 "Rowena
had been admitted to the hospital because of serious
medical complications during her pregnancy... [W]hen
her mood began to decline dramatically, I was called
in to see her. But despite the fact that I had ample
opportunity to speak with her one-on-one for long periods
of time, I didn't see what was right before my eyes.
After she'd given birth and was medically stabilized,
Rowena attempted suicide."
This sad case is one of many recounted
in Pregnancy Blues, a new book by Vancouver reproductive
psychiatrist Dr Shaila Kulkarni Misri. The book sheds
light on a condition that's seriously underdiagnosed
and undertreated: antenatal depression.
PREGNANCY
BLUES
Dr Misri, founder of the Reproductive Mental Health
Program at St Paul's and BC Women's hospitals, was part
of the movement that made post-partum depression the
cause-célèbre it is today (along with
Brooke Shields' 2005 bestseller Down Came the Rain:
My Journey Through Postpartum Depression). Then
an odd thing happened. "Over the last 10-15 years I
realized our referrals were more for pregnant women
needing help," she says. A desire to prevent more cases
like Rowena's spurred Dr Misri to rethink how depressed
women should be treated while they're still pregnant.
"If Brooke Shields' next book is on pregnancy-related
depression then it will hit the newspapers as well!"
she said.
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Antenatal depression checklist
Questions to determine if
your pregnant patient is at risk for antenatal
depression. Ask her:
1) Is there a history of depression
or mood disorders in your family?
2) Do you have a prior history
of depression? Have you discontinued treatment?
3) Are you living in stressful
circumstances, such as an abusive relationship?
Do you have a history of infertility or miscarriage?
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ANTENATAL
FACTS & FIGURES
"We really don't know what causes antenatal depression,"
admits Dr Misri, "but it seems that in vulnerable women
the neurotransmitters that are responsible for keeping
your mood stable can go out of sync because of the hormonal
changes." (See Antenatal depression checklist, right,
for more on how to spot vulnerable patients.)
The rate of antenatal depression
is thought to be about 12%, but fewer than 25% of cases
are detected. When it comes to treatment, the rates
plummet further. A study in the July-August issue of
General Hospital Psychiatry screened 1,837 pregnant
women and found 16% to be at risk for depression —
17% of these were in the midst of a major depressive
episode (MDD). Disturbingly, just 20% of the overall
at-risk group, and 33% of the MDD group, were receiving
depression treatment of any kind.
So why are detection and treatment
rates so abysmally low? The reasons are multifarious,
says Dr Sheila Marcus, a University of Michigan psychiatrist
specializing in pregnancy-related depression and author
of the above study. "The symptoms are often confused
with common pregnancy symptoms like changes in eating
and sleeping patterns," she notes. Underreporting is
another hurdle. "If it's a wanted pregnancy, women can't
understand why they're feeling this way," says Dr Marcus.
"And if it's an unwanted pregnancy, there may be other
issues. For instance, they may worry if they say something
the baby will be removed from their care."
Dr Misri says physicians share
responsibility too. She applauds the fact that her colleagues
are so vigilant about screening for physical conditions,
but is disappointed they haven't made the leap to mental
health screening in their pregnant patients. "They should
be looking for early symptoms of depression, as they're
looking for high blood pressure, thyroid conditions
and blood sugar," she says.
Dr Marcus agrees. "Antenatal visits
are very quick — usually around 10 minutes —
and depression simply falls to the bottom of the list."
She adds that unfortunately, in the case of women with
a prior history of depression, communication between
the treating psychiatrist and the obstetrician doesn't
always happen. She says her clinic's EHR system has
helped enormously. "Physicians can see the psychiatric
files for all patients in the University of Michigan
system."
TREATING
THE BLUES
"At the present time, we're using antidepressants as
the main line of treatment for those who are suffering
from moderate to severe illness," says Dr Misri. Both
she and Dr Marcus note that, contrary to the public's
— and some physicians' — perception, most
SSRIs appear to be safe in pregnancy. (Paroxetine is
the one exception; it's recently been associated with
increased cardiovascular and hypertension risk.) Both
physicians say the relative risk of taking medication
must be weighed against the risk of a worsening depressive
episode. "Exposing a baby to untreated depression is
a risk, too," observes Dr Marcus.
Dr Marcus says the treatment approach
should always be individualized and chosen with the
patient. She recommends cognitive behavioural or interpersonal
therapy for mild to moderate depression. For more severe
cases, she suggests medication.
"There is no one better medication
compared to another, they all have the same effects,"
notes Dr Misri. "What is different is that if your patient
has responded to say sertraline before, then they should
take sertraline in pregnancy, because pregnancy is not
the time to experiment."
"ECT is also under-utilized and
may be very useful in pregnancy," adds Dr Marcus.
IN
THE SPOTLIGHT
In the meantime, Dr Misri hopes to raise the profile
of antenatal depression as she did with post-partum
before (incidentally, the two conditions are frequently
linked, and "Antenatal always continues into post-partum,
it never stops when baby's born.") "Post-partum depression
is better-known because people like myself have written
books and raised awareness," says Dr Misri.
Sadly, there are very few Canadian
specialists in reproductive psychiatry — there
are seven in Dr Misri's program, and to her knowledge
it's the only such program in the country. "One day,
before I retire, I hope to put into place some sort
of screening to help doctors screen for antenatal depression.
That is my wish."
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