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Postpartum Depression

Will PPD Occur if There's Depression During Pregnancy?
By Karen Kleiman, MSW
Karen KleimanQ. I am 35 weeks pregnant with my second child (my daughter is 18 months old). I did not have any kind of depression during or after my first pregnancy, or even any time during my life for that matter. However, a few months ago I had a "bout" of depression. I use that term because it lasted only a couple of months, but was so severe and unlike anything I have ever known, that I ended up calling my OB in tears in a near breakdown. She prescribed Prozac for me and after taking it for about a month, I felt good enough to go off the meds. I have had no problems since then, and have been feeling like my usual happy (well, most of the time) self. My OB thinks that we should be "proactive" and have me start on the Prozac after my baby is born because the chances of me having PPD is a lot higher than "average" as I had depression during this pregnancy. How common is it to have PPD after having depression during pregnancy, or is there no correlation? What I was hoping to do was to just take a "wait and see" attitude after my baby is born and if I need the meds I will go on them, but only if I need them. Do you think that is a good idea, or are you inclined to go with my doctor's advice?

A. Your doctor is right that if you experience symptoms of depression during pregnancy, you are more at risk to experience postpartum depression. This doesn't mean it will happen, it just means your risk is increased. Recurrence rates for women with a major depression during pregnancy are estimated to be as high as 50% within 6 months following discontinuation of antidepressant treatment. This is why many doctors opt to treat with prophylactic antidepressants, prescribing the medication to help protect the woman, rather than "waiting and seeing". But it's a tough call and since your history is relatively depression-free, one would need to consider other risk factors (family history of depression, history of abuse, external stressors, marital relationship, for example). And one more thing: during the first month postpartum, childbearing women have a 3 times greater risk for depression compared to nonchildbearing women. That's a significant risk. This is why doctors worry about a woman who is depressed for any period of time during pregnancy.

Discuss the options with your doctor and come up with a plan that feels comfortable to both of you. I would include your husband in that discussion, also. The other thing to consider is connecting with a therapist if you don't already have one. This can provide substantial support during the postpartum period and may be a effective compromise in terms of protecting you from PPD. Your doctor has a point, though, and remember that if you *do* develop symptoms of depression after the birth, they are harder to treat then, than if you were taking the meds prophylactically.

As far as the specific med, many doctors have their own preferences, though most will agree that all of the SSRIs (selective serotonin reuptake inhibitors) are equally effective in treating depression. Some prefer one over another because of side-effects or their own clinical successes. Prozac, being the granddaddy of the SSRIs, has the most research behind it, which is why many docs opt to use it during pregnancy. (although more and more are comfortable using Zoloft and Paxil now). It used to be believed that Prozac was *not* recommended for breastfeeding moms due to the fact that it has a very long half life and the thinking was that it would be more difficult for the baby to clear the med from his system, so docs preferred to use the shorter acting meds for nursing moms. Current research, however, points out that although all antidepressants are excreted into the breast milk, there is no data to support neonatal medication accumulation AND no SSRI is safer than another. (Wisner KL. Am J Psychiatry. 1996; Llewellyn A, Stowe ZN. J Clin Psychiatry. 1998;59:41) Therefore, it's reasonable to assume that as a breastfeeding mom, you can discuss the options of either Prozac or Paxil.

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