Dr. Donna Stewart
Dr. Donna Stewart, UHN Centre for Mental Health, Women’s Health Program, Senior Scientist at Toronto General Research Institute and Professor at University of Toronto, is suggesting use of a less time-consuming way to screen moms for possible postpartum depression. (Photo: UHN Visual Services)

Depression after giving birth remains undiagnosed in many new moms, and often begins before or during pregnancy, says a clinical practice feature published in the New England Journal of Medicine (NEJM).

The feature entitled, "Postpartum Depression," is published in today's issue of NEJM by lead author Dr. Donna Stewart at University Health Network Centre for Mental Health, Women's Health Program, Senior Scientist at Toronto General Research Institute and University Professor at University of Toronto.

Postpartum depression is a disabling but treatable mental disorder that is one of the most common complications of childbearing. It can occur within four weeks or up to a year after child-birth. 

"Depression in general is often missed," Dr. Stewart says. "Physicians often don't ask. Women often don't tell. In the time-pressed environment of a physician visit, the usual screening method is far too long."

Since untreated postpartum depression affects the health of women, families and infants and is underreported, Dr. Stewart recommends that a simplified version of a widely used test to screen all new mothers for postnatal depression be used first to determine if a more comprehensive evaluation is needed.

Two simple questions

The Edinburgh Postnatal Depression Scale (EPDS) is a widely used 10-item test to screen women for postnatal depression, on symptoms such as sleep disturbance, low energy, lack of pleasure, and suicidal thoughts.

However, Dr. Stewart and some national authorities suggest that instead of using the more time-consuming EPDS, a physician could ask two questions during every perinatal visit:

  1. During the past month, have you often been bothered by feeling down, depressed, or hopeless?
  2. During the past month, have you often been bothered by little interest or pleasure in doing things?

If the woman answers "yes" to either question, then the EPDS and further evaluation is warranted.

This two-question screening tool is a more efficient way of eliciting who might be at risk, Dr. Stewart says.

The estimated prevalence of postpartum depression ranges from 6.5 per cent to 12.9 per cent, or even higher in lower-income and middle-income countries. About one in five women with postpartum depression still have depression beyond the first year after delivery, and 13 per cent after two years.

The strongest risk factor for postpartum depression is a history of mood and anxiety problems and untreated depression and anxiety during or even before pregnancy.   

Shame and stigma also at play

Women who have untreated depression during pregnancy have a risk of postpartum depression that is more than seven times that of women who have no symptoms during pregnancy. One study of 78 women who were diagnosed with depression in the first three months of pregnancy and treated, showed that none went on to develop depression after giving birth.

Dr. Stewart notes that, on the whole, mothers who receive certain antidepressant medications can also breastfeed. Antidepressant medications such as the selective serotonin reuptake inhibitors (SSRIs) – pass into breast milk at a dose that is less than 10 per cent of the dose taken by the mother.  The best safety data for breastfeeding mothers exist for an antidepressant named sertraline.

She adds that although breastfeeding offers infants some health benefits, clinicians should support women in their choice not to breastfeed if they are having difficulties in breastfeeding, or lack of sleep is contributing to their depression.

"Shame and stigma are associated with depression, so adding guilt to depressed mothers who are already coping with a new baby and want to stop breastfeeing is not helpful, and can aggravate their depressive symptoms," says Dr. Stewart.​

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