Pharmacists are well-placed to spot this common condition in their patients, says pharmacy consultant Alan Pollard
Key learning points
• Symptoms can start to show from the point of conception
• Perinatal depression can be easier to spot in regular patients
• Medication may be required to treat the condition
Although the medical definition regards the perinatal period as not starting until at least week 20 of gestation, in terms of depression, signs and symptoms might show from the point of conception to the early weeks post-partum. Spotting depression early is invaluable to both the mother and developing foetus. Depression may also occur shortly after giving birth. As a community pharmacist, you are ideally placed to spot changes that suggest the mother is suffering postnatal depression.
Depression in pregnancy is one of the strongest predictors for depression postnatally.1 Around 12% of women experience depression during pregnancy and between 15-20% may experience depression and anxiety in the first year after childbirth.2
Untreated depression is associated with low birth weight and pre-term delivery. Antenatal maternal depression and anxiety have been associated with developmental problems in the child, including emotional and behavioural problems as well as links to autism, ADHD and impaired cognitive function.3
Postnatal depression can lead to women’s poor engagement with their infant and impair the child’s cognitive development and learning.
What signs and symptoms should I look out for?
The mnemonic INSADCAGES is a useful framework and the table (below) has been constructed with an emphasis on a mother during the perinatal period. Some elements you may pick up on by a change in behaviour – others when you are having a conversation with the mother.
If the woman is a regular customer of yours, you are likely to be well placed to spot changes that might put depression or another mental health concern on your radar.
Hopefully you have a good customer relationship in place, so it will be easier to ask some opening non-threatening questions such as:
• How are you getting on with your pregnancy?
• What are you most looking forward to?
If you have noticed changes that cause you concern, you could move to more focused questions. For example:
• I notice you have not bought your regular [self-care product] recently.
• Have you found something different?
• How is your appetite?
When it comes to appetite, poor nutrition can put both mother and baby at risk. Many women require supplemental iron to avoid frank anaemia. Good sources of folic acid may be lacking and a prescribed 5mg dose supplement may be indicated. This could be the situation if the woman is taking medicines that induce drug-metabolising enzymes such as carbamazepine or other drugs that can increase the risk of neural tube defects.4
Poor sleep may prompt the woman to ask about safe medicines to take in pregnancy to help with this. Or you might find that you are taking the initiative over a chosen purchase. If a sedative is likely to prove helpful, promethazine in small doses and for a limited period could be an option.4
What are the possible causes of perinatal depression?
Many of the recognised trigger factors for depression are likely to occur in the perinatal period, not least all the hormonal changes and discomfort that pregnancy itself brings about.
Postnatally there will be a lot of adjustment required and good support from family or other networks is very important. Breastfeeding and any poor bonding with the new infant may add to the stress burden; add lack of sleep to this and it becomes a vulnerable time for depression to develop.
Medication in pregnancy and breastfeeding
Whatever stage depression kicks in, effective treatment is vital and the axiom ‘healthy mums make for healthy babies’ cannot be overstated. Treatment may include medication and mothers may be anxious about such treatments during pregnancy and also any impact on breastfeeding.
There are many resources to help you as a pharmacist identify optimum treatment. Toxbase (UKTIS) provides information on drugs in pregnancy and Lactmed on medicines and breastfeeding.
If the woman is already taking an antidepressant and becomes pregnant, it is generally better to not switch treatment as outcomes are not so good. You may be asked if it is possible to reduce doses during pregnancy but sub-therapeutic dosing is worse than not treating as you have exposure to drugs and an untreated illness.
In fact, some drug doses may need to increase to maintain consistent levels because of the increasing volume of distribution in the second and third trimesters together with some increase in drug metabolising
What are the next steps?
If you are concerned, encourage the mother to get in touch with her GP or midwife for further help and support. Signposting mum to support networks or providing her with some relevant leaflets may also prove helpful. The resource section gives further details of useful sites.
You might also want to encourage mum to register her pregnancy outcome with Best Use of Medicines in Pregnancy (BUMPS) if there is regular medication in place. This will develop the data base of safety of medicines during pregnancy.
For your own personal development and networking, get in touch with the local specialist mental health pharmacist or perinatal mental health team. There are also a few specialist perinatal mental health pharmacists around the country.
If there are safeguarding issues such as concerns about self-harm or other children or vulnerable adults, you may need to approach the relevant statutory authorities, over-riding your customer’s preferences. Make notes of any urgent action you have to take.
INSADCAGES: signs of perinatal depression
Insomnia Waking early in morning is a common finding in depression. A more pervasive fatigue may be present and lying awake at night feeling anxious may be described
Neurosis This captures pervasive symptoms of stress and anxiety. It is natural for a woman to have some anxiety about how things will be different with a new baby and how she will care for the new arrival but if it is taking over her life then it may be time to seek help
Self-harm If dark thoughts start to overwhelm and they cannot be shaken off, this is a case for urgent consultation with the GP or midwife
Anhedonia There is a lot of pressure to be joyful about a new baby but this is not always the reality. However, if there is a loss of pleasure from all the things that she would normally enjoy, this may be a sign of depression
Depressed mood There is no doubt that mood changes will happen as a lot of hormonal changes are taking place. However, constantly feeling down and bad-tempered and crying suggests more
Concentration Thinking may be slowed and it may be harder to make simple choices. The mother might be overwhelmed by all the planning and preparation needed
Appetite Often reduced in depression and lack of good nutrition is not good for both mother and baby. Folic acid, iron, vitamin D and other supplements may be especially indicated and here the pharmacist is ideally placed to spot unmet need
Guilt Over-concern about not being a good mother and not connecting to developing baby (poor foetal attachment) may identify here
Energy Reduced energy levels may lead to poorer self-care. You may notice that personal care and cosmetic related items are no longer being purchased
Sex Reduced libido and lack of interest in sex may not be a cause for concern but reassurance about sexual activity during pregnancy may be helpful
Alan Pollard is an independent mental health pharmacy consultant
• Best Use of Medicines in Pregnancy (BUMPS) http://www.medicinesinpregnancy.org/
• United Kingdom Teratology Information Service (UKTIS) incorporating TOXBASE
• Telephone helpline 0344 892 0909 www.uktis.org
• Drugs and Lactation Database (LactMed) https://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm
• National Childbirth Trust (www.nct.org.uk): 0300-330-0770 for practical and emotional support on all aspects of pregnancy, birth and early parenthood. Available every day 8am – midnight
• MumsMeetUp (Mumsmeetup.com) An online forum to connect mums locally and across the UK
• The Association for Postnatal Illness (APNI) (www.apni.org) Chat line: 020 7386 0868 10am-2pm Mon-Fri; information leaflets for women with postnatal mental illness. Also a network of volunteers (telephone and postal) who have themselves experienced postnatal mental illness
1 Robertson E et al. Antenatal risk factors for postpartum depression: a synthesis of recent literature. Gen Hospital Psychiatry 2004; 26:289-95
2 National Institute for Health and Care Excellence (NICE) Antenatal and Postnatal mental health: clinical management and service guidance CG192 (updated 2018)
3 Talge NM et al. Antenatal maternal stress and long-term effects on child neurodevelopment: how and why? J Child Psychol Psychiatry 2007; 48:245-261
4 Pollard AD, Brotchie E. Psychotropics in pregnancy. Hospital Pharmacy Europe 2017; 86/87: 37-43
5 MHRA Drug Safety Update November 2018 https://www.gov.uk/drug-safety-update/medicines-taken-during-pregnancy-please-report-suspected-adverse-drug-reactions-including-in-the-baby-or-child-on-a-yellow-card