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Gestational depression: what to do?

Gestational depression: what to do?

The emergence of a depressive condition during pregnancy puts a woman in the face of a new and intense suffering situation in a remarkable phase of life. The fascinating subject of growing scientific interest demands expertise from both psychiatrists and general practitioners.

More than 70% of women in the world have some anxious or depressed pregnancy complaint. Prevalence studies show that women of childbearing age are on average at least twice as likely as men to have an episode of major depression, suggesting, contrary to popular belief, that pregnancy does not protect women from this risk.

The prevalence of major depression in pregnancy varies from 10 to 16%, and 25% of the postpartum depressions begin at the gestation itself. Despite the high frequency of depressive complaints in pregnancy, the perception and management of psychiatric symptoms during pregnancy are far from receiving the attention of gynecologists and obstetricians, making the issue worrying as there may be negative consequences for the mother and her baby . The presence of hormonal variations and socioenvironmental stressors during pregnancy may lead to a greater risk of mental disorders.

Removal of the placenta during childbirth leads to abrupt drop in hormonal rates and consequent increase in mood and psychotic changes in the mother . In the infant, prenatal stress is associated with aggression, hyperactivity, anxiety, inattention and cognitive impairment during the period of neuropsychomotor development.

How to recognize the problem

Gestational depression can occur with somatic complaints such as insomnia, lack or lack of appetite, nausea and fatigue, which because they are common to gestation should not be seen as depressive symptoms. Introspective behavior and decreased libido are also common to both situations. Affective and cognitive complaints are the most characteristic of gestational depression and include depressed mood, anecdotal (lack of sensation of pleasure), easy crying, anxiety, fear, feelings of guilt, hopelessness, irritability, and disinterest in pregnancy. suicide is reported despite the risk of suicide in this population being low and even considered a protective factor by some authors. Other situations that contribute to the presence of major depression in pregnancy are lack of planning, not acceptance, ambivalence, loss or separation of a loved one, school failure, unemployment, poor working conditions, debts, marital conflict, absence of partner and absence support family or spouse. Also, a family history of depression, risky pregnancy, early maternal age (adolescence), large numbers of children, premenstrual dysphoric disorder (a more intense PMS), and previous history of abortions are also associated with higher rates of gestational depression.

Women with previous depression have more relapses, rates can reach 80%, most in the first trimester of pregnancy. It is important to have a close and reliable relationship between the pregnant woman and her doctor throughout her pregnancy.

Treating depression in pregnancy

Appropriate treatment of gestational depression is critical to the good health of the mother and her baby and comprises somatic and non-somatic therapies. In mild cases, psychotherapy and psychosocial support are recommended, while moderate to severe cases require pharmacological treatment. When depression occurs that is refractory to these approaches, with the risk of suicide or psychosis, electroconvulsive therapy is the most appropriate and effective intervention.

Prescription of drugs in pregnant women requires consideration of some points, such as potential drug damage to pregnant women and the fetus, and on the other hand, the harm caused by non-medication. Some possible consequences of the use of medication may be abortion, neonatal death, fetal developmental delay, preterm birth, intoxication or withdrawal from the use of the drug by the newborn, and fetal malformation.The greatest fear reported by mothers is the risk of fetal malformation from the 12th day (placental fetal circulation) to the 12th week (end of organ formation). The prevalence of this problem is 2 to 4% and in 70% of cases the cause is unknown. That is, in any of the options (whether or not to use the antidepressant) it is impossible to guarantee if the baby will be born without any anomaly. The pregnant woman using psychotropic medication should remain in her use during pregnancy. Withdrawal of the antidepressant just before postpartum can bring significant risk of relapse soon after delivery. Another important but often neglected point concerns the risks that untreated depression can properly generate for pregnant women, to the fetus. Depressed pregnant women have higher rates of non-adherence to prenatal care, increased use of alcohol, cigarettes and other psychoactive substances and an irregular pattern of sleep and eating.

There is also a relationship between depression in pregnancy and a number of situations such as pre- neonatal death, preterm birth, low birth weight, low APGAR (test done on the newborn baby), increased use of neonatal ICU and more difficulty in the formation of the mother-baby bond. The presence of depression increases at least three times the risk of postpartum depression.

Some care should be taken by the psychiatrist when prescribing medication, such as choosing the drugs most studied, the lowest effective dose and if possible, for some medication previously used successfully by the pregnant woman. Of the antidepressants, tricyclics and SSRIs (selective serotonin reuptake inhibitors) are the most used. Benzodiazepine anxiolytics are not part of the treatment of gestational depression, but can be used in the beginning and in low doses. The recognition and correct approach to depression in the obstetrical setting will allow a calmer and healthier gestation to the mother and her baby.


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