More than the Baby Blues: Depression in Pregnancy and the Postpartum Period April 3, 2008 11:00 am - 12:00 pm Meir Steiner, M.D., Ph.D., a professor of psychiatry and behavioral neurosciences, obstetrics and gynecology at McMaster University in Hamilton, Ontario, Canada, will answer questions about depression in women during pregnancy and the postpartum period. These can be periods of great change, stress and hormonal fluctuations for women that can trigger serious or potentially dangers mood disorders that go beyond normal mood swings. Submit your questions and comments before or during the discussion. Moderator: Good morning and welcome to today's online moderated discussion on depression around pregnancy the postpartum period. Here to answer your questions is Dr. Meir Steiner, M.D., Ph.D., a professor of psychiatry and behavioral neurosciences, obstetrics and gynecology at McMaster University in Hamilton, Ontario, Canada. Dr. Steiner is both a researcher and a clinician and he participated in a Society media roundtable on this event last November in New York. Cohasset, Massachusetts: Why do you think the U.S. is so far behind Canada and European countries in research relating to the link to estradiol levels in post partum depression and psychosis? Also, why are studies in this area of medicine not being done by reproductive endocrinologist? Meir Steiner, M.D., Ph.D.: The U.S. is not so far behind. This is a very difficult topic to research and we still do not have sufficient evidence to show that postpartum hormonal treatment is effective. Saginaw, MI: Is there any mitigating or aggravating effect from oral contraceptives or depoprovera in the immediate post partum period? Meir Steiner, M.D., Ph.D.: Not really. The newer oral contraceptives are regarded as mostly safe in most women who do not have any of the risk factors that would be considered a contraindication to their use at any other time as well.There is some suggestion that in a small percentage of breastfeeding mothers the pill might cause a small decrease in milk production. Overall it might be better, if at all possible, to wait until periods are back before restarting the pill postpartum and use other methods of birthcontrol in the interim. McKinney, Tx: If a woman has significant PMS, almost pathological, is she more apt to have more dangerous mood disorders that go beyond normal mood swings during the postpartum year? Thanks, Barbara Meir Steiner, M.D., Ph.D.: Yes, the risk is somewhat higher. Truckee, California: Is it true that Omega 3 fatty acids help with or even help prevent postpartum depression. If so, what dosage is recommended? Meir Steiner, M.D., Ph.D.: Omega 3 fatty acids are generally regarded as safe during pregnancy and are considered beneficial for both mother and child but there is as yet no evidence that they can prevent postpartum depression. Gardiner, Maine: Is it best to discuss depression possibilities when they first occur with your doctor, or could this just be the "baby blues" that so many women talk about? Can I get a prescribed SAFE antidepressant while pregnant? Meir Steiner, M.D., Ph.D.: It is always best to discuss it with your doctor as soon as possible. Your doctor will be able to reasure you that this is only the "blues" (which should normally resolve within 2-3 weeks postpartum) or if it is depression to initiate the appropriate intervention. There are antidepressants that are considered safe during pregnancy (if absolutely indicated). Deschutes County Health Department: Would you please discuss the pros and cons of taking women with pre-existing conditions (ie bi-polar, serious depression) off their RX during pregnancy and in the breast feeding postpartum period? Meir Steiner, M.D., Ph.D.: Stress, depression and anxiety are "health hazards" for both the mother and her child. The mother-at-risk together with her doctor must way the risk-benefit ratio of using or not using medications during pregnancy and while breastfeeding. Lexinton, Ky: There are so many things going on with your mind and body around the time of pregnancy, what should expectant or new mothers be on the look out for and how do you distinguish those things from what's normal? Meir Steiner, M.D., Ph.D.: You are right. A lot is going on that is new and unfamiliar and it is "normal" to be worried but you should still be able to be positive, to enjoy the pregnancy, to look forward to the arrival of the baby and at the same time be able to continue with almost all your usual activities. Also, check with friends and relatives if you are not sure whether any of your thoughts or signs and symptoms are unusual and if so consult your doctor. Iowa City, IA: If you've been prone to depression or depression like symptoms since puberty are you at higher risk for post partum depression? Meir Steiner, M.D., Ph.D.: Unfortunately yes. State College, PA: The Society for Women's Health Research press release from the Nov. 13 roundtable event you participated in said that postpartum depression affects 10-15 percent of women. How much higher is that than the depression rate in the general women's population? Meir Steiner, M.D., Ph.D.: It is much the same. Ithaca, N.Y.: Is there much data on whether medications for mental illness, particularly depression, have a negative effect on the fetuses of pregnant women who take them? Or whether those babies exhibit any developmental differences from the general population? Meir Steiner, M.D., Ph.D.: The overall concensus is that some of the newer antidepressants are safe and that babies born to mothers who took them during pregnancy are not developmentally different. It is nevertheless important to emphasize that meds should be used in pregnancy only when absolutely indicated. Washington, D.C.: I have a question about the Society's survey of women and doctors. It found that virtually every doctor (97%) says it is okay to take depression medication in the postpartum period, while only half of women said it was okay. There's clearly a consensus from doctors on this issue. Why are many women so cautious, even after pregnancy? Meir Steiner, M.D., Ph.D.: For the longest time women were told that medications during pregnancy are dangerous to the fetus. It is only in recent years that evidence has started to accumulate that some of the antidepressants are safe. It takes time for this change in perception to reach the population at large. Macon, Georgia: Based on your clinical experience, do many patients wait to seek help until their symptoms or depression is quite severe, and does waiting make their condition more difficult to treat? Put another way, are the outcomes better if you detect and treat depression early? Meir Steiner, M.D., Ph.D.: Yes, the sooner treatment is initiated the better the outcome. Columbus, IN: What kind of role can social support networks like family and friends play in preventing postpartum depression? Meir Steiner, M.D., Ph.D.: A huge role, but it may not always be enough. Some women will develop postpartum depression despite the best support and will need additional professional intervention. Logan, UT: Are all pregnancy and postpartum depressions hormonally related or can the depression just be triggered by situational circumstances like: lack of support or help taking care of the baby; dealing with a sick or difficult baby; a general sense of being overwhelmed as a new mother. Meir Steiner, M.D., Ph.D.: In most cases it is a combination of all or at least some of the factors you mentioned. Vancouver: I would like to know if there are health benefits to using SAD (seasonal affective disorder) light therapy lamps to help with PPD? Is there documented research with this information? Thanks Meir Steiner, M.D., Ph.D.: There are only less than a handfull of studies that tried this intervention (look up Barbara Perry from San Diego and Ray Lam and Maria Coral from Vancouver who published on this topic). The evidence is not overwhelming, but there is no harm in trying. Orange County, CA: I have chronic depression and social anxiety disorder and am taking Cymbalta. I'm worried about the effects of taking antidepressants when I decide to have a baby. How safe is it to take antidepressants while pregnant? Does it depend on what trimester of pregnancy you're in? Meir Steiner, M.D., Ph.D.: Cymbalta is the "newest kid on the block" and we have very little evidence on its safety during pregnancy. Consult your doctor for the most recent data (which should be available to your doctor from the manufacturer of the drug). Orange County, CA: After I have a baby, I would like to breast feed. I also have chronic depression and social anxiety disorder and need to take antidepressants. How safe is it for a newborn? Is it even feasable to be on antidepressants and breastfeed? Meir Steiner, M.D., Ph.D.: Yes, some of the antidepressants are safe for breastfeeding. United States: I took 400 mg of Lamictal with my first pregnancy and nursed for 8 months. Everything was fine mood-wise. This second pregnancy has had alot of mood swings- to the point that I almost feel like I'm not on my medication. I wonder if you think my chances of post partum depression will be higher this time around. Meir Steiner, M.D., Ph.D.: It is difficult for me to guess. I hope not, but you may wish to consult your doctor and consider an adjustment in dose. Alexandria, VA: Is disinterest in the upcoming birth of a baby a sign of depression? Meir Steiner, M.D., Ph.D.: Absolutely. Bonding should start already during the second part of pregnancy. If it does not happen, it could be a sign of depression. Bowling Green, KY: Are the symptoms of depression around pregnancy or postpartum any different than the symptoms of depression you might experience at different times of life? Meir Steiner, M.D., Ph.D.: Most symptoms are the same but some of the focus may be on concerns related directly to the pregnancy, the delivery and the baby. Boston, Ma: Mood disorders run in my family. Is there a way to "prevent" becoming depressed during pregnancy? Meir Steiner, M.D., Ph.D.: Acknowledging that you might be at risk is already a huge step in the right direction. Keep tabs on yourself and make sure that you have access to prof. help in advance if needed. LA, CA: Is non-stop crying a sign of depression, or is that just the hormones talking? (I can't wait to have this baby! Five more weeks!) Meir Steiner, M.D., Ph.D.: It could be. You should see your doctor as soon as possible. California: I had my first child about a year ago and shortly thereafter was diagnosed with depression. I was prescribed and am still taking an antidepressant. I feel okay and my daughter is now 1 year old and I feel like I should be past postpartum depression issues, but I'm afraid to stop taking the medications because I fear a relapse. How can I know when it is safe to stop using them? Meir Steiner, M.D., Ph.D.: Assuming that you have been symptom free for at least 6 months you could try tapering of your meds very very slowly and gradually and hopefully symptoms will not resurface. Mich.: I thought pregnancy was more likely to protect you against developing depression. Is that not true? Meir Steiner, M.D., Ph.D.: Unfortunately not! 10-20% of pregnant women will have symptoms of depression/anxiety and many of them will need help. Punta Gorda, Fla: I have battled depression for most of my adult life and I'm on medication right now that works really well for me. By all accounts, my mood is normal and generally positive. I'm ready to start a family and I think I should stop taking the medication. Is the risk of me having a relapse greater during pregnancy than at other times? Meir Steiner, M.D., Ph.D.: You are at greater risk than the rest of the population, but there is no test to establish whether it will happen to you or not. Canada!: Do you think a lot of women feel guilty about being depressed after they've given birth? It's supposed to be the best time of their life. Meir Steiner, M.D., Ph.D.: Yes, a lot of women with postpartum depression feel guilty, but since it is not their fault that they became depressed I usually tell them that in this case guilt is a useless emotion. Hagerstown: I'm bipolar and when I'm on medication, I'm fine. Do my meds pose a danger to my baby when I'm breastfeeding? Meir Steiner, M.D., Ph.D.: Some meds are safe. You should consult your pediatrician. Atlanta: How big of a role does sleep play in depression? Meir Steiner, M.D., Ph.D.: Sleep deprivation is your biggest "enemy," especially during the first 12 weeks postpartum. California: It has been 3 months since I had my baby and recently I have begun to feel depressed. I normally think of postpartum depression as immediately following the birth of the baby. Can this be categorized as postpartum depression or is this just 'regular' depression? How can you tell the difference? Meir Steiner, M.D., Ph.D.: We still consider an episode to be postpartum if it starts within the first year. New York: Are any racial groups more likely to develop postpartum depression? Meir Steiner, M.D., Ph.D.: No. Ohio: I am currently pregnant and have recently been feeling very depressed. Are there any risks to my baby? Can my mood effect the baby's well-being? Meir Steiner, M.D., Ph.D.: Stress, anxiety and depression are in themselves not healthy for you and for your unborn child. You should consult your doctor and get some help. D.C.: What is the postpartum period? How long after birth? Moderator: The postpartum period is the period beginning immediately after the birth of a child and lasts about six weeks. Biologically, it is the time after birth when the mother's body, including hormone levels and uterus size, return to pre-pregnancy conditions. Postpartum depression affects 10-15 percent of women any time from one month to one year after childbirth. New York: If I didn't experience Post Partum depression with my first child is it still possible that I can experience it with subsequent children? Meir Steiner, M.D., Ph.D.: Rarely. U MD SOM: What kinds of outcome measure should we be using for intervention studies? Meir Steiner, M.D., Ph.D.: The Edinburgh Postnatal Depression Scale. NJ: How can the stress of this disease affect the baby? Meir Steiner, M.D., Ph.D.: Continuous and high levels of the stress hormones circulating in your body (primarily Cortisol) are shared via the placenta with your unborn child and may affect the baby later in life. Maine: I have heard that stress can cause a miscarriage. Is this true? If so, can sadness (or depression) have similar effects? How does the rate of miscarriages differ for women with PPD differ from women without it? Meir Steiner, M.D., Ph.D.: Extreme stress, anxiety and depression have all been associated with an increased incidence of miscarriages. Moderator: This concludes our live discussion today. Thank you to everyone for participating, especially Dr. Steiner for taking time out of his busy schedule to answer questions. A common theme runs throughout this discussion: It is vitally important that you talk extensively with your health care providers to ensure that you select the best treatment plan, if any is needed, to address a mood disorder. No one, including pregnant women and new mothers, should feel guilty or personally responsible for depression or other mental health issues. Open, honest and effective communication is the key for all of us as patients. If any of today's questions or answers have raised health concerns or issues for you, talk to your own doctors as soon as possible. A full archive of today's discussion will be available here on the Society’s Web site for future viewing. To learn about upcoming chats and other women’s health information, sign up for our e-newsletter. Thank you again for joining us.