Published on: Saturday, August 06, 2005 |
Kota Kinabalu: Depression affects 10 to 15 per cent of women during pregnancy and in the first three months postpartum (after delivery).
Dr Janet Atsumi Martin, from the Cedars-Sinai Medical Centre in Los Angeles, said depression can be a part of many disorders.
"These include major depressive disorder, postpartum depressive disorder, bipolar disorder, psychotic disorder and anxiety disorder," she said at the recent 2005 Malaysian Psychology Conference.
In her presentation on "Treatment of Depression during Pregnancy" at the plenary session, she said in major depressive disorder, depressed mood persists most of the day for at least two weeks.
"This condition is present along with three or four of the following - impairment of sleep, impairment of appetite, impairment of energy level, impairment of concentration, agitation or lethargy, guilt or worthlessness and thoughts of death or suicidal ideation," she explained.
On bipolar disorder, the psychiatrist said this condition may have a major depressive episode such as mania with elevated, expansive or irritable mood persisting for at least one week.
"This is accompanied by at least four of the following characteristics - need little sleep, grandiosity, agitation, rapid speech, flight of ideas or racing thoughts, pleasure-seeking and goal-directed activity."
The conference also heard that psychotic disorders affect two per cent of women of child-bearing age.
"Half of these women give birth," said Dr Martin.
Such disorders are characterised by delusions, hallucinations, disorganised thinking and behaviour, and lack of behaviour.
"Examples are schizoaffective disorder, schizophrenia and delusional disorder."
Dr Martin enlightened the women on the impact of depression during pregnancy:
* Poorer maternal self-care and nutrition
* Decreased birth weight
* Increased use of tobacco, alcohol and drugs
* Increased risk to foetus
* Increased stress hormones
* Increased risk of pre-term delivery
* Increased risk of postpartum depression
* Impairs care of and bonding with infant
The doctor cautioned against the risks of treatment during pregnancy such as effects on the foetus, which are congenital malformations (examples, prematurity, toxicity and withdrawal).
"There are also effects on the infant via breast-feeding."
The other side of the coin is that there are risks of non-treatment during pregnancy:
l Impaired maternal-fetal bonding (eg, decreased gaze at infant or delayed and less consistent responses to infant)
l Behaviour problems and reduced intelligence quotient (IQ) On the effect of non-treatment (during pregnancy) on previously treated mothers, Dr Martin said discontinuation leads to 75 per cent relapse rate during pregnancy.
While Selective Serotonin Reuptake Inhibitors (SSRIs) are a cornerstone of treatment for moderate to severe depression, and also an effective treatment for anxiety disorders, the psychiatrist warned of their risks in pregnancy.
"Start low and go slow with these medications by using a minimal effective dose because they have effects on the mother (example, potential side effects of increased anxiety, nausea and insomnia) and also effects on pre-term labour (that is, increased pre-term labour)."
It was pointed out that for bipolar disorder, mood stabilisers are very effective in reducing manic and depressive episodes.
But, according to Dr Martin, lithium risks in pregnancy take the form of Ebstein's anomaly in baby and neonatal toxicity (or 'floppy baby' syndrome).
"The risk of Ebstein's anomaly in baby is 1 in 20,000 (baseline risk) and 1 in 1,000 (or 0.1 per cent) in the case of first-trimester use of lithium."
On the risks of anti-convulsants in pregnancy, she said one of these is orofacial clefts "which are associated with the first trimester exposure to (anti-convulsants).
"Minor foetal malformations are also observed when used during pregnancy. These include rotated ears, depressed nasal bridge, short nose, elongated upper lip and fingernail hypoplasia (incomplete development)."
Dr Martin listed out the risks of treatment with anti-psychotic drugs during pregnancy and the period after delivery although such medication is very effective in reducing or eliminating delusions and hallucinations. These are:
* Obstetric complications
* Birth defects
* Neurobehavioural and neonatal adverse effects
There are a number of risks of non-treatment for psychotic disorders:
* Exacerbation of existing symptoms or relapse
* Increased risk of self-harm or suicide
* Increased risk of pre-term delivery, low birth weight, and neonates who are small for their gestational age
* Poorer mother-infant interaction and deficits in infant/child development
"In addition, there are potential consequences of an untreated psychosis - the mother may attempt suicide and, or, infanticide."
As for medications for acute anxiety, the psychiatrist said the benefits must be weighed against the risks.
According to her, acute anxiety is often treated with benzodiazepines which are effective in reducing anxiety but do not treat the underlying psychosis (severe mental disorder) or depression.
"On top of it, there are three types of benzodiazepine risk in pregnancy."
These are the formation of oral clefts in the first trimester (risk is 6 in 10,000 or 0.06 per cent), floppy baby syndrome in the third trimester (characterised by failure to feed, impaired temperature regulation and apnoea which is temporary inability to breathe), and withdrawal syndrome in the third trimester (characterised by vigorous sucking, tremors and irritability).
