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Monday, November 01, 2010
Developing Depression
By Amanda Schoenberg
Journal Staff Writer
After a pilot project showed that 23 percent of pregnant women had symptoms of depression, a New Mexico group is urging doctors to screen for depression.
While postpartum depression is more widely recognized, depression can occur at any point from conception to delivery.
"The word is sort of out there about postpartum depression," says Stefanie Luna, a marriage and family therapist who runs Wallin & Luna Counseling Associates with therapist Kristin Wallin. "But being pregnant does not necessarily protect a woman from becoming depressed."
Nationwide, 10 percent to 16 percent of women meet criteria for depression when pregnant and about 70 percent show some symptoms, according to a report by the American College of Obstetricians and Gynecology. One third of pregnant women take some kind of psychotropic medication while pregnant.
Ignoring the problem is not the answer. Untreated depression can increase the risk of premature birth and low birth weight. When women are depressed, they are less likely to care for themselves and more likely to smoke and drink, says Dr. Steven Jenkusky, medical director for behavioral health at Presbyterian Medical Group. Women with untreated depression may have trouble bonding with or caring for a baby.
In April, a 10-week pilot project funded by the New Mexico Human Services Department screened pregnant women who had prenatal care at Women, Infants and Children clinics in Santa Fe and Las Vegas.
Twenty-three percent, or 109 of the 467 clients, scored high enough on the Edinburgh Postnatal Depression Scale to require a referral, says Carol Tyrrell, maternal child health section manager for the state Department of Health and a member of the Maternal Depression Workgroup, which organized the project.
"We concluded that screening should be done as routine prenatal and postnatal care," Tyrrell says.
The work group, which includes doctors, nurses, epidemiologists, midwives and staff from the New Mexico Health Department and the Human Services Department, also wants to see more training on depression screening tools for providers and more support groups for women in English and Spanish.
Screening patients
While not all obstetricians screen for depression, the American College of Obstetricians and Gynecologists said in July that screening should be "strongly considered" although there is not enough evidence to recommend it for all pregnant woman.
"I don't think we do a good enough job at screening for depression," says Dr. Paul Shelburne, an obstetrician and gynecologist with the women's health department at ABQ Health Partners. "I bet we miss a lot."
More primary care doctors should consider screening because depression is so common, says Jenkusky. About 10 percent of men and 20 percent of women will experience depression at some point in their lives.
In his practice, Shelburne doesn't do formal screenings but does ask patients about mental health, such as whether they sleep well or feel motivated. Screening is difficult because many women chalk up symptoms of depression to hormones or other pregnancy problems.
Discomfort and tiredness are normal. Depression is different, he says.
"It's not like you're just exhausted," Shelburne says. "It's like, 'I just don't care. I can't get motivated.'"
Many pregnant women are ashamed when they don't feel what they think they should.
"They want to be really happy and they just don't feel it," says Wallin. "They're often very confused. It's a pretty tough situation for a woman to be in."
Others factors contribute to depression, including poverty, unwanted pregnancy or a history of miscarriage or abortion, says Luna.
Depression also spikes during major life changes.
"Having a baby is a very exciting thing, but it's also a big life change," she says.
Red flags include anxiety, dreading pregnancy, isolation from loved ones, self-harm and suicidal thoughts, says Luna. Other signs include consistent sadness, lack of ability to experience pleasure and changes in appetite or sleep, says Jenkusky.
Lack of support is also a warning sign for depression.
"Anyone who is pregnant and doesn't have a good support system in place is at risk of being depressed," says Luna.
When Wallin and Luna treat pregnant women they also act as case managers who refer women to resources such as support groups.
Depressed patients often come to see him with concerned friends or family members, Shelburne says. He encourages family and friends to address concerns with statements like, "I'm really worried about you. You seem depressed, you don't seem like yourself."
The good news, Shelburne says, is that people are more willing to discuss depression.
"Depression is no longer where it was 15 or 20 years ago, when it was something that people were ashamed of," he says. "Now people are more willing to talk about it. Physicians and providers are more comfortable saying, 'Look, this is a chemical imbalance, we can help you get through this.'"
Medication risks
Weighing the risks and benefits of anti-depressants during pregnancy can be difficult.
For women who have mild to moderate depression, Jenkusky recommends interpersonal psychotherapy or cognitive behavioral therapy. Support groups also help. For severe depression, medication may be necessary.
Ideally, conversations about medication should happen as soon as possible when a woman becomes pregnant. If a woman is already on anti-depressants she should speak with her doctor when she wants to have a child, he says.
"There are anti-depressants that have been shown to be very safe during pregnancy and some that have not," he says. "It is important to discuss it with your doctor."
Prozac, Zoloft and Wellbutrin appear to be the safest, he says.
Women who take anti-depressants shouldn't stop taking them abruptly if they are pregnant, Jenkusky says. If they do, they can experience withdrawal and put themselves at risk for recurrence of depression. It can take time for new medication to work, he says.
Many people experience mild withdrawal when they stop taking anti-depressants, he says. Babies may have similar symptoms, like difficulty sleeping, jitteriness, muscle weakness and mild respiratory distress. Studies haven't shown long-term negative effects, he says.
There is no medication that won't cross into the placenta, says Wallin. But an unmedicated mother struggling with depression may also impact the fetus.
"It all becomes a benefit to risk ratio," says Luna. "We don't want a woman limping along through her pregnancy and then being unable to care for her baby."
Resources
• Postpartum Support International offers a telephone line for pregnant or postnatal women who are depressed. Call 1-800-944-4PPD or see www.postpartum.net. In Albuquerque, women can call PSI volunteers Stefanie Luna and Kristin Wallin at 821-5894.
• The University of New Mexico Midwifery Division has had a postpartum support group for parents for two years. They are planning a new group for 2011 on maternal depression using peer support and yoga. Call 272-6387 for information.
• New parents' support group meets in Auditorium B of Lovelace Women's Hospital at 4701 Montgomery NE from 10 a.m.-11:30 a.m. every Wednesday. For information, call 727-6085. Topics include postpartum depression, stress management and growth and development.
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