Women with Depression—“You Can't Tell by Looking”™

Depression is currently the leading cause of disease-related disability among women worldwide [1]. Depression can cause moodiness, irritability, changes in sleep patterns, sexual interest or appetite, and an inability to carry on with daily activities. In the most severe cases depression can cause thoughts of harming others or oneself or suicide. Prevalence rates of perinatal depression, which occurs during pregnancy or at some point within the first postpartum year, are similar to those in the general population, affecting 10–15% of women and up to 28% of women living in poverty [2, 3]. Some studies suggest that a woman's risk of becoming depressed during the early postpartum period is approximately three times that of women in the general population [4]. Depression may affect how a woman is able to relate and respond to her infant and if untreated, may lead to thoughts of harming the infant or infanticide. In addition, depression can have significant effects on prenatal care-seeking behavior [5], substance abuse [6], and infant/child mental health [7‐9] and nutrition [10]. Depression has also been associated with low birthweight [11] and premature delivery [12].

Approximately 50% of women with perinatal depression remain undiagnosed when they are screened based on clinical observations alone [13]. Perhaps the strongest argument for routine screening of all pregnant and postpartum women is the fact that you can't tell simply by looking that a woman is depressed. However, there are some women who may be at increased risk for perinatal depression, including women living in poverty, those in abusive relationships, and women with a prior history of depression [14]. In fact, it is thought that having a history of depression is the strongest predictor that a woman will suffer from an episode of major depression during pregnancy or the postpartum period [15, 16]. Women with other mental disorders are at risk as well. For example, women with bipolar disorder also have an increased risk of experiencing postpartum depression, and some studies suggest an increased risk for a much more serious illness, postpartum psychosis [17]. Due to the predictive value of a history of depression, it is vital that women with a history of depression be counseled about the relationship between pregnancy and depression prior to conception.

Counseling about depression should become a routine part of preconception care. Health care providers who have contact with women during the preconception period can assist women in becoming aware of how pregnancy and depression can affect one another. By controlling depression prior to conception, just as one would with an illness such as diabetes or epilepsy, a woman's chances for healthy perinatal outcomes may improve [18].

The Wisconsin Association for Perinatal Care (WAPC) is a 35-year-old statewide, non-profit organization dedicated to the improvement of healthy outcomes for women, infants and their families. Since 1989, WAPC has been working toward infusing depression screening and counseling into preconception care by encouraging health care providers to ask women and their partners about their histories with depression and other mental illnesses prior to conception. One tool that has been developed by WAPC is an information sheet entitled Women with Depression that answers four basic questions: How does depression affect pregnancy? How does pregnancy affect depression? How could medications for depression affect the pregnancy? What can you do before pregnancy?

The benefits of counseling women about depression prior to conception are numerous. By treating depression as a chronic condition and by actively managing depression prior to conception, a woman's chances of being prepared for a depressive episode during the perinatal period greatly increase. In a recent meta-analysis of psychosocial and psychological interventions to reduce the risk of postpartum depression there was no statistically significant effect on the prevention of postpartum depression [19]. In the absence of preventive treatment, then, understanding postpartum depression could allow families to anticipate possible consequences of maternal depression so they could take steps to help assure healthy outcomes [20]. By fully disclosing the increased risk of depression if she chooses to become pregnant, a woman can make informed decisions about planning for a family [21]. If the woman is taking antidepressant medication, she can discuss the impact of those medications on her future pregnancy and breastfeeding. By working with her health care provider, steps can be taken to change the medication or dose if necessary.

One of the most devastating effects of perinatal depression is that it occurs at a time when most women feel they should be experiencing joy. By educating women prior to pregnancy or birth about the high prevalence of perinatal depression, they may be better prepared for an episode, should it occur. Women with a history of depression especially should have a plan of action in place in the event of perinatal depression.

Women who have suffered from depression once may be more likely to recognize the signs and symptoms of a subsequent episode whether or not the first episode occurred preconceptionally or postpartum. This may be especially true if they are counseled about the possibility of a subsequent episode occurring. Women are not the only ones who can be counseled about the interaction between pregnancy and depression. Loved ones often do not know how to help women suffering from perinatal depression and cannot understand why the woman is depressed. By counseling significant others and family members, they, too, can become better prepared and in addition, can help recognize signs of severe depression and assist with accessing treatment.

Seeking treatment may present fewer challenges to women who have been successfully treated and counseled about depression as well. Women with a history of depression can be counseled about seeking treatment at the earliest possible sign of depression, rather than waiting, as so often happens in primary episodes. The earlier treatment can be sought, the better the outcomes [22]. Stigma may be reduced as well if women are counseled ahead of time, making them more open to seeking treatment and more comfortable with their treatment decisions.