Prenatal depression effects and interventions: A review

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Abstract

This review covers research on the negative effects of prenatal depression and cortisol on fetal growth, prematurity and low birthweight. Although prenatal depression and cortisol were typically measured at around 20 weeks gestation, other research suggests the stability of depression and cortisol levels across pregnancy. Women with Dysthymia as compared to Major Depression Disorder had higher cortisol levels, and their newborns had lower gestational age and birthweight. The cortisol effects in these studies were unfortunately confounded by low serotonin and low dopamine levels which in themselves could contribute to non-optimal pregnancy outcomes. The negative effects of depression and cortisol were also potentially confounded by comorbid anxiety, by demographic factors including younger age, less education and lower SES of the mothers and by the absence of a partner or a partner who was unhappy about the pregnancy or a partner who was depressed. Substance use (especially caffeine use) was still another risk factor. All of these problems including prenatal depression, elevated cortisol, prematurity and low birthweight and even postpartum depression have been reduced by prenatal massage therapy provided by the women's partners. Massage therapy combined with group interpersonal psychotherapy was also effective for reducing depression and cortisol levels. Several limitations of these studies were noted and suggestions for future research included exploring other predictor variables like progesterone/estriol ratios, immune factors and genetic determinants. Further research is needed both on the potential use of cortisol as a screening measure and the use of other therapies that might reduce prenatal depression and cortisol in the women and prematurity and low birthweight in their infants.

Section snippets

Prenatal depression increases prematurity and low birthweight

Higher cortisol levels in prenatally depressed women have been noted in several samples (see Field & Diego, 2008 for a review). In addition, depressed women have lower dopamine and serotonin levels and are more likely to deliver prematurely and have low birthweight infants (Field et al., 2004a). The newborns of the depressed mothers in the Field et al. (2004a) study also had higher cortisol levels and lower dopamine and serotonin levels, thus mimicking their mothers’ prenatal levels. And, in

Prenatal cortisol contributes to fetal growth delays and prematurity

To further investigate the prenatal cortisol effects, relationships were assessed between the mothers’ prenatal depression and biochemistry and fetal activity, fetal growth and neonatal outcomes (Diego et al., 2006, Field et al., 2005a, Field et al., 2006c). In these studies, growth measures were taken on fetuses of depressed and non-depressed women during ultrasound sessions at approximately 16–20 weeks gestation. On fetal growth measures (estimated weight, femur length, abdominal

Stability of mood states and cortisol across pregnancy

Cortisol and mood states across pregnancy appear to be stable (from 20 to 32 weeks gestation) and cortisol was related to both depression and anxiety (Field, Hernandez-Reif, & Diego, 2006a). Significant stability was noted between the 20-week and the 32-week measures including depression, anxiety and cortisol. These were, in turn, correlated with each other and with low back pain, leg pain and sleep disturbances. These data suggested the stability of cortisol, depression and anxiety across

Sleep disturbances

Sleep disturbances were highly correlated with elevated cortisol in the Field et al. (2006a) study. Based on animal data, the HPA axis (hypothalamic pituitary adrenal axis) is a potential underlying mechanism for the effects of prenatal depression on sleep problems (Ader, 1975). At least one study has reported a relationship between the diurnal pattern in cortisol and sleeping through the night (de Weerth, van Hees, & Buitelaar, 2003). We have also noted relationships between prenatal

Dysthymia versus Major Depression Disorder effects

Comparing Dysthymia versus Major Depression Disorder effects was another way to assess chronic depression effects. To determine differences between pregnant women with Dysthymia versus Major Depression, the depressed pregnant women were divided by their diagnoses on the Structured Clinical Interview for DSM IV Diagnoses into Dysthymic and Major Depression Disorder groups, and they were compared on self-report measures (depression, anxiety, anger, daily hassles and behavioral inhibition), on

Prenatal dopamine effects

In a study on the effects of prenatal dopamine, depressed pregnant women were divided into high and low prenatal maternal dopamine (HVA) groups based on a tertile split on their dopamine levels at 20 weeks gestation (Field et al., 2008b). The high versus the low dopamine group had lower CES-D scores and higher norepinephrine levels at the 20-week gestational age assessment and higher dopamine and serotonin levels at both the 20- and the 32-week gestational age assessments. The neonates of the

Prenatal serotonin effects

Serotonin has long been associated with depression (Cubala and Landwiski, 2006, Neumeister, 2003, Neumeister et al., 2004). Serotonin receptors and serotonin transporters are reduced in depression, suggesting that serotonin systems play a key role in the pathophysiology of depression (Neumeister et al., 2004).

In a study on relationships between prenatal serotonin levels and other biochemical variables during pregnancy as well as their relationships to neonatal biochemical and behavioral

Comorbid depression and anxiety effects

Anxiety is often comorbid with depression, making it difficult to assess the independent effects of either depression or anxiety (Beuke, Fisher, & Mc Dowall, 2003). This comorbidity is not surprising given that depression and anxiety are thought to share a common genetic pathway (Kendler et al., 2007, Williamson et al., 2005). Because depressed pregnant women have also been noted to experience high anxiety (Dieter et al., 2001, Hoffman and Hatch, 2000, Lundy et al., 1999), we assessed the

Demographic risk factors

Because demographic risk factors emerged in our studies, we combined several predominantly Hispanic samples and explored multiple risk factors (Field, Hernandez-Reif, & Diego, 2006b). The women were diagnosed as depressed based on the Center for Epidemiological Studies Depression Scale (CES-D) and the Structured Clinical Interview for DSM IV Diagnoses (SCID). They were interviewed on several demographic risk factors and stress questionnaires. On average, the depressed pregnant women were

Substance use as a risk factor

Although rates of smoking, drinking and drug use during pregnancy have been relatively low (Marcus et al., 2003, Orr et al., 2007), some prenatal studies have reported relationships between these risk factors and negative neonatal outcomes independent of prenatal depression (Dole et al., 2004, Monk et al., 2004). In a study on substance use as a risk factor, depressed pregnant women reported more substance use including cigarettes, caffeine and medications (primarily antibiotics) (Field et al.,

Paternal depression as a risk factor

Paternal depression was an additional risk factor in at least one study on the effects of paternal depression on prenatal depression symptoms, anxiety, anger and daily hassles in depressed and non-depressed pregnant women and their depressed and non-depressed partners (fathers-to-be) (Field et al., 2006d). Depressed versus non-depressed fathers had higher depression, anxiety and daily hassles scores. Although the pregnant women in general had lower anxiety, anger and daily hassles scores than

Massage therapy reduces prenatal depression and cortisol and improves neonatal outcomes

Various forms of stimulation have been noted to lower prenatal depression and cortisol including yoga (Narendran, Nagarathna, Narendran, Gunasheela, & Nagendra, 2005) and massage therapy (Field, Diego, Hernandez-Reif, Schanberg, & Kuhn, 2004b). And, serotonin and dopamine are increased following massage therapy (Field, Hernandez-Reif, Diego, Schanberg, & Kuhn, 2005c) and after exercise (Struder et al., 1997). Thus, with these cost-effective interventions, the costly problems of prematurity may

Limitations of these studies

Several limitations of these studies should be noted. First, the samples were not representative of women who seek treatment including psychotherapy and antidepressants. Less than 3% of our prenatal clinic population was in treatment, which is consistent with the incidence of psychiatric treatment in other samples of depressed pregnant women (Flynn et al., 2006, Suri et al., 2007). Notably, antidepressants have their own negative effects (see Chambers et al., 2007, Field, 2010 for reviews).

Summary

In summary, this review highlights the negative effects of prenatal depression and cortisol on fetal growth, prematurity and low birthweight. The stability of depression and cortisol levels across pregnancy highlighted the chronicity of prenatal depression. The finding that women with Dysthymia as opposed to Major Depression Disorder had the highest cortisol levels and that their newborns had lower gestational age and birthweight suggests that chronic prenatal depression had the most negative

Acknowledgements

We would like to thank the mothers, fathers and infants who participated in our studies which were supported by NIH Senior Research Scientist Awards (# MH 00331 and # AT 01585) and an NIMH Merit award (MH # 46586) and March of Dimes grant (#12-FY03-48) to Tiffany Field and funding from Johnson and Johnson Pediatric Institute.

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