Healthcare Providers

Perinatal Depression and Anxiety

Depression and anxiety are two of the most common complications women experience during pregnancy and the postpartum period. Much of the research in the past has focused on postpartum depression. More recent research has shown that women experience depression and anxiety disorders, as well as other mental health conditions, during pregnancy and postpartum. These conditions, sometimes termed perinatal mood and anxiety disorders, are associated with significant effects on the health of the mother and her child if not treated. 

The American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM)-V does not recognize perinatal depression as a separate diagnosis. Rather, patients must meet the criteria for a major depressive episode and the criteria for the peripartum-onset specifier. The definition is therefore a major depressive episode with an onset in pregnancy or within 4 weeks of delivery.1 However, research indicates women are at risk for depression and anxiety up to 12 months postpartum.

Perinatal depression and anxiety are generally treatable conditions. Effective screening, diagnosis, and treatment of symptoms can substantially improve health outcomes for children, mothers, and families.

Take this free continuing education activity (PDF 644 KB) for primary care, obstetric and pediatric healthcare providers. Note: Accreditation for this activity has expired, however it is still available as a learning tool.

Signs and Symptoms

Many women experience transient and mild mood disturbances during the perinatal period. However, some women experience a more disabling and persistent form of depression or anxiety that requires treatment.2

Signs and symptoms of perinatal depression and anxiety include:

  • Persistent sadness
  • Impaired concentration or indecisiveness
  • Disconnection from emotions
  • Anxiety around the newborn
  • Feelings of inadequacy or guilt
  • Irritability or mood changes
  • Lack of interest in the newborn, family, or activities
  • Recurrent thoughts of death or suicidal ideation*
  • Racing thoughts

*May also be a sign of psychosis

Prevalence

The prevalence of perinatal depression varies with the population surveyed. However, there is agreement that depression is one of the most common complications women experience during the perinatal period. According to recent research:

  • As many as 13% of women in the U.S. reported frequent symptoms of depression after childbirth.3 The most prevalent concurrent disorders in depressed pregnant and postpartum women were anxiety disorders (43%).4
  • Among non-depressed pregnant or postpartum women, 11% screened positive for anxiety disorders.5
  • Among teen mothers, the prevalence of postpartum depression ranged from 53% to 61%.6
  • Among active duty servicewomen, close to 10% who gave birth for the first time were diagnosed with postpartum depression, while 8.2% of dependent spouses of military personnel were diagnosed.7

Researchers suspect many women go undiagnosed and that the actual number of women who experience depression and anxiety during the perinatal period may be much higher.

Etiology and Risk Factors

The etiology of perinatal anxiety and depression is not readily known. Researchers think depression and anxiety during this time is likely caused by a combination of physical, emotional, and environmental factors.

However, several factors are associated with increased risk of perinatal depression and anxiety, including:

  • A history of depression, anxiety, or other mental health problems8
  • Family history of depression, anxiety, or other mental health disorders9
  • Traumatic pregnancy or birth experience10
  • Multiple births, including twins or higher order multiples11 
  • Poor partnership relationship quality12
  • Lower socioeconomic status13
  • Low levels of social support14
  • Unintended pregnancy15
  • Teen pregnancy16
  • Military service17  
  • Domestic violence18

Adverse Effects to Mother and Infant

Prenatal Health Consequences

Research continues to explore the effects of women’s prenatal psychological distress on fetal behavior and child development, and the biological pathways for this influence. Studies have shown depression during pregnancy is associated with harmful prenatal health consequences, which may compromise the health of both the mother and her fetus: 

  • Poor nutrition
  • Poor prenatal medical care
  • Risk of suicide
  • Harmful health behaviors (e.g., smoking and alcohol or other substance misuse)19

Women with depression during pregnancy are at increased risk for preterm birth and infant low birth weight.20

Postpartum Health Consequences

Disruption of early maternal-infant bonding has been shown to impact an infant’s early development. Depressed women have been found to have poorer responsiveness to infant cues and more negative, hostile or disengaged parenting behaviors.21 These disruptions in maternal-infant interactions have been associated with adverse effects on the infant:  

  • Cognitive and language development delays.22,23,24
  • Social engagement, stress level, and fear reactivity.25

Clinical Evaluation

Screening

In early 2016, the U.S. Preventive Services Task Force (USPSTF) released recommendations for the screening for depression in the general adult population, including pregnant and postpartum women.26

Although screening is important for detecting perinatal depression and anxiety, screening by itself is insufficient to improve clinical outcomes and must be coupled with appropriate follow-up and treatment when indicated.

Obstetricians and Gynecologists

The American College of Obstetricians and Gynecologists (ACOG) 2015 Committee Opinion external link recommends women be screened at least once during the perinatal period for depression and anxiety.27 The College recommends that clinical staff in obstetrics and gynecology practices be prepared to initiate medical therapy, refer patients to appropriate behavioral health resources when indicated, or both.

Pediatricians

The American Academy of Pediatrics, based on a 2010 clinical report, encourages pediatric practices to screen mothers for postpartum depression, use community resources for the treatment and referral of the depressed mother, and provide support to the mother-child relationship.28  

Nurses

The Association of Women’s Health, Obstetric and Neonatal Nurses recommends that all women be screened for mood and anxiety disorders. Nurses are in key positions to screen women, provide education regarding perinatal mood and anxiety disorders to pregnant and postpartum women, and their families, and to ensure appropriate referrals.29

In addition, the American Psychological Association supports universal screening for depression in the perinatal period, noting that maternal depression often goes unrecognized and untreated because pregnant and postpartum women are not universally screened for depression.30,31  

The recommendations correlate with recent studies finding that screening can significantly reduce postpartum depressive symptoms when there is adequate follow up.32

Screening Tools

Several screening instruments have been validated for use during pregnancy and the postpartum period. The USPSTF recommends clinicians choose the method most consistent with the patient being served, the practice setting, and their personal preference.33

A screening tool measures the level of risk and should not be used to diagnose a patient. Referral to the patient’s primary care provider or to a mental health professional can ensure women get the diagnosis and treatment they need. 

ToolNumber of ItemsTime to Complete (Min)Sensitivity and SpecificitySpanish Version Available
Edinburgh Postnatal Depression Scale (EPDS)10Less than 5Sensitivity 59% to 100%
Specificity 49% to 100%		Yes
Postpartum Depression Screening Scale355 to 10Sensitivity 91% to 94%
Specificity 72% to 98%		Yes
Patient Health Questionnaire 99Less than 5Sensitivity 75%
Specificity 90%		Yes
Beck Depression Inventory215 to 10Sensitivity 47.6% to 82%
Specificity 85.9% to 89%		Yes
Beck Depression Inventory-II215 to 10Sensitivity 56% to 57%
Specificity 97% to 100%		Yes
Center for Epidemiologic Studies -- Depression Scale205 to 10Sensitivity 60%
Specificity 92%		Yes
Zung Self-Rating Depression Scale205 to 10Sensitivity 45% to 89%
Specificity 77% to 88%		No

Source: American College of Obstetricians and Gynecologists external link, 2015.

Management

In most cases, depression and anxiety will not subside on their own and require treatment. The two most common forms of treatment for perinatal depression are medication and/or psychotherapy. Lifestyle behaviors can work in tandem with treatment and help patients to manage symptoms. 

The choice of treatment depends on the severity of symptoms, the woman’s needs and preferences, and the availability of services. 

Pharmacologic Treatments

Appropriate pharmacologic treatment is available for most pregnant and breastfeeding women.34 The benefits and risks, as well as alternatives to medications, should be carefully explained to the patient. The research on the use of psychiatric medications during pregnancy is limited. The risks are different depending on which medication is taken, and at what point during the pregnancy the medication is taken.35 Antidepressants, especially selective serotonin reuptake inhibitors (SSRIs), are considered to be safe during pregnancy. However, antidepressant medications do cross the placental barrier and may reach the fetus. Congenital anomalies or other problems are possible, but they are very rare. The effects of antidepressants on childhood development remain under study.36

Similarly, pharmacological treatment while a woman is breastfeeding can put the infant at risk for adverse effects. The U.S. National Library of Medicine LactMed® database lists possible effects of drugs and other chemicals to a breastfed baby.

Psychotherapy

Psychotherapy, such as cognitive behavioral therapy, is a suitable treatment option for some women, particularly those concerned about taking medications while pregnant or nursing. For others, psychotherapy may be used in conjunction with pharmacological treatments. Psychotherapy should be provided by a qualified mental health professional.

Lifestyle and Behaviors

Perinatal depression and anxiety generally require treatment. In addition to treatment, there is some evidence that lifestyle changes may help to build on the treatment plan and help speed recovery. Therefore, it may be helpful to recommend lifestyle or behavior changes to your patients who are dealing with depression or anxiety. These may include finding ways to be physically active, getting more rest, optimizing nutrition and overall health, and finding help with childcare. Women can find tips on our Moms’ Mental Health Matters page for moms.

Resources for Patients

Recent studies have found that screening can significantly reduce postpartum depressive symptoms when systems are in place to ensure adequate follow up of women with positive results.37

If you do not have mental health providers within your practice or network, you can suggest that your patient contact these resources.

Order our free Moms’ Mental Health Matters materials for your patients.

LactMed® is a registered trademark of the U.S. Department of Health and Human Services.

Citations

  1. Diagnostic and Statistical Manual of Mental Disorders, 5th edition. (2013). American Psychiatric Association: Washington, DC.
  2. Le Strat, Y., Dubertret, C., & Le Foll, B. (2011). Prevalence and correlates of major depressive episode in pregnant and postpartum women in the United States. Journal Of Affective Disorders, 135(1-3), 128-138. doi: 10.1016/j.jad.2011.07.004.
  3. Le Strat, Y., Dubertret, C., & Le Foll, B. (2011). Prevalence and correlates of major depressive episode in pregnant and postpartum women in the United States. Journal Of Affective Disorders, 135(1-3), 128-138. doi: 10.1016/j.jad.2011.07.004.
  4. Le Strat, Y., Dubertret, C., & Le Foll, B. (2011). Prevalence and correlates of major depressive episode in pregnant and postpartum women in the United States. Journal Of Affective Disorders, 135(1-3), 128-138. doi: 10.1016/j.jad.2011.07.004
  5. Le Strat, Y., Dubertret, C., & Le Foll, B. (2011). Prevalence and correlates of major depressive episode in pregnant and postpartum women in the United States. Journal Of Affective Disorders, 135(1-3), 128-138. doi: 10.1016/j.jad.2011.07.004
  6. McGuinness, T.M., Medrano, B., & Hodges, A. (2013). Update on adolescent motherhood and postpartum depression. Journal of Psychosocial Nursing & Mental Health Services, 51(2), 15-18. doi: http://dx.doi.org/10.3928/02793695-20130109-02 external link.
  7. Do, T., Hu, Z., Otto, J., & Rohrbeck, P. (2013). Depression and suicidality during the postpartum period after first time deliveries, active component service women and dependent spouses, U.S. Armed Forces, 2007-2012. Medical Surveillance Monthly Report, 20(9), 2-7.
  8. Milgrom, J., Gemmill, A.W., Bilszta, J.L., Hayes, B., Barnett, B., Brooks, J., et al. (2008). Antenatal risk factors for postnatal depression: A large prospective study. Journal of Affective Disorders. 108(1-2), 147-157.
  9. Dietz, P.M., Williams, S.B., Callaghan, W.M., Bachman, D.J., Whitlock, E.P., & Hornbrook, M.C. (2007). Clinically identified maternal depression before, during, and after pregnancies ending in live births. American Journal of Psychiatry, 164(10), 1515-1520.
  10. Blom, E.A., Jansen, P.W., Verhulst, F.C., Hofman, A., Raat, H., Jaddoe, V.W., et al. 2010. Perinatal complications increase the risk of depression or anxiety during pregnancy or after birth. The Generation R Study. BJOG: An International Journal of Obstetrics and Gynaecology, 117, 1390-1398.
  11. Blom, E.A., Jansen, P.W., Verhulst, F.C., Hofman, A., Raat, H., Jaddoe, V.W., et al. 2010. Perinatal complications increase the risk of depression or anxiety during pregnancy or after birth. The Generation R Study. BJOG: An International Journal of Obstetrics and Gynaecology, 117, 1390-1398.
  12. Robertson, E., Grace, S., Wallington, T., & Stewart, D.E. (2004). Antenatal risk factors for depression or anxiety during pregnancy or after birth: A synthesis of recent literature. General Hospital Psychiatry, 26(4), 289-295.
  13. Howell, E.A., Mora, P., & Leventhal, H. (2006). Correlates of early postpartum depressive symptoms. Maternal and Child Health Journal, 10(2), 149-157.
  14. Robertson, E., Grace, S., Wallington, T., & Stewart, D.E. (2004). Antenatal risk factors for depression or anxiety during pregnancy or after birth: A synthesis of recent literature. General Hospital Psychiatry, 26(4), 289-295.
  15. Milgrom, J., Gemmill, A.W., Bilszta, J.L., Hayes, B., Barnett, B., Brooks, J., et al. (2008). Antenatal risk factors for postnatal depression: A large prospective study. Journal of Affective Disorders. 108(1-2), 147-157.
  16. McGuinness, T.M., Medrano, B., & Hodges, A. (2013). Update on adolescent motherhood and postpartum depression. Journal of Psychosocial Nursing & Mental Health Services, 51(2), 15-18. doi: http://dx.doi.org/10.3928/02793695-20130109-02 external link.
  17. Do, T., Hu, Z., Otto, J., & Rohrbeck, P. (2013). Depression and suicidality during the postpartum period after first time deliveries, active component service women and dependent spouses, U.S. Armed Forces, 2007-2012. Medical Surveillance Monthly Report, 20(9), 2-7.
  18. Howard, L., Oram, S., Galley, H., Trevillion, K., & Feder, G. (2013). Domestic Violence and Perinatal Mental Disorders: A Systematic Review and Meta-Analysis. Plos Medicine, 10(5). DOI: 10.1371/journal.pmed.1001452
  19. Alder J, Fink N, Bitzer J, et al. Depression and anxiety during pregnancy: a risk factor for obstetric, fetal and neonatal outcome? A critical review of the literature. J Matern Fetal Neonatal Med. 2007 Mar;20(3):189-209. PMID: 17437220.
    Henry AL, Beach AJ, Stowe ZN, et al. The fetus and maternal depression: implications for antenatal treatment guidelines. Clin Obstet Gynecol. 2004 Sep;47(3):535-46. PMID: 15326416.
  20. Grote NK, Bridge JA, Gavin AR, et al. A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Arch Gen Psychiatry. 2010 Oct;67(10):1012-24. PMID: 20921117.
    Murray L, Cooper PJ. Postpartum depression and child development. Psychol Med. 1997 Mar;27(2):253-60. PMID: 9089818.
  21. Murray L, Fiori-Cowley A, Hooper R, Cooper PJ. The impact of postnatal depression and associated adversity on early mother infant interactions and later infant outcome. Child Dev. 1996;67:2512–2526.
  22. Field T. Postpartum depression effects on early interactions, parenting, and safety practices: A review. Infant Behavior and Development. 2009
  23. O’Hara MW, McCabe, JE. Postpartum depression: current status and future directions. (2013) Annual Review of Clinical Psychology. 9:379-407.
  24. Children of depressed mothers 1 year after the initiation of maternal treatment. Findings from the SaTAR*D Child Study. (2008) American Journal of Psychiatry. 165(9): 1136-1147.
  25. Feldman R, Granat A, Pariente C, Kanety H, Kuint J, Gilboa-Schechtman E. (2009) Maternal depression and anxiety across the postpartum year and infant social engagement, fear regulation, and stress reactivity. Journal of the American Academy of Child and Adolescent Psychiatry. 48(9):919-27. doi: 10.1097/CHI.0b013e3181b21651.
  26. U.S. Preventive Services Task Force. (2016). Depression in Adults: Screening. Available from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/depression-in-adults-screening external link
  27. The American College of Obstetricians and Gynecologists (ACOG). (2015). Screening for perinatal depression. Committee Opinion No. 630. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:1268–71.
    http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Screening-for-Perinatal-Depression external link.
  28. Earls, MF, The Committee on Psychosocial Aspects of Child and Family Health. November 2010. Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice. Pediatrics, 126(5): 1032-1039.
  29. AWHONN Position Statement. (2015) Mood and Anxiety Disorders in Pregnant and Postpartum Women. Journal of Obstetric, Gynecologic & Neonatal Nursing,44 (5): 687- 689. http://www.jognn.org/article/S0884-2175%2815%2935319-3/fulltext external link 
  30. American Psychological Association. Advocates for Perinatal Depression Screening. (2014) https://www.apa.org/advocacy/health/perinatal-depression-screening.pdf external link (PDF 40 KB). 
  31. American Psychological Assocation. APA Public Interest Government Relations Office, Postpartum Depression, (2014). Available from https://www.apa.org/advocacy/health/postpartum.pdf external link (PDF 89 KB). 
  32. Myers E, Aubuchon-Endsley N, Bastian L, et al. Efficacy and Safety of Screening for Postpartum Depression. Comparative Effectiveness Review 106. (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-2007-10066-I.) AHRQ Publication No. 13-EHC064-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2013. https://effectivehealthcare.ahrq.gov/products/depression-postpartum-screening/research.
  33. U.S. Preventive Services Task Force. (2016). Depression in Adults: Screening. Available from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/depression-in-adults-screening external link
  34. Use of Psychiatric Medications During Pregnancy and Lactation. ACOG Practice Bulletin No. 92. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008; 111:1002-20.
  35. Adam MP1, Polifka JE, Friedman JM. Evolving knowledge of the teratogenicity of medications in human pregnancy.  Am J Med Genet C Semin Med Genet. 2011 Aug 15;157C(3):175-82. doi: 10.1002/ajmg.c.30313. Epub 2011 Jul 15.
  36. Urato AC. Are the SSRI antidepressants safe in pregnancy? Understanding the debate. Int J Risk Saf Med. 2015;27(2):93-9. doi: 10.3233/JRS-150646.

  37. Myers E, Aubuchon-Endsley N, Bastian L, et al. Efficacy and Safety of Screening for Postpartum Depression. Comparative Effectiveness Review 106. (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-2007-10066-I.) AHRQ Publication No. 13-EHC064-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2013. http://www.effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1437.

     

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