Introduction Perinatal depression, a mood disorder that occurs during pregnancy or the first year postpartum, affects 10–15% of women and up to 28% of women living in poverty. A previous history of depression, either preconceptionally or during the interconception period, is the strongest predictor that a woman will suffer from perinatal depression. Perinatal depression can adversely affect not only the woman, but also her fetus or infant, and has been linked with prematurity, difficulties with maternal-infant bonding and infant behavior problems later in life. If a woman has a known history of depression, she can be counseled preconceptionally about her increased risk of experiencing a subsequent episode during the perinatal years and thus take an active role in recognizing signs and symptoms of depression and accessing treatment as early as possible should an episode occur. The earlier treatment is sought for perinatal depression, the greater the chance for improved outcomes. Background 1 2 3 4 5 6 7 9 10 11 12 13 14 15 16 17 One method to incorporate depression screening & counseling into preconception care 18 Women with Depression How does depression affect pregnancy? How does pregnancy affect depression? How could medications for depression affect the pregnancy? What can you do before pregnancy? Case examples interconception Women with Depression Case example #1 Sara began experiencing symptoms of depression six months after giving birth to her first child. She had no prior history of depression and had received no counseling prior to conception about the symptoms and presentation of perinatal depression. Sara waited approximately six months before seeking help, but encountered numerous barriers to accessing care. She did eventually get into treatment and attended 15 sessions of interpersonal therapy. Through both her therapy and additional self-education, Sara became quite informed about the effects and consequences of postpartum depression. Approximately six months after giving birth to her second child, Sara began experiencing depression again. This time, Sara sought treatment within one week of the presentation of symptoms. In addition to being able to recognize the signs of depression earlier, as reported by both her and her husband, Sara also remarked on how much easier it was to access treatment, as she knew how to “navigate the system.” She knew what type of therapy worked for her and was able to resolve her depression in only seven sessions. Case example #2 Melanie had a history of anxiety and depression prior to conception, but was never diagnosed or treated. Melanie experienced extreme continuous sleep disturbances almost immediately after the birth of her first child. When this problem had not resolved itself within two months, Melanie sought treatment. She was initially reticent about taking medications because she was breastfeeding her infant, but at nine months postpartum, Melanie began a regimen of paroxetine, which finally resolved the depression. After Melanie's second birth, she felt slight anxiety about the possibility of suffering from postpartum depression again, but this time had a plan of action in place. When she began having trouble sleeping at two months postpartum, she immediately contacted her therapist and began treatment. She was once again hesitant about taking medication, but at nine months postpartum, began taking paroxetine on the recommendation of her care provider. Although she waited to begin medications with the second depressive episode, Melanie reported having “a kind of comfort knowing I was on paroxetine before and it didn't hurt my baby.” Benefits of preconception counseling for women with a history of depression 19 20 21 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. 22 Conclusions Women with Depression The major challenge currently lies in convincing health care providers to address women's mental health and to screen and counsel for depression during the preconception period. Intervention strategies using medication or counseling have not been significantly effective in preventing postpartum depression. Anticipating the potential interplay between depression and pregnancy may be an intervention that can lead to better mental health and perinatal outcomes. Future research should address the content and timing of preconception counseling, including what information is needed and when and how it should be disseminated. Treatment algorithms and strategies could then be developed for practitioners and families to help prepare for the postpartum period. Finally, well-controlled intervention studies utilizing the materials developed could focus on maternal mental health, perinatal, and infant outcomes to answer questions about efficacy and effectiveness.