Prenatal depression: Early intervention Abstract: Frequently undiagnosed and untreated, prenatal depression affects approximately one in four childbearing women. Screening and appropriate management is essential to prevent adverse consequences to both the woman and her unborn infant. Early conversations between the woman and her nurse practitioner are essential to making medical management decisions.
epression is the fourth leading cause of worldwide disease burden, accounting for almost 12% of all total years lived with a disability. Depression is the leading cause of disability among 18- to 44-year-olds in the United States, affecting about 14.8 million adults (or about 6.7% of the U.S. population).1 Women are particularly susceptible to depression with a lifetime prevalence of 25%. While the onset of depression occurs most often during the midtwenties, 8.2% of adolescents exhibit depression symptoms. During adolescence, girls begin to show a 2:1 ratio of depression over boys.2 Although the variability by gender is not specifically understood, this difference is possibly related
D
to the hormonal changes that occur as girls enter puberty.2 Only a small percentage of individuals seek pharmacotherapy (36.1%) or psychotherapy (16.7%) following a positive depression screen.3 Yet, even when treated, depression often reoccurs at rates of 50% to 60% after one episode and 80% after two episodes.4 Approximately one-third of adolescents will remain depressed following treatment.5 Diagnostic features of depression include a sad, empty, or irritable mood and/or a loss of pleasure or interest in life, with somatic and cognitive changes that significantly affect the individual’s capacity to function. According to the Diagnostic and Statistical Manual of Mental Disorders,
Keywords: childbearing women, depression, management of prenatal depression, pregnancy
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By Cheryl A. Anderson, PhD, RN, CNS and Carol Lieser, PhD, RN, OFS,PMHNP-BC
Prenatal depression: Early intervention
5th edition (DSM-5), criteria for diagnosis of a major depressive disorder include: loss of pleasure, sad mood, alterations in sleep, appetite, or weight, poor concentration, psychomotor changes, low energy, feelings of guilt, and thoughts of suicide.6 The specifier “with peripartum onset” within childbearing populations can be applied to the diagnosis of major depressive disorder if the onset of symptoms occurs during pregnancy or within 4 weeks of delivery.6 Depression rates among pregnant women, especially those with low socioeconomic status, have been reported from 5% to over 50%.7-9 ■ Prenatal depression Ms. C, a Hispanic 17-year-old, arrives at the clinic for her first prenatal visit at 34-weeks pregnant. This unplanned pregnancy is her second baby. The father of the baby is 17, abusive, and uninvolved. The nurse practitioner (NP) notices bruising and burns on both arms. With gentle prodding and a nonjudgmental attitude, Ms. C begins to cautiously speak with the NP. She reports a poor appetite, little weight gain, feeling overwhelmed, crying most days, and feeling guilty because of the “mess” she has gotten into when “money is so tight.” Her mother currently works two jobs and blames Ms. C for the current situation. Between tears, she quietly states that she feels hopeless, that there is no money for two babies, and that she does not want this baby. The NP notices limited disclosure of abuse in the conversation, little face-to-face interaction, apparent sadness, and a flat, dull affect. A later review of her medical record indicates a previous suicide attempt at the age of 15. The NP provides educational pamphlets and community resources on partner violence, dietary information with education on weight gain during pregnancy, materials for women, infants, and children, and encouragement to continue prenatal care until her delivery. It is important to note that each state has different legal requirements for reporting and documenting partner violence. Continued conversation related to the recurring depression, past suicide attempt, and the patient’s feelings about the baby prompts the NP to consult the hospital social worker who contacts Ms. C. Ongoing discussion with Ms. C allows for joint decisions for her individual management plan during pregnancy and after birth. Despite being a frequently found medical disorder among pregnant women, major depression remains undetected and undertreated in prenatal care.10 Understanding the prevalence and associated risk factors can potentially improve both diagnosis and treatment rates of severe depressive disorders among pregnant women.11 A meta-analysis of 24 studies conducted by Gavin and colleagues revealed an overall prevalence of prenatal depression (PND) to be 18.4% with 12.7% of women experiencing www.tnpj.com
an episode of major depression.12 Nearly one in six women were found to experience a new episode of major depression while pregnant.12 A separate, large prospective study (N = 1,888), however, found lower rates for both major depression (5.1%) and minor depression (4.8%).11 Rate variations seen in the literature for PND may be due to timing of assessments across different trimesters and type/variety of assessment tools. A meta-analysis of 28 studies revealed rates of diagnosed PND vary by trimester: 11% in the 1st trimester, 8.5% in the 2nd trimester, and 8.5% in the 3rd trimester.12 Bennett and colleagues reported an opposite finding with prevalence rates to be lowest during the first trimester at 7.4% as compared with 12.8% and 12.0% for the second and third trimesters.7 Two additional studies, one using a diagnostic tool for assessment and the other study administering a commonly used screening tool, supported higher rates (33%) among women experiencing PND in the third trimester.13,14 Research supports potential variation in PND across trimesters and provides plentiful information suggesting both risk and protective factors that may either trigger or buffer against PND. ■ Risk factors Risk factors including life stressors, lack of social support, unintended pregnancy, a less positive view of the pregnancy, young age, greater number of children, smoking, single status, history of depression, domestic violence, substance abuse, lower income, lower education, and poor relationships have been shown to increase the risk of PND.8,10,15 Ms. C’s situation is not that uncommon to the NP. The case history illustrates several risk factors particularly evident with depressed adolescents. As it relates to age, childbearing adolescents have been found to have higher rates of both prenatal and postpartum depression than adult women.16,17 Depression among adolescents is associated with significant impairment in functioning and an increased risk of developing major depressive episodes and other psychiatric disorders in the future.5 However, lacking recognition of depressive symptoms, the first entry into the healthcare system may be prompted by a pregnancy. Current signs of depression, a past history of a suicide attempt, and suspected physical (and emotional) abuse increase the likelihood of major depression and cause heightened vigilance in providing care to Ms. C and her unborn infant. Suicide ideation or suicide attempt with depression symptoms has been found to result in poor infant outcomes. Infants of depressed adolescents with suicide ideation or attempt weighed almost 240 g (8.5 oz) less than infants of depressed adolescents without suicide ideation or attempt.18 A history of depression prior to pregnancy (individual or familial history) is a major predictor of current PND.19 This The Nurse Practitioner • July 2015 39
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Prenatal depression: Early intervention
ology directing the mother’s cortisol levels. Postpartum depression perhaps leads to increased fetal cortisol levels due to the environmental stress of the mother’s depression. Both types of exposure lead to an increased vulnerability to personal psychopathology, perhaps, linked to higher cortisol levels, which continue through adolescence. Yet studies have shown that maternal psychotropic medication use during pregnancy and continued in the postpartum period can reduce maternal depression, lower HPA axis cortisol, and offset the infant’s cortisol levels. Infants, however, whose mothers were depressed during pregnancy and postpartum and who received no psychotropic medications had As depression and stress often occur together, the highest levels of cortisol. The use of depression has also been found to be antidepressants during these times both associated with cortisol levels. reduced the mothers’ cortisol levels and normalized the early caregiving environment, often allowing infant cortisol 27,28 levels to be normal. to increase the odds of experiencing PND by fivefold among minority adolescents.8 A history of abuse has been shown Depression can result in serious consequences for pregto be a more significant factor for severe depression than nant women, with loss of productivity, ensuing family and the history of alcohol use, history of drug use, or history of relationship difficulties, poor physical health, and increased depression.21 risk for suicide.29 Maternal suicide is one of the leading causes of maternal mortality in the perinatal period and Ethnic-racial backgrounds have been shown to be asaccounts for up to 20% of all postpartum deaths.30 Addisociated with PND, but research findings reveal variations 11,22-25 among Asian, Black, and Hispanic women. tional complications associated with PND can include preThe eclampsia, gestational bleeding, increased uterine artery potential influence of acculturation on PND is of addiresistance, increased cesarean births, and increased epitional interest; however, research examining the influence dural use. Adverse birth outcomes may include preterm of acculturation is sparse and inconsistent.23,26 birth, small for gestational age infants, low APGAR scores, Specific protective factors may also be in place to prevent admission to neonatal ICUs, and effects on brain developPND. Strong social support and resources, desirability of ment with altered gene expression and altered immune pregnancy, marital satisfaction, and personality factors, function in the infant, spontaneous abortion, and fetal including the ability to cope with challenges and stress, may death.8,24,31,32 One study evaluated infants with colic and help mitigate the effects of depressive symptoms.14 found a greater percentage of the colicky infants had mothers who were depressed. Furthermore, the risk of infantile ■ Consequences of PND colic increased threefold in mothers who were depressed in Any woman is potentially vulnerable to complications of pregcomparison to mothers who were not.33 Depressed mothers nancy associated with depression, stress, substance use, and/ or partner violence. However, childbearing women of diverse are often more harsh in the care of their infants and exhibit ethnicities are more frequently confronted with a constellation lower rates of infant safety practices, such as poor use of car of issues that can engender stress and potentially affect materseats and safety latches.34 These mothers also may exhibit 15 nal and infant outcomes. Researchers have hypothesized that less healthy child development activities, such as reading, singing, and playing games with their children.35 PND affects the fetus through biochemical channels secondary to stress. As stress increases, the maternal cortisol level elevates leading to poor uterine perfusion, and therefore, slowed fetal ■ Assessment growth rate and increased preterm births.19 Initial assessments must recognize co-occurring mental health disorders. NPs focusing on depression must rule As depression and stress often occur together, depression out the potential for bipolar disorder due to differences in has also been found to be associated with cortisol levels. management and the possibility of provoking mania with Infants who are exposed to maternal perinatal depresthe treatment of unipolar depression. The diagnosis of sion potentially become genetically linked to elevated generalized anxiety disorder must also be considered and hypothalamus-pituitary axis (HPA) cortisol through physicycle of depression, which frequently presents prior to a pregnancy and continues throughout pregnancy into postpartum, is of concern to the NP because of management issues for potential maternal, fetal, and infant consequences. Dietz and colleagues conducted a unique study of women between 39 weeks before pregnancy through 39 weeks postpartum and found that approximately one in seven women were identified and treated for depression during this time period.20 The experience of trauma heightens the vulnerability for depression. Physical and/or sexual abuse has been found
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Prenatal depression: Early intervention
commonly co-occurs with depression in pregnant women.11,36 Additional assessments of posttraumatic stress disorder, panic disorder, evidence of trauma and abuse, alcohol and other substance abuse, and presence of multiple psychosocial stressors are also essential. In Ms. C’s case, initial screenings for abuse, trauma symptoms, anxiety, and depression are needed. The easily administered, Abuse Assessment Screen is simple, quick, and effective in determining abuse in a relationship.37 A verbal inquiry assessing a history of abuse, as well as perceived trauma from a past childbirth, may provide important information for Ms. C. Both partner violence and birth trauma can generate symptoms of posttraumatic stress or posttraumatic stress disorder. The use of The Short Post-Traumatic Stress Disorder (PTSD) Rating Interview for core symptoms of PTSD (intrusion, avoidance, numbing, arousal, somatic malaise, stress vulnerability, role, or social function impairment) helps the provider identify these symptoms. Role/ social functional impairment can be helpful.38 The Generalized Anxiety Disorder-7 (GAD-7) is appropriate for identifying co-occurring generalized anxiety, which includes excessive worry and anxiety markers; the GAD-7 can be an appropriate and useful assessment tool.39 The Panic Disorder Severity Scale assessing for abrupt surges of intense fear may also be warranted.40 A comprehensive assessment for the specific disorder using DSM-5 diagnostic criteria would follow with positive findings. Assessing PND may be challenging because it may be difficult to differentiate depression symptoms from pregnancy-related problems. A review of research shows that only 20% of depressed pregnant women are identified.41 Some providers may incorrectly attribute depression symptoms to the pregnancy, while others may over diagnose depression, relating the common somatic symptoms, such as poor sleep, fatigue, emotional swings, and concentration issues of pregnancy to depression.42 Despite potential difficulties, all pregnant women should be screened for depression, and the choice of screening tools is important. Some screening tools may tend to yield increased false positives. The Beck Depression Inventory (BDI), which is widely used, includes many somatic symptoms common to pregnancy and may mislead the provider.43,44 Using the Edinburgh Postnatal Depression Scale (EPDS), which is designed to differentiate common pre- and postpartum complaints from symptoms of depression, may provide a more accurate assessment in this population.41,45-47 More medical settings are beginning to mandate or highly encourage all healthcare providers to screen for prenatal and postpartum depression; therefore, NPs must be knowledgeable of available screening tools and resources (see Depression resources). www.tnpj.com
Depression resources Web-based resources Exposure to psychotropic medications and other substances during pregnancy and lactation: A handbook for healthcare providers (knowledgex.camh.net/primary_care/guidelines_ materials/Pregnancy_Lactation/Documents/ psychmed_preg_lact.pdf) U.S. Department of Health and Human Services. Health Resources and Service Administration. Maternal and Child Health. Depression During and After Pregnancy: A Resource for Women, Their Families, and Friends (http://mchb.hrsa.gov/ pregnancyandbeyond/depression/index.html) Motherrisk is a program created by The Hospital for Sick children in Toronto, Canada. The website provides updated research and answers to questions about toxins and other environmental risks to the unborn child. This site is a resource for professionals as well as families. (www.motherrisk.org) Substance Abuse and Mental Health Services Administration National Mental Health Information Center. Phone: 800-789-2647 For information on depression, including a locator to find a mental health center in the patient’s area National resources American Congress of Obstetricians and Gynecologists Phone: 800-762-2264 Resources for both patients and healthcare providers Office of Women’s Health, U.S. Department of Health and Human Services Phone: 800-994-WOMAN (800-994-9662) Frequently asked questions about depression and pregnancy (https://www.womenshealth.gov/index.html) Book Bennett S, Indman P. Beyond the blues: Understanding and treating prenatal and postpartum depression and anxiety. San Jose, CA: Moodswings Press; 2010. ISBN: 978-0971712454. (Recommended by U.S. Department of Health and Human Services).
It is essential to follow up with diagnostic testing if the childbearing woman screens positive for depression. Trained professionals can use the criteria in the DSM-5 or administer a diagnostic, such as the Structured Clinical Interview for DSM Disorders (SCID). Diagnostic screening for younger childbearing adolescents may be performed via the Kiddie-Schedule for Affective Disorders and SchizophreniaPresent and Lifetime version (K-SADS-PL).5 ■ Management of perinatal depression Fifty percent of postpartum major depressive episodes occur prior to birth according to the DSM-5.6 The frequency of depression among childbearing women mandates an The Nurse Practitioner • July 2015 41
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Prenatal depression: Early intervention
effective management plan. Attention must be given to the issues occurring if no treatment is provided, if treatment overlaps a pregnancy, and if prepregnant management of depression is halted. Providers who care for childbearing women must assume the potential for pregnancy. The use of birth control for female adolescents may be hindered by depression.48 Nearly 50% of all pregnancies are unplanned, and prenatal care and management of existing depression may begin late into the pregnancy.49 The provider can optimize perinatal health with instructions on good nutrition, vitamin intake, adequate sleep and exercise, and assessment of abuse, trauma, and substance use. Suggestions could be made for household help and childcare assistance. A listing of community support groups should be provided as appropriate. Ideally, preconceptual counseling would occur taking the management of many health concerns into consideration, including depression. Early use of folic acid is standard practice for pregnant women and is essential for fetal growth and development.50,51 However, study findings indicate that use of citalopram by women during pregnancy was associated with neural tube defects.52 Additionally, medication changes may need to occur prior to a pregnancy if the woman is receiving pharmacotherapy for depression. The American Congress of Obstetricians and Gynecologists suggests women on medications, with mild or no symptoms for 6 months or longer, may be tapered and medication discontinued before becoming pregnant.53 However, discontinuation is not appropriate in women with a history of severe, recurrent depression or a history of suicide attempts. Maternal depression has far reaching consequences, and although it affects children and family dynamics, it can be treated. Future children of women with controlled depression have shown improved mental health status.54 Psychotherapy is first-line treatment for mild-to-moderate depression during pregnancy. 55 In fact, many women prefer psychotherapy to help with their depression symptoms during their pregnancies.56 Despite this fact, psychotherapy requires more of a time commitment and may involve increased expense, depending on insurance coverage. However, women may overcome this expense by seeking therapy in neighborhood or community clinics where reduced rates or sliding scales are available. Recommendations strongly support interpersonal psychotherapy (IPT) that can focus on social support; work on interpersonal conflicts; and address areas such as expectations about newborn care, intimacy and sexuality, negotiation of responsibilities, and renegotiation of relationships. Additionally, IPT allows the woman to examine issues, such as loss of independence, parenting skills, and decisions related to working outside the home. IPT also
promotes discussion on how to integrate the new role as mother with other established roles.57 Cognitive behavioral therapy (CBT) has less research supporting its use in pregnancy but is often cited as an adjunctive to medication management. CBT is often aimed at the woman’s beliefs about herself, her child, and her pregnancy.46,58 Other choices such as psycho-education teach the woman about her condition and inform her about her diagnosis and treatment plan. Alternative therapies including acupuncture, light therapy, relaxation techniques, massage therapy, and mindfulness practices such as yoga have been found to be helpful in minimizing depressive symptoms.59,60 Electroconvulsive therapy (ECT) has also been useful during pregnancy with treatment-resistant depression; ECT has been found to have few adverse reactions.61 Psychotherapy is also a primary approach to treating adolescent depression. Many families prefer psychosocial treatments given the concerns with the use of antidepressants for adolescents. CBT is the most studied psychosocial intervention for adolescent depression and is considered a well-established model of treatment for this age-group.5 Issues of importance for depressed childbearing adults parallel those for childbearing adolescents related to choices of therapy and medication. Antidepressant usage generates controversial discussion despite a two to fourfold increase in usage over the past decade.62 If depression is resistant to therapy alone, a decision to use medications requires discussion between the pregnant woman and her healthcare provider. In providing care to depressed childbearing age women in general, it is important to discuss a course of action regarding medications because women do conceive while on prescribed medications. Almost all medications will pass through the placenta. No psychotropic medication has FDA approval for use during pregnancy.55 Although pregnancy risk categories are available, these categories do not provide enough information on specific benefits and risks and do not provide management approaches if a decision to use the medication is made. The NP will frequently see pregnant adolescents who are depressed and who may benefit from antidepressant use. The patient is always able to refuse treatment but may choose to control her depression with medications. A full disclosure to the patient of the benefits and risks of medications on her and her fetus must be made and documented. In addition, the NP should collaborate with the woman’s obstetrician as well as the pediatrician for postpartum depression when using any medication for the childbearing population. In addition, the patient who has severe symptoms may need a referral to a specialist, such as a psychiatric mental health NP or a psychiatrist.
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Prenatal depression: Early intervention
Thirteen percent of pregnant women take antidepressants.62,63 Usage continues to increase over time with the development of selective serotonin reuptake inhibitors (SSRIs).64 Many women make the choice to remain on their medications during a pregnancy. Treatment for depression is generally safe during pregnancy and breastfeeding, but providers must weigh the benefits and risks of management with each woman individually.29 Several adverse physical conditions related to antidepressant use have been seen, including intrauterine death, spontaneous abortion, preterm birth, fetal growth impairment, neonatal toxicity, structural malformations, gastrointestinal problems, persistent pulmonary hypertension of the newborn (PPHN), cardiac malformations, or long-term effects on infant neuro-cognitive development (see Neonatal toxicity).29,64-67 Yet without effective treatment, decreased fetal body and head growth may occur along with increased newborn developmental delays. Treatment decisions must continue to weigh the effects of untreated depression versus potential effects of selected treatment options. Maternal risks from ineffective treatment, including poor sleep and nutritional intake, selfharm ideation, psychosis, and suicide may also occur.64 Additionally, an increased risk for severe depression, psychosis, and serotonin withdrawal syndrome may occur if the antidepressant is abruptly stopped.68 Recurrence of symptoms during pregnancy has been found to occur in 68% of women if medications are discontinued close to the time of conception.69 Most research supports the use of SSRIs as first-line medications because of minimum adverse reaction profiles.55 However, selective norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and in rare occurrences, monoamine oxidase inhibitors (MAOIs) may be prescribed.70 Numerous studies have examined infants exposed to antidepressants. Malm and colleagues examined first trimester fetal exposure to SSRIs and found that anomalies were not more common in infants exposed to SSRIs than in infants of women not using SSRIs.52 Yet, specific issues are known with some of these medications (see Risks associated with antidepressant use during pregnancy). A fetus can be exposed to the effects of medications in any trimester. Malformations due to SSRIs or other antidepressant use can occur in the first trimester. Maladaptation to the lack of serotonin, illustrated by jitteriness, muscles weakness, and a poor suck reflex at birth may present in infants exposed to antidepressants in late pregnancy.64 Late trimester exposure to antidepressants may also be associated with infant PPHN. However, Andrade and colleagues reported the absolute risk of PPHN to be at less than 1% and stated that discontinuing or lowering the dose of medication during the pregnancy was not recommended.71 Guidelines recommend antidepressants for some women during pregnancy, and it is suggested that SSRIs should be www.tnpj.com
Neonatal toxicity • Third trimester use of a few newer antidepressants has been associated with neonatal adaptation syndrome. • The cause of this syndrome may be due to drug withdrawal or serotonin reuptake inhibitor toxicity. • Neonatal symptoms can include tremors, jitteriness, shivering, increased muscle tone, feeding difficulties, irritability, agitation, or respiratory distress of varying degrees. • Signs are usually mild and typically resolve within a couple of weeks. • Assessment of the degree of potential withdrawal may be assessed via a Modified Finnegan’s scale. Both terms of adaptation and abstinence represent same syndrome of neonatal toxicity depending on the author. Sources: Finnegan LP. Neonatal abstinence syndrome: Assessment and pharmacotherapy. In: Nelson N, ed. Current Therapy in Neonatal-Perinatal Medicine. 2nd ed. Ontario: BC Decker; 1990. Way CM. Safety of newer antidepressants in pregnancy. Pharmacotherapy. 2007;27(4):546-552.
continued if a history of past or recurring episodes of depression exists.55 The provider can offer an ultrasound or echocardiogram in early pregnancy for pregnant women taking antidepressants to rule out a fetal cardiac anomaly associated especially with paroxetine. Providers should also offer ongoing, updated information and education to the woman to aide in her decision making throughout pregnancy and postpartum. Tricyclic antidepressant medications have only shown limited effectiveness in adolescents and are associated with negative adverse reactions.5 More research has focused on the use of SSRIs. Until recently, the FDA had only approved fluoxetine for the treatment of adolescent depression. In March 2009, escitalopram was approved for acute and maintenance treatment for adolescent depression. The risk of increased suicidal ideation and behavior has been a major concern with the use of SSRIs in adolescents. In 2004, the FDA concluded that a warning box indicating a risk of suicidality needed to be included in the prescribing information of all antidepressant drugs.5 Careful monitoring of prenatally depressed women and frequent NP-to-specialty provider (such as obstetrics, psychiatry) communication is essential in delivering quality care.72 The key to management of depression in pregnancy is to thoroughly discuss with the patient the benefits and the risks to her and her unborn infant that may occur with each of the various treatment options. A younger, pregnant adolescent’s voice may be framed within parental or guardian’s decisions on her behalf. However, if the pregnant adolescent is an emancipated minor, she may have legal voice to her opinions and decisions–much depends on individual and developmental aspects. Care to understand the specific needs of the pregnant woman includes respecting women’s rights The Nurse Practitioner • July 2015 43
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Prenatal depression: Early intervention
Risks associated with antidepressant use during pregnancy Antidepressant
Class
Medication risk to exposed infants in utero
Comments
Fluoxetine
SSRI
• Cardiac anomalies (2.04% in exposed versus 1.29% unexposed infants) • Ventral septal defects (1.43% versus 0.8%) Infantile hypertrophic pyloric stenosis
Pregnancy category C
Paroxetine
SSRI
Right ventricular outflow defects (0.31% versus 0.07%)–Increased risk in 1st and 3rd trimester.
• Pregnancy category D teratogenicity in 1st trimester • Persistent pulmonary hypertension of the newborn (PPHN) in 3rd trimester
Citalopram
SSRI
Neural tube defects (0.29% versus 0.09%)
Pregnancy category C
All SSRIs
• Increased risk of PPHN after week 20 of pregnancy. Increased from 1:700 to 7:1,000 • Estimated absolute risk less than 1% in infants exposed (for example, 99% with no PPHN).
PPHN can be fatal in 10%-20% of newborns. Exposure in late pregnancy associated with increased risk of PPHN with similar rate for citalopram, paroxetine, and fluoxetine.
Spontaneous abortion
Inconclusive research
Preterm birth
Inconclusive findings
Fetal death
Most studies–no increased risk.
All SSRIs and SNRIs
Poor neonatal adaptation (serotonin withdrawal and serotonin syndrome) Jitteriness, poor muscle tone, weak or absent cry; respiratory distress; Hypoglycemia; feeding difficulties; irritability, agitation, low APGAR scores; seizures.
• Inform pediatrician of intrauterine exposure. • Closely observe infants who have been exposed. • Must consider the risks of untreated depression during the 3rd trimester.
Venlafaxine
SNRI
Increased risk of preterm birth and withdrawal syndrome–similar with SSRIs.
Pregnancy category C–One study reported seizures in neonate (N = 1)
Duloxetine
SNRI
No studies
Pregnancy category C
Mirtazapine
Noradrenergic and Specific Serotonergic Antidepressant
Limited data; no increased risk of congenital malformations; increased risk of preterm birth; neonatal withdrawal similar to SSRIs.
Pregnancy category C
Amitriptyline; Nortriptyline
TCAs
No significant association between TCA and congenital malformations. In 3rd trimester associated with similar neonatal adaptation problems as the SSRIs and SNRIs.
Pregnancy category C
Isocarboxazid
MAOI
May limit fetal growth; may aggravate maternal BP.
Pregnancy category C
Bupropion
Norepinephrine Dopamine Reuptake Inhibitor
Not a 1st-line treatment for depression in pregnancy. No increased risk of congenital malformations or increased risk of heart defects. Increased risk of miscarriage.
Pregnancy category C Lowered seizure threshold possible for women with preeclampsia.
Table created by Carol Lieser, PhD, RN, OFS,PMHNP-BC.
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Prenatal depression: Early intervention
to make informed decisions regarding their care. As providers remain current on the research available on maternal depression, the challenges of managing this problem can be overcome, and significant benefits for the woman, her unborn infant, and her family can occur. REFERENCES 1. World Health Organization (WHO). The global burden of mental disorders and the need for a comprehensive, coordinated response from health and social sectors at the country level: The 65th World Health Assembly. Agenda item 13.2. 2012. http://www.prb.org/Articles/2006/DepressionaLeadingContributortoGlobalBurdenofDisease.aspx. 2. Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication—Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010;49(10):980-989. 3. Henshaw E, Sabourin B, Warning M. Treatment-seeking behaviors and attitudes survey among women at risk for perinatal depression or anxiety. J Obstet Gynecol Neonatal Nurs. 2013;42(2):168-177. 4. Burcusa SL, Iacono WG. Risk for recurrence in depression. Clin Psychol Rev. 2007;27(8):959-985. 5. Young JF, Miller MR, Khan N. Screening and managing depression in adolescents. Adolesc Health Med Ther. 2010;1:87-95. 6. American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Washington, DC: American Psychiatric Publishing; 2013. 7. Bennett HA, Einarson A, Taddio A, Koren G, Einarson TR. Prevalence of depression during pregnancy: systematic review. Obstet Gynecol. 2004;103(4):698-709. 8. Meltzer-Brody S, Bledsoe-Mansori SE, Johnson N, et al. A prospective study of perinatal depression and trauma history in pregnant minority adolescents. Am J Obstet Gynecol. 2013;208(3):211.e1-e7. 9. Salazar-Pousada D, Arroyo D, Hidalgo L, Pérez-López FR, Chedraui P. Depressive symptoms and resilience among pregnant adolescents: a case-control study. Obstet Gynecol Int. 2010;2010:952493. 10. Lancaster CA, Gold KJ, Flynn HA, Yoo H, Marcus SM, Davis MM. Risk factors for depressive symptoms during pregnancy: a systematic review. Am J Obstet Gynecol. 2010;202(1):5-14. 11. Melville JL, Gavin A, Guo Y, Fan MY, Katon WJ. Depressive disorders during pregnancy: prevalence and risk factors in a large urban sample. Obstet Gynecol. 2010;116(5):1064-1070. 12. Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol. 2005;106(5 Pt 1):1071-1083. 13. Parcells DA. Women’s mental health nursing: depression, anxiety and stress during pregnancy. J Psychiatr Ment Health Nurs. 2010;17(9):813-820. 14. Records K. Prenatal depression. Int J Childbirth Educ. 2011;26(4):19-22. 15. Holden KB, McKenzie R, Pruitt V, Aaron K, Hall S. Depressive symptoms, substance abuse, and intimate partner violence among pregnant women of diverse ethnicities. J Health Care Poor Underserved. 2012;23(1):226-241. 16. Figueiredo B, Pacheco A, Costa R. Depression during pregnancy and the postpartum period in adolescent and adult Portuguese mothers. Arch Womens Ment Health. 2007;10(3):103-109. 17. Lanzi RG, Bert SC, Jacobs BK. Depression among a sample of first-time adolescent and adult mothers. J Child Adolesc Psychiatr Nurs. 2009;22(4):194-202. 18. Hodgkinson SC, Colantuoni E, Roberts D, Berg-Cross L, Belcher HM. Depressive symptoms and birth outcomes among pregnant teenagers. J Pediatr Adolesc Gynecol. 2010;23(1):16-22. 19. Records K, Rice M. Psychosocial correlates of depression symptoms during the third trimester of pregnancy. J Obstet Gynecol Neonatal Nurs. 2007;36(3):231-242. 20. Dietz PM, Williams SB, Callaghan WM, Bachman DJ, Whitlock EP, Hornbrook MC. Clinically identified maternal depression before, during, and after pregnancies ending in live births. Am J Psychiatry. 2007;164(10):1515-1520. 21. Tzilos GK, Zlotnick C, Raker C, Kuo C, Phipps MG. Psychosocial factors associated with depression severity in pregnant adolescents. Arch Womens Ment Health. 2012;15(5):397-401. 22. Lara MA, Le HN, Letechipia G, Hochhausen L. Prenatal depression in Latinas in the U.S. and Mexico. Matern Child Health J. 2009;13(4):567-576. 23. Fortner RT, Pekow P, Dole N, Markenson G, Chasan-Taber L. Risk factors for prenatal depressive symptoms among Hispanic women. Matern Child Health J. 2011;15(8):1287-1295.
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24. Ruiz RJ, Marti CN, Pickler R, Murphey C, Wommack J, Brown CE. Acculturation, depressive symptoms, estriol, progesterone, and preterm birth in Hispanic women. Arch Womens Ment Health. 2012;15(1):57-67. 25. Jesse DE, Swanson MS. Risks and resources associated with antepartum risk for depression among rural southern women. Nurs Res. 2007;56(6):378-386. 26. Davila M, McFall SL, Cheng D. Acculturation and depressive symptoms among pregnant and postpartum Latinas. Matern Child Health J. 2009;13(3):318-325. 27. Brennan PA, Pargas R, Walker EF, Green P, Newport DJ, Stowe Z. Maternal depression and infant cortisol: influences of timing, comorbidity and treatment. J Child Psychol Psychiatry. 2008;49(10):1099-1107. 28. Halligan SL, Herbert J, Goodyer IM, Murray L. Exposure to postnatal depression predicts elevated cortisol in adolescent offspring. Biol Psychiatry. 2004;55(4):376-381. 29. Toohey J. Depression during pregnancy and postpartum. Clin Obstet Gynecol. 2012;55(3):788-797. 30. Lindahl V, Pearson JL, Colpe L. Prevalence of suicidality during pregnancy and the postpartum. Arch Womens Ment Health. 2005;8(2):77-87. 31. Bonari L, Pinto N, Ahn E, Einarson A, Steiner M, Koren G. Perinatal risks of untreated depression during pregnancy. Can J Psychiatry. 2004;49(11):726-735. 32. National Scientific Council on the Developing Child. Early experiences can alter gene expression and affect long-term development: Working paper No. 10. 2010. www.developingchild.harvard.edu. 33. Akman I, Kusçu K, Ozdemir N, et al. Mothers’ postpartum psychological adjustment and infantile colic. Arch Dis Child. 2006;91(5):417-419. 34. McLearn KT, Minkovitz CS, Strobino DM, Marks E, Hou W. The timing of maternal depressive symptoms and mothers’ parenting practices with young children: implications for pediatric practice. Pediatrics. 2006;118(1):e174-e182. 35. McLearn KT, Minkovitz CS, Strobino DM, Marks E, Hou W. Maternal depressive symptoms at 2 to 4 months post-partum and early parenting practices. Arch Pediatr Adolesc Med. 2006;160(3):279-284. 36. Ross LE, McLean LM. Anxiety disorders during pregnancy and the postpartum period: a systematic review. J Clin Psychiatry. 2006;67(8):1285-1298. 37. Parker B, McFarlane J. Identifying and helping battered pregnant women. MCN Am J Matern Child Nurs. 1991;16(3):161-164. 38. Connor KM, Davidson JR. SPRINT: a brief global assessment of posttraumatic stress disorder. Int Clin Psychopharmacol. 2001;16(5):279-284. 39. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10): 1092-1097. 40. Wuyek LA, Antony MM, McCabe RE. Psychometric properties of the panic disorder severity scale: clinician-administered and self-report versions. Clin Psychol Psychother. 2011;18(3):234-243. 41. Hübner-Liebermann B, Hausner H, Wittmann M. Recognizing and treating peripartum depression. Dtsch Arztebl Int. 2012;109(24):419-424. 42. Moses-Kolko EL, Roth EK. Antepartum and postpartum depression: healthy mom, healthy baby. J Am Med Womens Assoc. 2004;59(3):181-191. 43. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561-571. 44. Gaynes BN, Gavin N, Meltzer-Brody S, et al. Perinatal depression: prevalence, screening accuracy, and screening outcomes. Evid Rep Technol Assess (Summ). 2005;(119):1-8. 45. 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. 46. Choate L, Gintner G. Prenatal Depression: Best Practice Guidelines for Diagnosis and Treatment. J Counseling & Development. 2011;89(3):373-381. 47. Freed RD, Chan PT, Boger KD, Tompson MC. Enhancing maternal depression recognition in health care settings: a review of strategies to improve detection, reduce barriers, and reach mothers in need. Fam Syst Health. 2012;30(1):1-18. 48. Barnet B, Liu J, Devoe M. Double jeopardy: depressive symptoms and rapid subsequent pregnancy in adolescent mothers. Arch Pediatr Adolesc Med. 2008;162(3):246-252. 49. Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception. 2011;84(5):478-485. 50. van Gelder MM, van Rooij IA, Miller RK, Zielhuis GA, de Jong-van den Berg LT, Roeleveld N. Teratogenic mechanisms of medical drugs. Hum Reprod Update. 2010;16(4):378-394. 51. Yi Y, Lindemann M, Colligs A, Snowball C. Economic burden of neural tube defects and impact of prevention with folic acid: a literature review. Eur J Pediatr. 2011;170(11):1391-1400. 52. Malm H, Artama M, Gissler M, Ritvanen A. Selective serotonin reuptake inhibitors and risk for major congenital anomalies. Obstet Gynecol. 2011;118(1):111-120.
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53. ACOG. Depression during pregnancy: Treatment recommendations. http:// www.ACOG.org/About_ACOG/News_Room/News_Releases/2009/Depression_During_Pregnancy. 54. Weissman MM, Pilowsky DJ, Wickramaratne PJ, et al. Remissions in maternal depression and child psychopathology: a STAR*D-child report. JAMA. 2006;295(12):1389-1398. 55. ACOG Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin: Clinical management guidelines for obstetrician-gynecologists number 92, April 2008 (replaces practice bulletin number 87, November 2007). Use of psychiatric medications during pregnancy and lactation. Obstet Gynecol. 2008;111(4):1001-1020. 56. Goodman SH, Dimidjian S. The developmental psychopathology of perinatal depression: implications for psychosocial treatment development and delivery in pregnancy. Can J Psychiatry. 2012;57(9):530-536. 57. Spinelli MG, Endicott J, Leon AC, et al. A controlled clinical treatment trial of interpersonal psychotherapy for depressed pregnant women at 3 New York City sites. J Clin Psychiatry. 2013;74(4):393-399. 58. Abel KM. Review: psychosocial and psychological interventions reduce postpartum depressive symptoms. Evid Based Ment Health. 2008;11(3):79. 59. Faucher MA. Mindfulness yoga improves scores on depression scales and fosters maternal-fetal attachment J Midwifery Womens Health. 2013;58(1):111-112. 60. Gossler SM. Use of complementary and alternative therapies during pregnancy, postpartum, and lactation. J Psychosoc Nurs Ment Health Serv. 2010;48(11):30-36. 61. Bulut M, Bez Y, Kaya MC, Copoglu US, Bulbul F, Savas HA. Electroconvulsive therapy for mood disorders in pregnancy. J ECT. 2013;29(2):e19-e20. 62. Meltzer-Brody S. New insights into perinatal depression: pathogenesis and treatment during pregnancy and postpartum. Dialogues Clin Neurosci. 2011;13(1):89-100. 63. Cooper WO, Willy ME, Pont SJ, Ray WA. Increasing use of antidepressants in pregnancy. Am J Obstet Gynecol. 2007;196(6):544.e1-e5.
64. Chaudron LH. Complex challenges in treating depression during pregnancy. Am J Psychiatry. 2013;170(1):12-20. 65. Hoppenbrouwers CJ, Bosma J, Wennink HJ, Hilgevoord AA, Heres M, Honig A. Neonatal seizures on EEG after in utero exposure to venlafaxine. Br J Clin Pharmacol. 2010;70(3):454-456. 66. Nijenhuis CM, Horst PG, Berg LT, Wilffert B. Disturbed development of the enteric nervous system after in utero exposure of selective serotonin re-uptake inhibitors and tricyclic antidepressants. Part 1: literature review. Br J Clin Pharmacol. 2012;73(1):16-26. 67. Nijenhuis CM, ter Horst PG, van Rein N, Wilffert B, de Jong-van den Berg LT. Disturbed development of the enteric nervous system after in utero exposure of selective serotonin re-uptake inhibitors and tricyclic antidepressants. part 2: testing the hypotheses. Br J Clin Pharmacol. 2012;73(1):126-134. 68. Wakil L, Perea E, Penaskovic K, Stuebe A, Meltzer-Brody S. Exacerbation of psychotic disorder during pregnancy in the context of medication discontinuation. Psychosomatics. 2013;54(3):290-293. 69. Cohen LS, Altshuler LL, Harlow BL, et al. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA. 2006;295(5):499-507. 70. Ramos E, Oraichi D, Rey E, Blais L, Bérard A. Prevalence and predictors of antidepressant use in a cohort of pregnant women. BJOG. 2007;114(9):1055-1064. 71. Andrade SE, McPhillips H, Loren D, et al. Antidepressant medication use and risk of persistent pulmonary hypertension of the newborn. Pharmacoepidemiol Drug Saf. 2009;18(3):246-252. 72. Morgan M, de Jong-van den Berg LT, Jordan S. Drug safety in pregnancy— monitoring congenital anomalies. J Nurs Manag. 2011;19(3):305-310. Cheryl A. Anderson is an associate professor and Carol Lieser is an associate professor of the Psych Nurse Practitioner Program at the University of Texas at Arlington, Arlington, Tex. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NPR.0000453645.36533.73
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epression is the fourth leading cause of worldwide disease burden, accounting for almost 12% of all total years lived with a disability. Depression is the leading cause of disability among 18- to 44-year-olds in the United States, affecting about 14.8 million adults (or about 6.7% of the U.S. population).1 Women are particularly susceptible to depression with a lifetime prevalence of 25%. While the onset of depression occurs most often during the midtwenties, 8.2% of adolescents exhibit depression symptoms. During adolescence, girls begin to show a 2:1 ratio of depression over boys.2 Although the variability by gender is not specifically understood, this difference is possibly related
D
to the hormonal changes that occur as girls enter puberty.2 Only a small percentage of individuals seek pharmacotherapy (36.1%) or psychotherapy (16.7%) following a positive depression screen.3 Yet, even when treated, depression often reoccurs at rates of 50% to 60% after one episode and 80% after two episodes.4 Approximately one-third of adolescents will remain depressed following treatment.5 Diagnostic features of depression include a sad, empty, or irritable mood and/or a loss of pleasure or interest in life, with somatic and cognitive changes that significantly affect the individual’s capacity to function. According to the Diagnostic and Statistical Manual of Mental Disorders,
Keywords: childbearing women, depression, management of prenatal depression, pregnancy
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Photo by Nic Cleave / Alamy ©
By Cheryl A. Anderson, PhD, RN, CNS and Carol Lieser, PhD, RN, OFS,PMHNP-BC
Prenatal depression: Early intervention
5th edition (DSM-5), criteria for diagnosis of a major depressive disorder include: loss of pleasure, sad mood, alterations in sleep, appetite, or weight, poor concentration, psychomotor changes, low energy, feelings of guilt, and thoughts of suicide.6 The specifier “with peripartum onset” within childbearing populations can be applied to the diagnosis of major depressive disorder if the onset of symptoms occurs during pregnancy or within 4 weeks of delivery.6 Depression rates among pregnant women, especially those with low socioeconomic status, have been reported from 5% to over 50%.7-9 ■ Prenatal depression Ms. C, a Hispanic 17-year-old, arrives at the clinic for her first prenatal visit at 34-weeks pregnant. This unplanned pregnancy is her second baby. The father of the baby is 17, abusive, and uninvolved. The nurse practitioner (NP) notices bruising and burns on both arms. With gentle prodding and a nonjudgmental attitude, Ms. C begins to cautiously speak with the NP. She reports a poor appetite, little weight gain, feeling overwhelmed, crying most days, and feeling guilty because of the “mess” she has gotten into when “money is so tight.” Her mother currently works two jobs and blames Ms. C for the current situation. Between tears, she quietly states that she feels hopeless, that there is no money for two babies, and that she does not want this baby. The NP notices limited disclosure of abuse in the conversation, little face-to-face interaction, apparent sadness, and a flat, dull affect. A later review of her medical record indicates a previous suicide attempt at the age of 15. The NP provides educational pamphlets and community resources on partner violence, dietary information with education on weight gain during pregnancy, materials for women, infants, and children, and encouragement to continue prenatal care until her delivery. It is important to note that each state has different legal requirements for reporting and documenting partner violence. Continued conversation related to the recurring depression, past suicide attempt, and the patient’s feelings about the baby prompts the NP to consult the hospital social worker who contacts Ms. C. Ongoing discussion with Ms. C allows for joint decisions for her individual management plan during pregnancy and after birth. Despite being a frequently found medical disorder among pregnant women, major depression remains undetected and undertreated in prenatal care.10 Understanding the prevalence and associated risk factors can potentially improve both diagnosis and treatment rates of severe depressive disorders among pregnant women.11 A meta-analysis of 24 studies conducted by Gavin and colleagues revealed an overall prevalence of prenatal depression (PND) to be 18.4% with 12.7% of women experiencing www.tnpj.com
an episode of major depression.12 Nearly one in six women were found to experience a new episode of major depression while pregnant.12 A separate, large prospective study (N = 1,888), however, found lower rates for both major depression (5.1%) and minor depression (4.8%).11 Rate variations seen in the literature for PND may be due to timing of assessments across different trimesters and type/variety of assessment tools. A meta-analysis of 28 studies revealed rates of diagnosed PND vary by trimester: 11% in the 1st trimester, 8.5% in the 2nd trimester, and 8.5% in the 3rd trimester.12 Bennett and colleagues reported an opposite finding with prevalence rates to be lowest during the first trimester at 7.4% as compared with 12.8% and 12.0% for the second and third trimesters.7 Two additional studies, one using a diagnostic tool for assessment and the other study administering a commonly used screening tool, supported higher rates (33%) among women experiencing PND in the third trimester.13,14 Research supports potential variation in PND across trimesters and provides plentiful information suggesting both risk and protective factors that may either trigger or buffer against PND. ■ Risk factors Risk factors including life stressors, lack of social support, unintended pregnancy, a less positive view of the pregnancy, young age, greater number of children, smoking, single status, history of depression, domestic violence, substance abuse, lower income, lower education, and poor relationships have been shown to increase the risk of PND.8,10,15 Ms. C’s situation is not that uncommon to the NP. The case history illustrates several risk factors particularly evident with depressed adolescents. As it relates to age, childbearing adolescents have been found to have higher rates of both prenatal and postpartum depression than adult women.16,17 Depression among adolescents is associated with significant impairment in functioning and an increased risk of developing major depressive episodes and other psychiatric disorders in the future.5 However, lacking recognition of depressive symptoms, the first entry into the healthcare system may be prompted by a pregnancy. Current signs of depression, a past history of a suicide attempt, and suspected physical (and emotional) abuse increase the likelihood of major depression and cause heightened vigilance in providing care to Ms. C and her unborn infant. Suicide ideation or suicide attempt with depression symptoms has been found to result in poor infant outcomes. Infants of depressed adolescents with suicide ideation or attempt weighed almost 240 g (8.5 oz) less than infants of depressed adolescents without suicide ideation or attempt.18 A history of depression prior to pregnancy (individual or familial history) is a major predictor of current PND.19 This The Nurse Practitioner • July 2015 39
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Prenatal depression: Early intervention
ology directing the mother’s cortisol levels. Postpartum depression perhaps leads to increased fetal cortisol levels due to the environmental stress of the mother’s depression. Both types of exposure lead to an increased vulnerability to personal psychopathology, perhaps, linked to higher cortisol levels, which continue through adolescence. Yet studies have shown that maternal psychotropic medication use during pregnancy and continued in the postpartum period can reduce maternal depression, lower HPA axis cortisol, and offset the infant’s cortisol levels. Infants, however, whose mothers were depressed during pregnancy and postpartum and who received no psychotropic medications had As depression and stress often occur together, the highest levels of cortisol. The use of depression has also been found to be antidepressants during these times both associated with cortisol levels. reduced the mothers’ cortisol levels and normalized the early caregiving environment, often allowing infant cortisol 27,28 levels to be normal. to increase the odds of experiencing PND by fivefold among minority adolescents.8 A history of abuse has been shown Depression can result in serious consequences for pregto be a more significant factor for severe depression than nant women, with loss of productivity, ensuing family and the history of alcohol use, history of drug use, or history of relationship difficulties, poor physical health, and increased depression.21 risk for suicide.29 Maternal suicide is one of the leading causes of maternal mortality in the perinatal period and Ethnic-racial backgrounds have been shown to be asaccounts for up to 20% of all postpartum deaths.30 Addisociated with PND, but research findings reveal variations 11,22-25 among Asian, Black, and Hispanic women. tional complications associated with PND can include preThe eclampsia, gestational bleeding, increased uterine artery potential influence of acculturation on PND is of addiresistance, increased cesarean births, and increased epitional interest; however, research examining the influence dural use. Adverse birth outcomes may include preterm of acculturation is sparse and inconsistent.23,26 birth, small for gestational age infants, low APGAR scores, Specific protective factors may also be in place to prevent admission to neonatal ICUs, and effects on brain developPND. Strong social support and resources, desirability of ment with altered gene expression and altered immune pregnancy, marital satisfaction, and personality factors, function in the infant, spontaneous abortion, and fetal including the ability to cope with challenges and stress, may death.8,24,31,32 One study evaluated infants with colic and help mitigate the effects of depressive symptoms.14 found a greater percentage of the colicky infants had mothers who were depressed. Furthermore, the risk of infantile ■ Consequences of PND colic increased threefold in mothers who were depressed in Any woman is potentially vulnerable to complications of pregcomparison to mothers who were not.33 Depressed mothers nancy associated with depression, stress, substance use, and/ or partner violence. However, childbearing women of diverse are often more harsh in the care of their infants and exhibit ethnicities are more frequently confronted with a constellation lower rates of infant safety practices, such as poor use of car of issues that can engender stress and potentially affect materseats and safety latches.34 These mothers also may exhibit 15 nal and infant outcomes. Researchers have hypothesized that less healthy child development activities, such as reading, singing, and playing games with their children.35 PND affects the fetus through biochemical channels secondary to stress. As stress increases, the maternal cortisol level elevates leading to poor uterine perfusion, and therefore, slowed fetal ■ Assessment growth rate and increased preterm births.19 Initial assessments must recognize co-occurring mental health disorders. NPs focusing on depression must rule As depression and stress often occur together, depression out the potential for bipolar disorder due to differences in has also been found to be associated with cortisol levels. management and the possibility of provoking mania with Infants who are exposed to maternal perinatal depresthe treatment of unipolar depression. The diagnosis of sion potentially become genetically linked to elevated generalized anxiety disorder must also be considered and hypothalamus-pituitary axis (HPA) cortisol through physicycle of depression, which frequently presents prior to a pregnancy and continues throughout pregnancy into postpartum, is of concern to the NP because of management issues for potential maternal, fetal, and infant consequences. Dietz and colleagues conducted a unique study of women between 39 weeks before pregnancy through 39 weeks postpartum and found that approximately one in seven women were identified and treated for depression during this time period.20 The experience of trauma heightens the vulnerability for depression. Physical and/or sexual abuse has been found
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Prenatal depression: Early intervention
commonly co-occurs with depression in pregnant women.11,36 Additional assessments of posttraumatic stress disorder, panic disorder, evidence of trauma and abuse, alcohol and other substance abuse, and presence of multiple psychosocial stressors are also essential. In Ms. C’s case, initial screenings for abuse, trauma symptoms, anxiety, and depression are needed. The easily administered, Abuse Assessment Screen is simple, quick, and effective in determining abuse in a relationship.37 A verbal inquiry assessing a history of abuse, as well as perceived trauma from a past childbirth, may provide important information for Ms. C. Both partner violence and birth trauma can generate symptoms of posttraumatic stress or posttraumatic stress disorder. The use of The Short Post-Traumatic Stress Disorder (PTSD) Rating Interview for core symptoms of PTSD (intrusion, avoidance, numbing, arousal, somatic malaise, stress vulnerability, role, or social function impairment) helps the provider identify these symptoms. Role/ social functional impairment can be helpful.38 The Generalized Anxiety Disorder-7 (GAD-7) is appropriate for identifying co-occurring generalized anxiety, which includes excessive worry and anxiety markers; the GAD-7 can be an appropriate and useful assessment tool.39 The Panic Disorder Severity Scale assessing for abrupt surges of intense fear may also be warranted.40 A comprehensive assessment for the specific disorder using DSM-5 diagnostic criteria would follow with positive findings. Assessing PND may be challenging because it may be difficult to differentiate depression symptoms from pregnancy-related problems. A review of research shows that only 20% of depressed pregnant women are identified.41 Some providers may incorrectly attribute depression symptoms to the pregnancy, while others may over diagnose depression, relating the common somatic symptoms, such as poor sleep, fatigue, emotional swings, and concentration issues of pregnancy to depression.42 Despite potential difficulties, all pregnant women should be screened for depression, and the choice of screening tools is important. Some screening tools may tend to yield increased false positives. The Beck Depression Inventory (BDI), which is widely used, includes many somatic symptoms common to pregnancy and may mislead the provider.43,44 Using the Edinburgh Postnatal Depression Scale (EPDS), which is designed to differentiate common pre- and postpartum complaints from symptoms of depression, may provide a more accurate assessment in this population.41,45-47 More medical settings are beginning to mandate or highly encourage all healthcare providers to screen for prenatal and postpartum depression; therefore, NPs must be knowledgeable of available screening tools and resources (see Depression resources). www.tnpj.com
Depression resources Web-based resources Exposure to psychotropic medications and other substances during pregnancy and lactation: A handbook for healthcare providers (knowledgex.camh.net/primary_care/guidelines_ materials/Pregnancy_Lactation/Documents/ psychmed_preg_lact.pdf) U.S. Department of Health and Human Services. Health Resources and Service Administration. Maternal and Child Health. Depression During and After Pregnancy: A Resource for Women, Their Families, and Friends (http://mchb.hrsa.gov/ pregnancyandbeyond/depression/index.html) Motherrisk is a program created by The Hospital for Sick children in Toronto, Canada. The website provides updated research and answers to questions about toxins and other environmental risks to the unborn child. This site is a resource for professionals as well as families. (www.motherrisk.org) Substance Abuse and Mental Health Services Administration National Mental Health Information Center. Phone: 800-789-2647 For information on depression, including a locator to find a mental health center in the patient’s area National resources American Congress of Obstetricians and Gynecologists Phone: 800-762-2264 Resources for both patients and healthcare providers Office of Women’s Health, U.S. Department of Health and Human Services Phone: 800-994-WOMAN (800-994-9662) Frequently asked questions about depression and pregnancy (https://www.womenshealth.gov/index.html) Book Bennett S, Indman P. Beyond the blues: Understanding and treating prenatal and postpartum depression and anxiety. San Jose, CA: Moodswings Press; 2010. ISBN: 978-0971712454. (Recommended by U.S. Department of Health and Human Services).
It is essential to follow up with diagnostic testing if the childbearing woman screens positive for depression. Trained professionals can use the criteria in the DSM-5 or administer a diagnostic, such as the Structured Clinical Interview for DSM Disorders (SCID). Diagnostic screening for younger childbearing adolescents may be performed via the Kiddie-Schedule for Affective Disorders and SchizophreniaPresent and Lifetime version (K-SADS-PL).5 ■ Management of perinatal depression Fifty percent of postpartum major depressive episodes occur prior to birth according to the DSM-5.6 The frequency of depression among childbearing women mandates an The Nurse Practitioner • July 2015 41
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Prenatal depression: Early intervention
effective management plan. Attention must be given to the issues occurring if no treatment is provided, if treatment overlaps a pregnancy, and if prepregnant management of depression is halted. Providers who care for childbearing women must assume the potential for pregnancy. The use of birth control for female adolescents may be hindered by depression.48 Nearly 50% of all pregnancies are unplanned, and prenatal care and management of existing depression may begin late into the pregnancy.49 The provider can optimize perinatal health with instructions on good nutrition, vitamin intake, adequate sleep and exercise, and assessment of abuse, trauma, and substance use. Suggestions could be made for household help and childcare assistance. A listing of community support groups should be provided as appropriate. Ideally, preconceptual counseling would occur taking the management of many health concerns into consideration, including depression. Early use of folic acid is standard practice for pregnant women and is essential for fetal growth and development.50,51 However, study findings indicate that use of citalopram by women during pregnancy was associated with neural tube defects.52 Additionally, medication changes may need to occur prior to a pregnancy if the woman is receiving pharmacotherapy for depression. The American Congress of Obstetricians and Gynecologists suggests women on medications, with mild or no symptoms for 6 months or longer, may be tapered and medication discontinued before becoming pregnant.53 However, discontinuation is not appropriate in women with a history of severe, recurrent depression or a history of suicide attempts. Maternal depression has far reaching consequences, and although it affects children and family dynamics, it can be treated. Future children of women with controlled depression have shown improved mental health status.54 Psychotherapy is first-line treatment for mild-to-moderate depression during pregnancy. 55 In fact, many women prefer psychotherapy to help with their depression symptoms during their pregnancies.56 Despite this fact, psychotherapy requires more of a time commitment and may involve increased expense, depending on insurance coverage. However, women may overcome this expense by seeking therapy in neighborhood or community clinics where reduced rates or sliding scales are available. Recommendations strongly support interpersonal psychotherapy (IPT) that can focus on social support; work on interpersonal conflicts; and address areas such as expectations about newborn care, intimacy and sexuality, negotiation of responsibilities, and renegotiation of relationships. Additionally, IPT allows the woman to examine issues, such as loss of independence, parenting skills, and decisions related to working outside the home. IPT also
promotes discussion on how to integrate the new role as mother with other established roles.57 Cognitive behavioral therapy (CBT) has less research supporting its use in pregnancy but is often cited as an adjunctive to medication management. CBT is often aimed at the woman’s beliefs about herself, her child, and her pregnancy.46,58 Other choices such as psycho-education teach the woman about her condition and inform her about her diagnosis and treatment plan. Alternative therapies including acupuncture, light therapy, relaxation techniques, massage therapy, and mindfulness practices such as yoga have been found to be helpful in minimizing depressive symptoms.59,60 Electroconvulsive therapy (ECT) has also been useful during pregnancy with treatment-resistant depression; ECT has been found to have few adverse reactions.61 Psychotherapy is also a primary approach to treating adolescent depression. Many families prefer psychosocial treatments given the concerns with the use of antidepressants for adolescents. CBT is the most studied psychosocial intervention for adolescent depression and is considered a well-established model of treatment for this age-group.5 Issues of importance for depressed childbearing adults parallel those for childbearing adolescents related to choices of therapy and medication. Antidepressant usage generates controversial discussion despite a two to fourfold increase in usage over the past decade.62 If depression is resistant to therapy alone, a decision to use medications requires discussion between the pregnant woman and her healthcare provider. In providing care to depressed childbearing age women in general, it is important to discuss a course of action regarding medications because women do conceive while on prescribed medications. Almost all medications will pass through the placenta. No psychotropic medication has FDA approval for use during pregnancy.55 Although pregnancy risk categories are available, these categories do not provide enough information on specific benefits and risks and do not provide management approaches if a decision to use the medication is made. The NP will frequently see pregnant adolescents who are depressed and who may benefit from antidepressant use. The patient is always able to refuse treatment but may choose to control her depression with medications. A full disclosure to the patient of the benefits and risks of medications on her and her fetus must be made and documented. In addition, the NP should collaborate with the woman’s obstetrician as well as the pediatrician for postpartum depression when using any medication for the childbearing population. In addition, the patient who has severe symptoms may need a referral to a specialist, such as a psychiatric mental health NP or a psychiatrist.
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Thirteen percent of pregnant women take antidepressants.62,63 Usage continues to increase over time with the development of selective serotonin reuptake inhibitors (SSRIs).64 Many women make the choice to remain on their medications during a pregnancy. Treatment for depression is generally safe during pregnancy and breastfeeding, but providers must weigh the benefits and risks of management with each woman individually.29 Several adverse physical conditions related to antidepressant use have been seen, including intrauterine death, spontaneous abortion, preterm birth, fetal growth impairment, neonatal toxicity, structural malformations, gastrointestinal problems, persistent pulmonary hypertension of the newborn (PPHN), cardiac malformations, or long-term effects on infant neuro-cognitive development (see Neonatal toxicity).29,64-67 Yet without effective treatment, decreased fetal body and head growth may occur along with increased newborn developmental delays. Treatment decisions must continue to weigh the effects of untreated depression versus potential effects of selected treatment options. Maternal risks from ineffective treatment, including poor sleep and nutritional intake, selfharm ideation, psychosis, and suicide may also occur.64 Additionally, an increased risk for severe depression, psychosis, and serotonin withdrawal syndrome may occur if the antidepressant is abruptly stopped.68 Recurrence of symptoms during pregnancy has been found to occur in 68% of women if medications are discontinued close to the time of conception.69 Most research supports the use of SSRIs as first-line medications because of minimum adverse reaction profiles.55 However, selective norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and in rare occurrences, monoamine oxidase inhibitors (MAOIs) may be prescribed.70 Numerous studies have examined infants exposed to antidepressants. Malm and colleagues examined first trimester fetal exposure to SSRIs and found that anomalies were not more common in infants exposed to SSRIs than in infants of women not using SSRIs.52 Yet, specific issues are known with some of these medications (see Risks associated with antidepressant use during pregnancy). A fetus can be exposed to the effects of medications in any trimester. Malformations due to SSRIs or other antidepressant use can occur in the first trimester. Maladaptation to the lack of serotonin, illustrated by jitteriness, muscles weakness, and a poor suck reflex at birth may present in infants exposed to antidepressants in late pregnancy.64 Late trimester exposure to antidepressants may also be associated with infant PPHN. However, Andrade and colleagues reported the absolute risk of PPHN to be at less than 1% and stated that discontinuing or lowering the dose of medication during the pregnancy was not recommended.71 Guidelines recommend antidepressants for some women during pregnancy, and it is suggested that SSRIs should be www.tnpj.com
Neonatal toxicity • Third trimester use of a few newer antidepressants has been associated with neonatal adaptation syndrome. • The cause of this syndrome may be due to drug withdrawal or serotonin reuptake inhibitor toxicity. • Neonatal symptoms can include tremors, jitteriness, shivering, increased muscle tone, feeding difficulties, irritability, agitation, or respiratory distress of varying degrees. • Signs are usually mild and typically resolve within a couple of weeks. • Assessment of the degree of potential withdrawal may be assessed via a Modified Finnegan’s scale. Both terms of adaptation and abstinence represent same syndrome of neonatal toxicity depending on the author. Sources: Finnegan LP. Neonatal abstinence syndrome: Assessment and pharmacotherapy. In: Nelson N, ed. Current Therapy in Neonatal-Perinatal Medicine. 2nd ed. Ontario: BC Decker; 1990. Way CM. Safety of newer antidepressants in pregnancy. Pharmacotherapy. 2007;27(4):546-552.
continued if a history of past or recurring episodes of depression exists.55 The provider can offer an ultrasound or echocardiogram in early pregnancy for pregnant women taking antidepressants to rule out a fetal cardiac anomaly associated especially with paroxetine. Providers should also offer ongoing, updated information and education to the woman to aide in her decision making throughout pregnancy and postpartum. Tricyclic antidepressant medications have only shown limited effectiveness in adolescents and are associated with negative adverse reactions.5 More research has focused on the use of SSRIs. Until recently, the FDA had only approved fluoxetine for the treatment of adolescent depression. In March 2009, escitalopram was approved for acute and maintenance treatment for adolescent depression. The risk of increased suicidal ideation and behavior has been a major concern with the use of SSRIs in adolescents. In 2004, the FDA concluded that a warning box indicating a risk of suicidality needed to be included in the prescribing information of all antidepressant drugs.5 Careful monitoring of prenatally depressed women and frequent NP-to-specialty provider (such as obstetrics, psychiatry) communication is essential in delivering quality care.72 The key to management of depression in pregnancy is to thoroughly discuss with the patient the benefits and the risks to her and her unborn infant that may occur with each of the various treatment options. A younger, pregnant adolescent’s voice may be framed within parental or guardian’s decisions on her behalf. However, if the pregnant adolescent is an emancipated minor, she may have legal voice to her opinions and decisions–much depends on individual and developmental aspects. Care to understand the specific needs of the pregnant woman includes respecting women’s rights The Nurse Practitioner • July 2015 43
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Prenatal depression: Early intervention
Risks associated with antidepressant use during pregnancy Antidepressant
Class
Medication risk to exposed infants in utero
Comments
Fluoxetine
SSRI
• Cardiac anomalies (2.04% in exposed versus 1.29% unexposed infants) • Ventral septal defects (1.43% versus 0.8%) Infantile hypertrophic pyloric stenosis
Pregnancy category C
Paroxetine
SSRI
Right ventricular outflow defects (0.31% versus 0.07%)–Increased risk in 1st and 3rd trimester.
• Pregnancy category D teratogenicity in 1st trimester • Persistent pulmonary hypertension of the newborn (PPHN) in 3rd trimester
Citalopram
SSRI
Neural tube defects (0.29% versus 0.09%)
Pregnancy category C
All SSRIs
• Increased risk of PPHN after week 20 of pregnancy. Increased from 1:700 to 7:1,000 • Estimated absolute risk less than 1% in infants exposed (for example, 99% with no PPHN).
PPHN can be fatal in 10%-20% of newborns. Exposure in late pregnancy associated with increased risk of PPHN with similar rate for citalopram, paroxetine, and fluoxetine.
Spontaneous abortion
Inconclusive research
Preterm birth
Inconclusive findings
Fetal death
Most studies–no increased risk.
All SSRIs and SNRIs
Poor neonatal adaptation (serotonin withdrawal and serotonin syndrome) Jitteriness, poor muscle tone, weak or absent cry; respiratory distress; Hypoglycemia; feeding difficulties; irritability, agitation, low APGAR scores; seizures.
• Inform pediatrician of intrauterine exposure. • Closely observe infants who have been exposed. • Must consider the risks of untreated depression during the 3rd trimester.
Venlafaxine
SNRI
Increased risk of preterm birth and withdrawal syndrome–similar with SSRIs.
Pregnancy category C–One study reported seizures in neonate (N = 1)
Duloxetine
SNRI
No studies
Pregnancy category C
Mirtazapine
Noradrenergic and Specific Serotonergic Antidepressant
Limited data; no increased risk of congenital malformations; increased risk of preterm birth; neonatal withdrawal similar to SSRIs.
Pregnancy category C
Amitriptyline; Nortriptyline
TCAs
No significant association between TCA and congenital malformations. In 3rd trimester associated with similar neonatal adaptation problems as the SSRIs and SNRIs.
Pregnancy category C
Isocarboxazid
MAOI
May limit fetal growth; may aggravate maternal BP.
Pregnancy category C
Bupropion
Norepinephrine Dopamine Reuptake Inhibitor
Not a 1st-line treatment for depression in pregnancy. No increased risk of congenital malformations or increased risk of heart defects. Increased risk of miscarriage.
Pregnancy category C Lowered seizure threshold possible for women with preeclampsia.
Table created by Carol Lieser, PhD, RN, OFS,PMHNP-BC.
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Prenatal depression: Early intervention
to make informed decisions regarding their care. As providers remain current on the research available on maternal depression, the challenges of managing this problem can be overcome, and significant benefits for the woman, her unborn infant, and her family can occur. REFERENCES 1. World Health Organization (WHO). The global burden of mental disorders and the need for a comprehensive, coordinated response from health and social sectors at the country level: The 65th World Health Assembly. Agenda item 13.2. 2012. http://www.prb.org/Articles/2006/DepressionaLeadingContributortoGlobalBurdenofDisease.aspx. 2. Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication—Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010;49(10):980-989. 3. Henshaw E, Sabourin B, Warning M. Treatment-seeking behaviors and attitudes survey among women at risk for perinatal depression or anxiety. J Obstet Gynecol Neonatal Nurs. 2013;42(2):168-177. 4. Burcusa SL, Iacono WG. Risk for recurrence in depression. Clin Psychol Rev. 2007;27(8):959-985. 5. Young JF, Miller MR, Khan N. Screening and managing depression in adolescents. Adolesc Health Med Ther. 2010;1:87-95. 6. American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Washington, DC: American Psychiatric Publishing; 2013. 7. Bennett HA, Einarson A, Taddio A, Koren G, Einarson TR. Prevalence of depression during pregnancy: systematic review. Obstet Gynecol. 2004;103(4):698-709. 8. Meltzer-Brody S, Bledsoe-Mansori SE, Johnson N, et al. A prospective study of perinatal depression and trauma history in pregnant minority adolescents. Am J Obstet Gynecol. 2013;208(3):211.e1-e7. 9. Salazar-Pousada D, Arroyo D, Hidalgo L, Pérez-López FR, Chedraui P. Depressive symptoms and resilience among pregnant adolescents: a case-control study. Obstet Gynecol Int. 2010;2010:952493. 10. Lancaster CA, Gold KJ, Flynn HA, Yoo H, Marcus SM, Davis MM. Risk factors for depressive symptoms during pregnancy: a systematic review. Am J Obstet Gynecol. 2010;202(1):5-14. 11. Melville JL, Gavin A, Guo Y, Fan MY, Katon WJ. Depressive disorders during pregnancy: prevalence and risk factors in a large urban sample. Obstet Gynecol. 2010;116(5):1064-1070. 12. Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol. 2005;106(5 Pt 1):1071-1083. 13. Parcells DA. Women’s mental health nursing: depression, anxiety and stress during pregnancy. J Psychiatr Ment Health Nurs. 2010;17(9):813-820. 14. Records K. Prenatal depression. Int J Childbirth Educ. 2011;26(4):19-22. 15. Holden KB, McKenzie R, Pruitt V, Aaron K, Hall S. Depressive symptoms, substance abuse, and intimate partner violence among pregnant women of diverse ethnicities. J Health Care Poor Underserved. 2012;23(1):226-241. 16. Figueiredo B, Pacheco A, Costa R. Depression during pregnancy and the postpartum period in adolescent and adult Portuguese mothers. Arch Womens Ment Health. 2007;10(3):103-109. 17. Lanzi RG, Bert SC, Jacobs BK. Depression among a sample of first-time adolescent and adult mothers. J Child Adolesc Psychiatr Nurs. 2009;22(4):194-202. 18. Hodgkinson SC, Colantuoni E, Roberts D, Berg-Cross L, Belcher HM. Depressive symptoms and birth outcomes among pregnant teenagers. J Pediatr Adolesc Gynecol. 2010;23(1):16-22. 19. Records K, Rice M. Psychosocial correlates of depression symptoms during the third trimester of pregnancy. J Obstet Gynecol Neonatal Nurs. 2007;36(3):231-242. 20. Dietz PM, Williams SB, Callaghan WM, Bachman DJ, Whitlock EP, Hornbrook MC. Clinically identified maternal depression before, during, and after pregnancies ending in live births. Am J Psychiatry. 2007;164(10):1515-1520. 21. Tzilos GK, Zlotnick C, Raker C, Kuo C, Phipps MG. Psychosocial factors associated with depression severity in pregnant adolescents. Arch Womens Ment Health. 2012;15(5):397-401. 22. Lara MA, Le HN, Letechipia G, Hochhausen L. Prenatal depression in Latinas in the U.S. and Mexico. Matern Child Health J. 2009;13(4):567-576. 23. Fortner RT, Pekow P, Dole N, Markenson G, Chasan-Taber L. Risk factors for prenatal depressive symptoms among Hispanic women. Matern Child Health J. 2011;15(8):1287-1295.
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24. Ruiz RJ, Marti CN, Pickler R, Murphey C, Wommack J, Brown CE. Acculturation, depressive symptoms, estriol, progesterone, and preterm birth in Hispanic women. Arch Womens Ment Health. 2012;15(1):57-67. 25. Jesse DE, Swanson MS. Risks and resources associated with antepartum risk for depression among rural southern women. Nurs Res. 2007;56(6):378-386. 26. Davila M, McFall SL, Cheng D. Acculturation and depressive symptoms among pregnant and postpartum Latinas. Matern Child Health J. 2009;13(3):318-325. 27. Brennan PA, Pargas R, Walker EF, Green P, Newport DJ, Stowe Z. Maternal depression and infant cortisol: influences of timing, comorbidity and treatment. J Child Psychol Psychiatry. 2008;49(10):1099-1107. 28. Halligan SL, Herbert J, Goodyer IM, Murray L. Exposure to postnatal depression predicts elevated cortisol in adolescent offspring. Biol Psychiatry. 2004;55(4):376-381. 29. Toohey J. Depression during pregnancy and postpartum. Clin Obstet Gynecol. 2012;55(3):788-797. 30. Lindahl V, Pearson JL, Colpe L. Prevalence of suicidality during pregnancy and the postpartum. Arch Womens Ment Health. 2005;8(2):77-87. 31. Bonari L, Pinto N, Ahn E, Einarson A, Steiner M, Koren G. Perinatal risks of untreated depression during pregnancy. Can J Psychiatry. 2004;49(11):726-735. 32. National Scientific Council on the Developing Child. Early experiences can alter gene expression and affect long-term development: Working paper No. 10. 2010. www.developingchild.harvard.edu. 33. Akman I, Kusçu K, Ozdemir N, et al. Mothers’ postpartum psychological adjustment and infantile colic. Arch Dis Child. 2006;91(5):417-419. 34. McLearn KT, Minkovitz CS, Strobino DM, Marks E, Hou W. The timing of maternal depressive symptoms and mothers’ parenting practices with young children: implications for pediatric practice. Pediatrics. 2006;118(1):e174-e182. 35. McLearn KT, Minkovitz CS, Strobino DM, Marks E, Hou W. Maternal depressive symptoms at 2 to 4 months post-partum and early parenting practices. Arch Pediatr Adolesc Med. 2006;160(3):279-284. 36. Ross LE, McLean LM. Anxiety disorders during pregnancy and the postpartum period: a systematic review. J Clin Psychiatry. 2006;67(8):1285-1298. 37. Parker B, McFarlane J. Identifying and helping battered pregnant women. MCN Am J Matern Child Nurs. 1991;16(3):161-164. 38. Connor KM, Davidson JR. SPRINT: a brief global assessment of posttraumatic stress disorder. Int Clin Psychopharmacol. 2001;16(5):279-284. 39. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10): 1092-1097. 40. Wuyek LA, Antony MM, McCabe RE. Psychometric properties of the panic disorder severity scale: clinician-administered and self-report versions. Clin Psychol Psychother. 2011;18(3):234-243. 41. Hübner-Liebermann B, Hausner H, Wittmann M. Recognizing and treating peripartum depression. Dtsch Arztebl Int. 2012;109(24):419-424. 42. Moses-Kolko EL, Roth EK. Antepartum and postpartum depression: healthy mom, healthy baby. J Am Med Womens Assoc. 2004;59(3):181-191. 43. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561-571. 44. Gaynes BN, Gavin N, Meltzer-Brody S, et al. Perinatal depression: prevalence, screening accuracy, and screening outcomes. Evid Rep Technol Assess (Summ). 2005;(119):1-8. 45. 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. 46. Choate L, Gintner G. Prenatal Depression: Best Practice Guidelines for Diagnosis and Treatment. J Counseling & Development. 2011;89(3):373-381. 47. Freed RD, Chan PT, Boger KD, Tompson MC. Enhancing maternal depression recognition in health care settings: a review of strategies to improve detection, reduce barriers, and reach mothers in need. Fam Syst Health. 2012;30(1):1-18. 48. Barnet B, Liu J, Devoe M. Double jeopardy: depressive symptoms and rapid subsequent pregnancy in adolescent mothers. Arch Pediatr Adolesc Med. 2008;162(3):246-252. 49. Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception. 2011;84(5):478-485. 50. van Gelder MM, van Rooij IA, Miller RK, Zielhuis GA, de Jong-van den Berg LT, Roeleveld N. Teratogenic mechanisms of medical drugs. Hum Reprod Update. 2010;16(4):378-394. 51. Yi Y, Lindemann M, Colligs A, Snowball C. Economic burden of neural tube defects and impact of prevention with folic acid: a literature review. Eur J Pediatr. 2011;170(11):1391-1400. 52. Malm H, Artama M, Gissler M, Ritvanen A. Selective serotonin reuptake inhibitors and risk for major congenital anomalies. Obstet Gynecol. 2011;118(1):111-120.
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53. ACOG. Depression during pregnancy: Treatment recommendations. http:// www.ACOG.org/About_ACOG/News_Room/News_Releases/2009/Depression_During_Pregnancy. 54. Weissman MM, Pilowsky DJ, Wickramaratne PJ, et al. Remissions in maternal depression and child psychopathology: a STAR*D-child report. JAMA. 2006;295(12):1389-1398. 55. ACOG Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin: Clinical management guidelines for obstetrician-gynecologists number 92, April 2008 (replaces practice bulletin number 87, November 2007). Use of psychiatric medications during pregnancy and lactation. Obstet Gynecol. 2008;111(4):1001-1020. 56. Goodman SH, Dimidjian S. The developmental psychopathology of perinatal depression: implications for psychosocial treatment development and delivery in pregnancy. Can J Psychiatry. 2012;57(9):530-536. 57. Spinelli MG, Endicott J, Leon AC, et al. A controlled clinical treatment trial of interpersonal psychotherapy for depressed pregnant women at 3 New York City sites. J Clin Psychiatry. 2013;74(4):393-399. 58. Abel KM. Review: psychosocial and psychological interventions reduce postpartum depressive symptoms. Evid Based Ment Health. 2008;11(3):79. 59. Faucher MA. Mindfulness yoga improves scores on depression scales and fosters maternal-fetal attachment J Midwifery Womens Health. 2013;58(1):111-112. 60. Gossler SM. Use of complementary and alternative therapies during pregnancy, postpartum, and lactation. J Psychosoc Nurs Ment Health Serv. 2010;48(11):30-36. 61. Bulut M, Bez Y, Kaya MC, Copoglu US, Bulbul F, Savas HA. Electroconvulsive therapy for mood disorders in pregnancy. J ECT. 2013;29(2):e19-e20. 62. Meltzer-Brody S. New insights into perinatal depression: pathogenesis and treatment during pregnancy and postpartum. Dialogues Clin Neurosci. 2011;13(1):89-100. 63. Cooper WO, Willy ME, Pont SJ, Ray WA. Increasing use of antidepressants in pregnancy. Am J Obstet Gynecol. 2007;196(6):544.e1-e5.
64. Chaudron LH. Complex challenges in treating depression during pregnancy. Am J Psychiatry. 2013;170(1):12-20. 65. Hoppenbrouwers CJ, Bosma J, Wennink HJ, Hilgevoord AA, Heres M, Honig A. Neonatal seizures on EEG after in utero exposure to venlafaxine. Br J Clin Pharmacol. 2010;70(3):454-456. 66. Nijenhuis CM, Horst PG, Berg LT, Wilffert B. Disturbed development of the enteric nervous system after in utero exposure of selective serotonin re-uptake inhibitors and tricyclic antidepressants. Part 1: literature review. Br J Clin Pharmacol. 2012;73(1):16-26. 67. Nijenhuis CM, ter Horst PG, van Rein N, Wilffert B, de Jong-van den Berg LT. Disturbed development of the enteric nervous system after in utero exposure of selective serotonin re-uptake inhibitors and tricyclic antidepressants. part 2: testing the hypotheses. Br J Clin Pharmacol. 2012;73(1):126-134. 68. Wakil L, Perea E, Penaskovic K, Stuebe A, Meltzer-Brody S. Exacerbation of psychotic disorder during pregnancy in the context of medication discontinuation. Psychosomatics. 2013;54(3):290-293. 69. Cohen LS, Altshuler LL, Harlow BL, et al. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA. 2006;295(5):499-507. 70. Ramos E, Oraichi D, Rey E, Blais L, Bérard A. Prevalence and predictors of antidepressant use in a cohort of pregnant women. BJOG. 2007;114(9):1055-1064. 71. Andrade SE, McPhillips H, Loren D, et al. Antidepressant medication use and risk of persistent pulmonary hypertension of the newborn. Pharmacoepidemiol Drug Saf. 2009;18(3):246-252. 72. Morgan M, de Jong-van den Berg LT, Jordan S. Drug safety in pregnancy— monitoring congenital anomalies. J Nurs Manag. 2011;19(3):305-310. Cheryl A. Anderson is an associate professor and Carol Lieser is an associate professor of the Psych Nurse Practitioner Program at the University of Texas at Arlington, Arlington, Tex. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NPR.0000453645.36533.73
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