Depression is a common complication of pregnancy and the postpartum period, with significant implications for a woman, her fetus, and her family. The biological, psychological, and social changes inherent in this time all contribute to the propensity toward mood disorder during this critical period. Women with mood disorders during the perinatal period are faced with challenging decisions when considering treatment. Mental health and obstetrical providers have important roles in helping women and their families weigh the impact of untreated mental health symptoms against the impact of potential treatments.
Case illustration: Shanté, a 23-year-old single woman, gave birth to her first child 6 weeks ago. Labor and delivery had been painful but uncomplicated, and her baby, a son she named Ryan, was healthy. Shanté was happy, although tired. She began to feel vulnerable and upset when she tried breastfeeding Ryan and he had difficulty latching on. Although the hospital nurse assured her this happens often, and a lactation consultant gave her tips about helping Ryan to latch, Shanté began to wonder if she would be able to parent Ryan successfully. After taking Ryan home 2 days later, she began to feel overwhelmed. She became afraid to fall asleep in case she would miss Ryan's crying or be unprepared to feed him. She felt exhausted. By 3 weeks postpartum, she felt emotionally numb and lost interest in food. She stopped showering, getting dressed or answering her phone, instead sitting leadenly in a chair near Ryan's crib as he napped. One night Ryan slept longer than usual, and Shanté became convinced he was dead. Even after seeing that he was breathing comfortably, she had the thought that unlike other mothers, she would be unable to keep her baby alive, so did not deserve to be alive herself. She had fleeting thoughts of overdosing on over-the-counter pills from the medicine cabinet, but did not act on these because she felt she could not burden anyone else with taking care of Ryan.
Depression is one of the most common disorders in the perinatal period, with higher prevalence than gestational hypertension or diabetes mellitus (Fig. 9-1). The risk of depression is elevated during pregnancy and the first year postpartum, particularly during the first 3 months postpartum. Meta-analysis shows a 7.5% incidence of major depression during pregnancy and 6.5% in the first 3 months of postpartum1 with point prevalence of major and minor depression of 11.0% in the first trimester and 8.5% later in pregnancy. In the first postpartum year, 13.9% of mothers and 3.6% of fathers develop unipolar, nonpsychotic major depression.2 Point prevalence rises postpartum to a high of 12.9% in the 3rd month, then drops to 9.9% to 10.6% from the 4th to 12th postpartum months, declining after that to 6.5%.1 The incidence of major depression was higher for mothers in the first year postpartum than in subsequent years.