of Psychiatry, October 2007; vol 164: pp1515-1520. Yonkers, K. American Journal of Psychiatry, October 2007; vol 164: pp1457-1459.
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