Suffering in Silence: The Burden of Perinatal Depression

The notion that pregnancy is a time of uninterrupted joy, happiness, and contentment has been challenged by evidence-based research showing that, to the contrary, many women are distressed by depressive disorders in pregnancy. ' Only in the past 2 decades have psychiatrists started to acknowledge and understand the morbidity and mortality associated with psychiatric disorders in the antenatal period. Although postnatal depression has acquired celebrity status, antenatal depression will need a massive campaign of equal magnitude to bring it into the limelight. Because the signs of pregnancy closely overlap with symptoms of depression, diagnosis of antenatal depression is often difficult. Similarly, the overwhelming transition into motherhood, with its attendant anxiety, can often mask underlying pathological postpartum mental illness and delay help seeking.2 Accurate and timely identification of perinatal depression has significant implications, both for the mother and for the developing fetus or child. In March 2007, recognizing and responding to this need, British Columbia's Ministry of Health, in partnership with the Reproductive Mental Health (RMH) program, implemented a screening initiative using the Edinburgh Postnatal Depression Scale.3 In keeping with best-practice guidelines, this screening, which will take place between 28 to 32 weeks of gestation and 6 to 8 weeks postpartum, will positively affect the lives of pregnant and postpartum women in British Columbia. Women are reluctant to accept any psychiatric diagnosis in pregnancy or postpartum, owing to the shock, fear, denial, and stigma that accompany mental illness. To help overcome this barrier, clinicians and women must share decision making, involve a significant other in the treatment plan, and deal with the woman's concerns compassionately. In the light of rapidly accumulating data on the adverse effects of persistent, relapsing mental illness on the mother and her child, maintaining emotional stability in the perinatal period is absolutely mandatory. The obvious concern that arises after a diagnosis is the availability of safe, effective, and affordable intervention for the suffering mother. The treatment issue has been in the forefront of treating physicians' minds, particularly in the last 2 years, as Federal Drug Administration warnings and Health Canada advisories have been appearing almost steadily. On the one hand, research demonstrates that discontinuing medication causes relapse in about 75% of women during pregnancy.4 On the other hand, reinstating psychotropic medications is fraught with trepidation and apprehension. Current research in relation to perinatal medication use is controversial, at best. The latest recommendation from the American College of Obstetrics and Gynecology clearly recognizes that the potential risk of continuing antidepressant use throughout pregnancy must be considered in the context of risk for relapse of depression if maintenance therapy is discontinued.5 Given the current unease regarding the safety of antidepresdant use, many clinicians and researchers are exploring other treatment modalities in this population. Cognitive-behavioural therapy (CBT) is one such treatment that is attracting interest and consideration because of its effectiveness in the nonperinatal population.6 Obviously, its efficacy, sustainability, accessibility, and affordability in perinatal women requires further research. The RMH program, in conjunction with the Ministry of Health, is currently piloting a project to develop a framework for applying CBT in perinatal women with mood and anxiety disorders. …