Nancy C. Lintner, MS, APRN-BC Bobbe Ann Gray, PhD, RNC

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1 Nancy C. Lintner, MS, APRN-BC Bobbe Ann Gray, PhD, RNC

2 The National Institute of Mental Health (NIMH) reports that 12.4 million American women are affected by depression in any given year (NIMH, 2004). The true incidence of depression is difficult to determine because the symptoms can be vague and can manifest in ways that are similar to symptoms of other medical conditions, including pregnancy. Women are almost twice as likely as men to be affected by depression. This may be because of gender-related differences found in neurotransmitter levels, such as serotonin, and fluctuations of female hormones related to the menstrual cycle, infertility treatments, menopause and childbearing (NIMH, 2004).

3 Depression during pregnancy and the postpartum period are major health problems that affect as many as one in three childbearing women, and up to half (51 percent) of childbearing women living in poverty. Unfortunately, it s estimated that less than one in four (25 percent) of these women seek treatment. This may be due to poor identification of depressive symptoms, underestimating the severity of depression, financial challenges or stigma. This article reviews current information on depression related to childbearing. Included is information on types of depression, risk factors and symptoms for antepartum as well as postpartum depression. Information about current treatments and nursing implications are provided to facilitate early identification and prompt intervention. Defining Depression The American Psychiatric Association s (APA) Diagnostic and Statistical Manual for Mental Disorders (4th ed.) Text Revision (DSM-IV-TR) bases its diagnostic criteria for depressive conditions on the occurrence of major depressive episodes (see Box 1). When all criteria for a major depressive episode are present, a diagnosis of major depressive disorder is made. Major depressive disorders are further categorized using a number of defining terms such as mild, moderate or severe, with or without psychotic features. One additional term used for major depressive disorders is postpartum onset defined as beginning within four weeks of childbirth. A minor depressive disorder may be diagnosed if the depressive symptoms don t meet the criteria for major depression. A number of other depressive conditions also exist. Among these is adjustment disorder with depressed mood, that occurs in response to psychosocial stressors such as new parenthood (APA, 2000). Antepartum Depression Currently, no DSM-IV-TR category specifically addresses antepartum depression. The symptoms of depression reported during pregnancy are similar to those seen in the nonpregnant population. Typical symptoms indicating major depression without psychotic features during the antepartum include depressed mood anxiety agitation irritability Nancy C. Lintner, MS, APRN-BC, is a program coordinator at Deaconess Hospital in Cincinnati, Ohio. Bobbe Ann Gray, PhD, RNC, is an assistant professor of nursing at Wright State University College of Nursing and Health in Dayton, Ohio. DOI: /j x Box 1. DSM-IV-TR Descriptions of Depression (APA, 2000) Major Depressive Episode Depressed mood or a loss of pleasure in nearly all normal activities for a period of at least two weeks, plus any of the four of the following symptoms that must be newly present and occurring almost daily for most of the day. Appetite or weight changes Sleep or activity changes Energy depletion Feelings of worthlessness or guilt Difficulty thinking, concentrating or making decisions Recurrent thoughts of suicide (also includes planning or actual attempts) Somatic complaints are common but not required for diagnosis. Symptoms must not be due to a general medical condition or drug induced. Result: Daily functioning (e.g., job, school, family life) requires excessive energy or is impaired. Duration: Untreated episodes typically last six months to two years. Major Depressive Disorders Without psychotic features: One or more major depressive episodes as defined above No history of manic or psychotic symptoms With psychotic features: One or more major depressive episodes as defined above Delusions and/or Hallucinations (typically auditory) Minor Depressive Disorder Depressive symptoms lasting at least two weeks Exhibit fewer symptoms, or symptoms to a lesser degree, than seen in major depressive disorders Adjustment disorder with depressed mood A response to a psychosocial stressor, either situational or developmental Symptoms are not a result of bereavement and must: Occur within three months of the stressor Resolve within six months of the termination of the stressor Either exceed those normally expected given the nature of the stressor Result in significant impairment of daily functioning 52 AWHONN Lifelines Volume 10 Issue 1

4 feelings of guilt diminished concentration feelings of sadness recurrent thoughts of death or suicide Physiological symptoms include significant changes in appetite, sleep patterns or energy level. Some of these symptoms can be confused with the normal physiological changes of pregnancy. A pregnant or a postpartum woman s loss of interest in pleasurable activities or marked impairment of daily functioning may be the significant indicator that she is presenting with symptoms of depression rather than normal responses to pregnancy. The reported incidence of depression during pregnancy ranges from 7.4 to 51 percent. The incidence varies with each trimester of pregnancy. Depression has been reported to be lowest during the first trimester and highest during the third trimester (Bennett, Einarson, Taddio, Koren, & Einarson, 2004b). African-American and Hispanic women and women who also report dealing with negative life events and/or decreased social support have been found to be particularly at risk for depression during pregnancy (Zayas, McKee, & Jankowski, 2002). Other risk factors associated with antepartum depression include a personal history of depression, the patient s perception of poor health and use of tobacco and alcohol (Marcus, Flynn, Blow, & Barry, 2003). Postpartum Depression Three terms are commonly used to describe depression during the postpartum period including postpartum blues, or the baby blues, postpartum depression (PPD) and postpartum psychosis. Postpartum blues don t meet the DSM-IV-TR criteria for a major depressive episode. Consequently, some authors list postpartum blues as an adjustment disorder with depressed mood or a minor depressive disorder. Postpartum blues are estimated to occur in 50 to 90 percent of childbearing women and are thought to be a response to the rapid changes in hormone levels and role transition demands occurring during the immediate postpartum. Symptoms include a rapid change in mood, episodic tearfulness, irritability, anxiety, feeling overwhelmed and problems with appetite and sleeping. These symptoms develop within a few days after childbirth, peak on the fourth to fifth day and may persist up to six weeks postpartum (International Childbirth Education Association [ICEA], 2003; Nonacs, 2002). Symptoms are transient and mild and don t interfere with the mother s functional capacity or with the care of the infant. The DSM-IV-TR lists PPD as a major depressive disorder of onset within four weeks of childbirth without psychotic features (APA, 2000). The World Health Organization (1992) extends this period to within six weeks after childbirth. Increasing evidence, however, suggests that PPD may manifest up through 12 months postpartum, with an increased incidence at weaning and return of menses. Diagnosis may be impeded as women may describe the symptoms of PPD in milder terms than those indicated in the DSM-IV-TR (Ugarriza, 2002). PPD may affect as many as 50 percent of women with a history of PPD and as many as 35 percent of women with a history of antepartum depression (Doskoch, 2001). Symptoms of PPD vary with culture and initially may resemble those of postpartum blues. However, the symptoms are not transient and tend to gradually worsen over time. In addition to the typical symptoms of a major depressive disorder, women experiencing PPD also may exhibit disinterest, anxiety, fear, anger or overconcern about the baby. In severe PPD, symptoms may escalate to thoughts of harming themselves, the baby or others (APA, 2000; Miller, 2002). Research suggests that the strongest predictor of PPD is antepartum depression. Numerous other significant predictors have been identified including (Beck, 1996, 2001) history of depression prior to pregnancy history of prenatal anxiety occurrence of postpartum blues low self-esteem a stressful life resulting in excessive demands lack of social support from family and friends a strained marital relationship the nature of the infant s temperament childcare stress Increased depressive symptoms during the midtrimester and obstetric complications also may influence PPD (Miller, 2002; Verdoux, Sutter, Glatigny-Dallay, & Minisini, 2002). Childbearing and Depression What Nurses Need to Know Depression during pregnancy and the postpartum period are major health problems; however, many women are not assessed for depression and many don t seek treatment for their symptoms. A loss of interest in pleasurable activities or marked impairment of daily functioning may be significant indicators that the pregnant woman is presenting with symptoms of depression. Postpartum blues tend to be transient in nature as opposed to postpartum depression, which tends to worsen over time. February March 2006 AWHONN Lifelines 53

5 Postpartum Psychosis Postpartum psychosis is a major depressive disorder of postpartum onset with psychotic features and is the most severe form of depression in the postpartum period. This is a rare but very serious condition developing in approximately 1 to 2 of every 1,000 childbearing women. Onset may be dramatic, beginning as early as 48 to 72 hours postpartum and most often appearing during the first two to six weeks following childbirth. In addition to the symptoms of a major depressive episode, women experience extremely disorganized thoughts, bizarre behavior, delusional beliefs and sensory hallucinations. These delusions and hallucinations can be destructive, with infanticide and suicide as the most serious consequences of postpartum psychosis. Women suffering from postpartum psychosis require antipsychotic medication and treatment on an inpatient basis to prevent harm to self and others. Risk factors for postpartum psychosis include previous episodes of postpartum psychosis (recurrence rate of 30 to 50 percent), a history of bipolar disease or obsessive-compulsive disorders, a family history of mood disorders and socioeconomic stressors during the antepartum period (APA, 2000; ICEA, 2003; Nonacs, 2002; Olds, London, Ladewig, & Davidson, 2004). Screening for Childbearing Depression The length of delay in obtaining appropriate treatment is the most important factor in the length of time PPD lingers. Researchers suggest that early identification of PPD may decrease long-term effects for both mothers and their families. All women may be at risk for developing depression during childbearing and should be assessed using validated screening methods. The Center for Epidemiological Studies-Depression Scale (CES-D), the Edinburgh Postnatal Depression Scale (EPDS), the Postpartum Depression Screening Scale (PDSS) and the Beck Depression Inventory Second Edition (BDI-II) are considered valid screening tools for childbearing depression, are easy to use and can be completed in approximately 5 to 10 minutes. The CES-D, EPDS and BDI-II are available in English and Spanish (see Box 2 for resources). The CES-D has become a standard for assessing depression. The scale consists of 20 items, with four responses ranging from rarely to most of the time, and measures depressive symptoms occurring during the past week (Radloff, 1977). The EPDS was originally developed to detect depression during the postpartum period. However, the EPDS is now commonly viewed as a valid screening tool to measure depressive symptoms both during pregnancy and the postpartum period. The EPDS consists of 10 brief statements, and the woman underscores one out of four possible responses that relates to her feelings over the last seven days (Cox, Holden, & Sagovsky, 1987). The PDSS consists of 35 items and assesses for dimensions of depression related to sleeping/eating disturbances, anxiety/ insecurity, emotional lability, loss of self, guilt/shame, cognitive impairment, contemplating harming oneself and thoughts of suicide (Beck & Gable, 2001). The BDI-II is a 21-item, multiple-choice screening tool that assesses for the presence of depression, as well as the severity of depression, and corresponds well with the DSM-IV-TR. This tool is clinically more sensitive than the original BDI (Beck, Steer, & Brown, 1996). Current Treatment Options Treatment for depression related to childbearing includes the use of both drug and nondrug interventions. Nondrug options may be more acceptable to women concerned with fetal or neonatal exposure to medication. Psychological interventions, such as individual, couples or group psychotherapy, are common nonpharmacological interventions. Cognitive behavioral therapy and interpersonal psychotherapy have been shown to be effective treatments for decreasing depressive symptoms and improving social relationships for women experiencing PPD. Intensive professional support during the postpartum period by nurses also has been shown to decrease depressive Box 2. Obtaining Depression Screening Tools CES-D: EPDS: or PDSS: request through custsvd@wpspublish.com BDI-II: 54 AWHONN Lifelines Volume 10 Issue 1

6 symptoms. While there is limited research available on the effect of other nondrug treatments targeted specifically at pregnancy-related depression, there is some support for the use of sunshine or light therapy, massage therapy, exercise, guided imagery and electroconvulsive therapy. However, no single nondrug alternative has been shown to be superior to others (Armstrong & Edwards, 2004; Dennis, 2004; Gjerdingen, 2003; O Hara, Stuart, Gorman, & Wenzel, 2000; Oren et al., 2002; Spinelli & Endicott, 2003). There is growing evidence that estrogen-replacement therapy during the postpartum period is of value in reducing symptoms of PPD. Ovarian hormones, including estrogen, readily cross the blood-brain barrier during pregnancy. Estrogen binds with specific estrogen receptors in the brain and appears to play a significant role in modulating several neurotransmitters including serotonin, norepinephrine and dopamine. These neurotransmitters are associated with regulation of mood and behavior. Studies indicate that some women are especially sensitive to the profound and sudden drop in estrogen levels after delivery that may result in neurotransmitter dysfunction and, subsequently, mood alteration (Ahokas, Kaukoranta, Wahlbeck, & Aito, 2001; Bloch et al., 2000). Drug therapy for childbearing depression, however, primarily focuses on antidepressants. All antidepressant medications cross the placenta and are found in breast milk to some degree. Recent findings suggest that prenatal exposure to antidepressants may be related to earlier delivery and associated lower Apgar scores. Both prenatal and postnatal exposure may be associated with at least transient neurobehavioral alternations in the newborn (Laine, Heikkinen, Ekblad, & Kero, 2003; Oberlander et al., 2005; Zeskind & Stephens, 2004). Examination of a variety of current pharmacology references reveals discrepancies in pregnancy risk categorization of antidepressant medications, however, sources vary. Both selective serotonin reuptake inhibitors (SSRI) and tricyclic antidepressants (TCA) have been suggested as the preferred pharmacological treatment of antepartum depression. SSRIs tend to be categorized as pregnancy risk B or C, indicating some animal risks have been seen but there is no evidence, or insufficient evidence, of risk for humans. TCAs are more often categorized as pregnancy risk C or D, indicating cautious use during pregnancy when the benefits outweigh the risks. Mononoamine oxidase inhibitors (MAOs) are not recommended during pregnancy as there is evidence that MAOs can elevate blood pressure and have an extensive list of drug and food interactions (American Academy of Pediatrics, 2000; Bennett, Einarson, Taddio, Koren, & Einarson, 2004a). Common SSRIs used during pregnancy include fluoxetine (Prozac), paroxetine (Paxil) and sertraline (Zoloft). Of these, fluoxetine has been most widely studied during human pregnancy and shown to be relatively safe and effective. Of the TCAs, nortriptyline (Aventyl) and desipramine (Norpramin) have been reported to have fewer side effects related to maternal sedation and gastrointestinal, cardiac and hypotensive disturbances. Women considering pharmacological interventions must understand the risks versus benefits in terms of fetal and newborn side effects. Nursing Implications Assessment recommendations for depression during childbearing include frequent, quick screening at multiple points during the antepartum and postpartum period. The British Columbia Reproductive Care Program, Reproductive Mental Health (BCRMH) recommends assessment at the initial prenatal visit and during the third trimester as well as during admission to the labor and delivery suite for a woman with a personal history of mental illness. Nurses must remember that there is some evidence to support that depression rates are quite high during the second trimester of pregnancy. Therefore, attentive nurses should assess for depression during the midtrimester as well. During the postpartum period, an assessment should be targeted during the first few postpartum days, then again at one to two weeks, six to eight weeks and four to six months postpartum (BCRMH, 2003). The U.S. Preventive Services Task Force (2002) suggests that the use of a two-question screening tool to identify depression may be as effective as using longer tools. The questions suggested are 1. During the past two weeks, have you felt down, depressed or hopeless? 2. During the past two weeks, have you felt little interest or pleasure in doing things? Box 3. Get the Facts Center for Postpartum Health: (818) or Depression After Delivery: (800) or National Woman s Health Information Center: (800) or postpartum.htm Pacific Postpartum Support Society: (604) or Postnatal Depression Support Association South Africa: (082) or Postpartum Education for Parents: (805) or Postpartum Stress Center: (610) or Postpartum Support International: (800) or February March 2006 AWHONN Lifelines 55

7 These two questions can be used during pregnancy and the postpartum to identify symptoms unrelated to pregnancy. A similar two-item tool (a) Are you often sad and depressed? and (b) Have you had a loss of pleasurable activities? has been shown to be sensitive and fairly specific for depression in the postpartum period (Jesse & Graham, 2005). If responses to the questions are affirmative, this suggests depression is likely and a more in-depth screening tool, such as the EPDS, can be initiated. Along with early identification of risk factors and screening, educational programs, such as parenting education, can give new parents knowledge and tools to realistically evaluate their parenting skills and provide them with strategies for stress reduction. Family education on childbearing depression can empower families with knowledge to identify possible symptoms and seek professional help quickly. Printed materials, in languages common to the local area, about symptoms of childbearing depression and methods to improve symptoms should be readily available at all prenatal visits, prepared childbirth classes, hospital discharge, the postpartum visit and well-baby checkups. When depression is identified, the goal of treatment is to provide early, culturally competent, family-centered and holistic care resulting in improvement of symptoms during pregnancy and the postpartum period. Nurses can assist to identify interventions that are acceptable within the family s cultural framework. Nursing interventions can include education about self-care activities such as maintaining a healthful diet, improvement of physical activity, increased rest, development of a support network and maintaining realistic parenting expectations. Other interventions suggested include educating families on how to decrease symptoms of depression through active participation in reading, prayer or meditation, guided imagery and listening to music. Nurses should make appropriate referrals to interdisciplinary team members equipped to provide pharmacological interventions, psychotherapy, family counseling, etc. In particular, women with severe symptoms of depression or postpartum psychosis, such as thoughts of suicide or a distorted sense of reality, must be immediately referred for psychiatric evaluation to prevent harm to self and others. Follow-up care can be arranged through telephone calls and home care nursing visits as well as referral to local or national self-help groups. (see Box 3 for more resources). Nurses, along with other health care professionals, serve a critical role in the early identification of depression, education, provision of information about local and national support groups and referral to psychiatric resources. By doing so, the incidence and/or duration of this major health threat may be decreased, protecting the health and wellness of women as well as their infants and significant others. References Ahokas, A., Kaukoranta, J., Wahlbeck, K., & Aito, M. (2001). Estrogen deficiency in severe postpartum depression: Successful treatment with sublingual physiologic 17ß-estradiol: A preliminary study. Journal of Clinical Psychiatry, 62(5), American Academy of Pediatrics (2000). Use of psychoactive medication during pregnancy and possible effects of the fetus and newborn (RE9866). American Academy of Pediatrics. Retrieved December 16, 2003, from American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, Text Revision (4th ed.). Washington, DC: American Psychiatric Association. Armstrong, K., & Edwards, H. (2004). The effectiveness of a pram-walking exercise programme in reducing depressive symptomatology for postnatal women. International Journal of Nursing Practice, 10(4), Beck, C. T. (1996). A meta-analysis of predictors of postpartum depression. Nursing Research, 45(5), Beck, C. T. (2001). Predictors of postpartum depression: An update. Nursing Research,50(5), Beck, C. T., & Gable, R. K. (2001). Further validation of the Postpartum Depression Screening Scale. Nursing Research, 50(3), Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory II. San Antonio, TX: Psychological Corporation. Bennett, H. A., Einarson, A. E., Taddio, A. T., Koren, G. K., & Einarson, T. R. (2004a). Depression during pregnancy: Overview of clinical factors. Clinical Drug Investigation, 24(3), Bennett, H. A., Einarson, A. E., Taddio, A. T., Koren, G. K., & Einarson, T. R. (2004b). Prevalence of depression during pregnancy: Systematic review. Obstetrics & Gynecology, 103(4), Bloch, M., Schmidt, P. J., Danaceau, M., Murphy, J., Nieman, L., & Rubinow, D. R. (2000). Effects of gonadal steroids in women with a history of postpartum depression. American Journal of Psychiatry, 157(6), British Columbia Reproductive Care Program. (2003). Reproductive mental health guideline 3: Identification and assessment of reproductive mental illness during the preconception and perinatal periods. Retrieved May 22, 2004, from percent2003 percent20 percent20new.jan2003/2003.pdf Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150(6), Dennis, C. L. (2004). Preventing postpartum depression part II: A critical review of nonbiological interventions. Canadian Journal of Psychiatry, 49(8), Doskoch, P. (2001). Which is more toxic to a fetus-antidepressants or maternal depression? NeuroPsychiatry Reviews, 2(5). Retrieved July 12, 2005, from npr_jun01_antidepressants.html 56 AWHONN Lifelines Volume 10 Issue 1

8 Gjerdingen, D. (2003). The effectiveness of various postpartum depression treatments and the impact of antidepressant drugs on nursing infants. The Journal of the American Board of Family Practice, 16(5), International Childbirth Education Association. (2003). ICEA position statement and review of postpartum emotional disorders. International Journal of Childbirth Education, 18(3), Jesse, D., & Graham, M. (2005). Are you often sad and depressed? Brief measures to identify women at risk for depression in pregnancy. MCN: The American Journal of Maternal/Child Nursing, 30(1), Laine, K., Heikkinen, T., Ekblad, U., & Kero, P. (2003). Effects of exposure to selective serotonin reuptake inhibitors during pregnancy on serotonergic symptoms in newborns and cord blood monoamine and prolactin concentrations. Archives of General Psychiatry, 60(7), Marcus, S. M., Flynn, H. A., Blow, F. C., & Barry, K. L. (2003). Depressive symptoms among pregnant women screened in obstetrics settings. Journal of Women s Health, 12(4), Miller, L. J. (2002). Postpartum depression. Journal of American Medical Association, 287(6), National Institute of Mental Health, (2004). Depression. National Institute of Mental Health. Retrieved May 1, 2004, from Nonacs, R. M. (2002). Postpartum depression. Emedicine. Retrieved June 7, 2004, from com/med/topic3408.htm Oberlander, T., Grunau, R., Fitzgerald, C., Papsdorf, M., Rurak, D., & Riggs, W. (2005). Pain reactivity in 2-month-old infants after prenatal and postnatal selective serotonin reuptake inhibitor medication exposure. Pediatrics, 115(2), O Hara, M. W., Stuart, S. Gorman, L. L., & Wenzel, A. (2000). Efficacy of interpersonal psychotherapy for postpartum depression. Archives of General Psychiatry, 57(11), Olds, S. B., London, M. L., Ladewig, P. A., & Davidson, M. R. (2004). Maternal-newborn nursing and women s health care. Upper Saddle River, NJ: Pearson Prentice Hall. Oren, D. A., Wisner, K. L., Spinelli, M., Epperson, C. N., Peindl, K. S., Terman, J. S., et al. (2002). An open trial of morning light therapy for treatment of antepartum depression. American Journal of Psychiatry, 159(4), Radloff, L. S. (1977). The CES-D scale: A self report depression scale for research in the general population. Applied Psychological Measurement, 1(6), Spinelli, M. G., & Endicott, J. (2003). Controlled clinical trial of interpersonal psychotherapy versus parenting education program for depressed pregnant women. American Journal of Psychiatry, 160(3), Ugarriza, D. N. (2002). Postpartum depressed women s explanation of depression. Journal of Nursing Scholarship, 34(3), U.S. Preventative Services Task Force. (2002). Screening for depression. Retrieved July 5, 2005, from ahrq.gov/clinic/uspstf/uspsdepr.htm Verdoux, H., Sutter, A. L., Glatigny-Dallay, E., & Minisini, A. (2002). Obstetrical complications and the development of postpartum depressive symptoms: A prospective survey of the MATQUID cohort. Acta Psychiatrica Scandinavica, 106(3), World Health Organization. (1992). The international statistical classification of diseases and related health problems (10th ed.). Geneva, Switzerland: Author. Zayas, L. H., McKee, M. D., & Jankowski, K. R. B. (2002). Depression and negative life events among pregnant African-American and Hispanic women. Women s Health Issues, 12(1), Zeskind, P., & Stephens, S. (2004). Maternal selective serotonin reuptake inhibitor use during pregnancy and newborn neurobehavior. Pediatrics, 113(2), February March 2006 AWHONN Lifelines 57

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