When initial screening suggests the possibility of depression, additional questions need to be asked to gain a more complete picture of the woman’s status. The following areas have been suggested for inclusion in a more thorough assessment:21
- History of depressive episodes, including postpartum episodes
- History of premenstrual dysphoric symptoms
- Family history of depression, including PPD
- Current and past stressors
- Inventory of available social supports, particularly those in a position to offer practical assistance with the care of a newborn
- The patient’s attitudes toward pregnancy and its ensuing role changes, including her expectations of herself as a mother.
Also ask about possible substance use; the onset, frequency, duration and severity of depressive symptoms; and suicide. Following completion of such an assessment, the PCP can meet with the patient to discuss results and options to help decrease depression risk or to initiate treatment.
Prevention and treatment
PCPs are well positioned to help women at risk for PPD by helping to gain access to therapeutic services and mobilizing support and monitoring progress. Since history of depression and depression during pregnancy are both significant risk factors for PPD, assessing perinatal women for these possibilities is essential.22
Once a determination is made that a woman is either depressed or at risk for depression, the PCP is in an excellent position to talk with the patient and her partner about her options, which include psychotherapy, antidepressant medication and exercise.
Compelling evidence in support of the value of early detection and treatment of depression in perinatal women is provided by a longitudinal study of a community sample of 649 pregnant women who were screened with the EPDS, referred for treatment with antidepressant medication or psychotherapy, and followed into the postpartum period.23
Psychotherapy was the preferred treatment during pregnancy, while medication was preferred in the postpartum period. The average EPDS score decreased over the course of the pregnancy into the postpartum period, more so for treated than for untreated study participants.
Psychotherapy. Psychotherapy has been found to be helpful in the treatment of depression in both pregnant and postpartum women.21 When initiated during pregnancy, psychotherapy has also been found to be effective in preventing depression during the postpartum period.22 These findings underscore the important role of the PCP in identifying women in need of referral for psychotherapy, which is the first line of treatment for mildly to moderately depressed perinatal women.24
The two types of psychotherapy that have received the most empirical support in the treatment of depression in pregnant and postpartum women are cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT).2 IPT was found to be superior to CBT, and individual therapy was found to be superior to group therapy.25 While CBT focuses more on the thoughts of the patient, IPT helps the patient to address such interpersonal issues as lack of support and role change, both of which have been identified as significant stressors in the lives of many perinatal women.26
Antidepressant medication. The decision to take antidepressant medication can be difficult for a pregnant woman or lactating mother because of her concerns about potential harm to the baby. The American Psychiatric Association and the American College of Obstetricians and Gynecologists jointly published guidelines on the management of depression during pregnancy in 2009.27 Hopefully, these guidelines will further sensitize practitioners to the possibility of depression during pregnancy and postnatally and provide guidance in helping patients make important decisions about their care.
Again, psychotherapy is the first line of treatment that should be recommended for mild to moderate depression.24 The joint guidelines recommend the initiation or continuation of antidepressant medication if a pregnant woman has a history of, or is currently experiencing, moderate to severe depression.27
According to the guidelines, potential risks of taking a selective serotonin reuptake inhibitor (SSRI) during pregnancy include small-for-gestational-age infants and preterm delivery. While antidepressants overall were not reported to be associated with birth defects, the FDA has labeled the SSRI paroxetine (Paxil, Pexeva) a cause of septal heart defects in infants.24
For a lactating mother, the main concern is passing on the antidepressant drug to her nursing infant. Research in this area suggests that the amount of drug carried in breast milk is small but variable across all women and for the same woman at different times. No significant risks have been found for healthy full-term infants, but data are lacking for preterm infants.1
Various antidepressant medications have been found to be effective in the treatment of PPD, including paroxetine, fluoxetine (Prozac, Rapiflux, Sarafem, Selfemra), sertraline (Zoloft), and nortriptyline (Aventyl, Pamelor) when given alone and in combination with psychotherapy.4
Exercise. Many women, especially those who are pregnant and postpartum, fear ingesting antidepressants28 or enduring therapy because they are unsure of the effects. There should be no such fear regarding exercise. Women who have the opportunity to be active regularly take up exercise postpartum,29 so these women may be unconsciously assuaging and dissuading their risk of PPD.
Exercise antepartum, during pregnancy, and postpartum has, on several occasions, been associated with a lessening of depressive symptoms and an increase in sense of well-being.30,31 This is especially true when women with PPD take part in exercise either alone or with a group of fellow PPD sufferers.29
Not everyone enjoys the same type or frequency of physical activity, but women with PPD who endure aerobic walking have an advantage. Compared with those who did not exercise or who did gentle stretching, aerobic walking PPD sufferers noted a more intense reduction of depressive symptoms and feelings.29
Not only does exercise provide some immediate relief from depression associated with the postpartum period, but respite from symptoms can be long lasting. Women who exercise regularly postpartum could cut their risk of developing PPD,32 especially if the exercise begins antepartum and continues during pregnancy.33 The results can be seen after as little as one month.31
Whether alone or in conjunction with antidepressant therapy and psychotherapy, exercise can yield remarkable and ongoing effects during the postpartum time. PCPs are advised to educate themselves and their patients on the advantages of exercising antepartum, during pregnancy and postpartum, especially if the women suffer from PPD or have depressive symptoms and feelings.
Left untreated, PPD can have significant negative consequences for mother and child. Implementing effective, well-coordinated procedures in the primary-care setting to identify at-risk women and to provide effective prevention and treatment strategies is essential. PCPs are well positioned to facilitate delivery of needed services, monitor progress, and provide support during pregnancy and beyond.
James P. Morgan, PhD, is Associate Professor of Psychology & Counseling, Gardner-Webb University, Boiling Springs, N.C., where Savanna R. Yount is a graduate. The authors thank June Hobbs, Gregory Davenport, David Carscaddon, Millie Lineberry, and Denise McKee for their support and assistance in the preparation of this manuscript.
- Yonkers KA, Vigod S, Ross LE. Diagnosis, pathophysiology, and management of mood disorders in pregnant and postpartum women. Obstet Gynecol. 2011;117:961-977.
- O’Hara MW. Postpartum depression: what we know. J Clin Psychol. 2009;65:1258-1269.
- Lusskin SI, Pundiak TM, Habib SM. Perinatal depression: hiding in plain sight. Can J Psychiat. 2007;52:479-488.
- Pearlstein T, Howard M, Salisbury A, Zlotnick C. Postpartum depression. Am J Obstet Gynecol. 2009;200:357-364.
- Doucet S, Jones I, Letourneau N, et al. Interventions for the prevention and treatment of postpartum psychosis: a systematic review. Arch Womens Ment Health. 2011;14:89-98.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. American Psychiatric Association: Washington, D.C.; 2000.
- Figueiredo B, Conde A. Anxiety and depression symptoms in women and men from early pregnancy to 3-months postpartum: parity differences and effects. J Affect Disord. 2011;132:146-157.
- Gress-Smith JL, Luecken LJ, Lemery-Chalfant K, Howe R. Postpartum depression prevalence and impact on infant health, weight, and sleep in low-income and ethnic minority women and infants. Matern Child Health J. 2012;16:887-893.
- Grace SL, Evindar A, Stewart DE. The effect of postpartum depression on child cognitive development and behavior: a review and critical analysis of the literature. Arch Womens Ment Health. 2003;6:263-274.
- Halligan SL, Murray L, Martins C, Cooper PJ. Maternal depression and psychiatric outcomes in adolescent offspring: a 13-year longitudinal study. J Affect Disord. 2007;97:145-154.
- Friedman SH. Postpartum mood disorders: genetic progress and treatment paradigms. Am J Psychiatry. 2009;166:1201-1204.
- Yim IS, Glynn LM, Schetter CD, et al. Prenatal beta-endorphin as an early predictor of postpartum depressive symptoms in euthymic women. J Affect Disord. 2010;125:128-133.
- Aubuchon-Endsley NL, Thomas DG, Kennedy TS, et al. Interactive relations among maternal depressive symptomatology, nutrition, and parenting. Women Health. 2012;52:197-213.
- Wachs TD. Models linking nutritional deficiencies to maternal and child mental health. Am J Clin Nutr. 2009;89:935S-939S.
- Baker CD, Kamke H, O’Hara MW, Stuart S. Web-based training for implementing evidence-based management of postpartum depression. J Am Board Fam Med. 2009;22:588-589.
- Wisner KL, Logsdon MC, Shanahan BR. Web-based education for postpartum depression: conceptual development and impact. Arch Womens Ment Health. 2008;11:377-385.
- Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782-786.
- Gibson J, McKenzie-McHarg K, Shakespeare J, et al. A systematic review of studies validating the Edinburgh Postnatal Depression Scale in antepartum and postpartum women. Acta Psychiatr Scand. 2009;119:350-364.
- Sharp LK, Lipsky MS. Screening for depression across the lifespan: a review of measures for use in primary care settings. Am Fam Physician. 2002;66:1001-1008.
- Mann R, Adamson J, Gilbody SM. Diagnostic accuracy of case-finding questions to identify perinatal depression. CMAJ. 2012;184:E424-430.
- Miller LJ, LaRusso EM. Preventing postpartum depression. Psychiatr Clin North Am. 2011;34:53-65.
- Clatworthy J. The effectiveness of antenatal interventions to prevent postnatal depression in high-risk women. J Affect Disord. 2012;137:25-34.
- Bowen A, Bowen R, Butt P, et al. Patterns of depression and treatment in pregnant and postpartum women. Can J Psychiatry. 2012;57:161-167.
- Kim DR, O’Reardon JP, Epperson CN. Guidelines for the management of depression during pregnancy. Curr Psychiatry Rep. 2010;12:279-281.
- Sockol LE, Epperson CN, Barber JP. A meta-analysis of treatments for perinatal depression. Clin Psychol Rev. 2011;31:839-849.
- Gauthier L, Guay F, Senécal C, Pierce T. Women’s depressive symptoms during the transition to motherhood: the role of competence, relatedness, and autonomy. J Health Psychol. 2010;15:1145-1156.
- Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Gen Hosp Psychiatry. 2009;31:403-413.
- Lewis BA, Kennedy BF. Effects of exercise on depression during pregnancy and postpartum: a review. Am J Lifestyle Med. 2011:5:370-378.
- Daley A, Jolly K, MacArthur C. The effectiveness of exercise in the management of post-natal depression: systematic review and meta-analysis. Fam Pract. 2009;26:154-162.
- Armstrong K, Edwards H. The effectiveness of a pram-walking exercise programme in reducing depressive symptomatology for postnatal women. Int J Nurs Pract. 2004;10:177-194.
- Da Costa D, Lowensteyn I, Abrahamowicz M, et al. A randomized clinical trial of exercise to alleviate postpartum depressed mood. J Psychosom Obstet Gynaecol. 2009;30:191-200.
- Sydsjö G, Sydsjö A, Gunnervik C, et al. Obstetric outcome for women who received individualized treatment for fear of childbirth during pregnancy. Acta Obstet Gynecol Scand. 2012;91:44-49.
- Ersek JL, Brunner Huber LR. Physical activity prior to and during pregnancy and risk of postpartum depressive symptoms. J Obstet Gynecol Neonatal Nurs. 2009;38:556-566.
All electronic documents accessed November 15, 2012.