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Depression during pregnancy is more common than postnatal blues. Hospitals here are starting to screen all pregnant women for the condition
 When Ms Chin (not her real name) finally became pregnant two years ago after two miscarriages, she was ecstatic. So when she completed a routine screening questionnaire for depression at her first antenatal visit at National University Hospital (NUH) and was advised to see a psychiatrist for further assessment, she did not think it was necessary.
The hospital started a depression screening programme in 2008. The programme covers both antenatal and postnatal depression. Ms Chin, 32, said: “I felt happy and on top of things.” But during her second trimester, she found herself plagued by anxious thoughts of losing the baby. She said: “I no longer felt as nauseous as I did during my first trimester. I thought that meant I was going to lose the baby.” It was then that she decided to see a psychiatrist at NUH. She said: “It was helpful to talk to someone who could help you put things in perspective.”
She was advised to enjoy her pregnancy and take things one day at a time. Her depression went away without the help of medication. However, it surfaced again at a later stage of her pregnancy after she was told she needed a caesarean section because her placenta was lowlying and her baby was not growing well. But she was able to stay calm with the help of her psychiatrist. She is now the mother of a ninemonthold boy. Ms Chin’s experience of becoming depressed before giving birth is not an unusual one, although depression during pregnancy is far less recognised than postnatal depression. But like the latter, antenatal depression can have devastating consequences.
 To identify such women and offer them help, Singapore General Hospital (SGH) has started screening pregnant women for signs of depression this year. Previously, SGH screened only for postnatal depression. KK Women’s and Children’s Hospital (KKH), Singapore’s largest maternity hospital which delivers about 12,000 babies every year, says it educates its obstetricians to look out for antenatal depression in women. It is a problem that is gaining recognition. Dr Helen Chen, who heads the KKH Mental Wellness Service, said the number of pregnant women referred to the service for depression and other psychological distress has superseded and is now almost double that involving postnatal women. With their hormones swinging wildly, it is not unusual for women to get the blues during and after pregnancy. But depression is when those feelings of sadness and emotional instability last for more than two weeks. While the incidence of depression during pregnancy is higher than after birth, screening for postnatal depression is much more established.
SGH has been screening women for postnatal depression since 2004, while KKH has been doing it since 2008. This may be because the detrimental effects of postnatal depression on the mother and child are welldocumented. But recent studies have shown that the effects of antenatal depression are equally detrimental to mother and child, said Dr Tan Lay Kok, a senior consultant at the department of obstetrics and gynaecology at SGH. Women with depression during pregnancy have up to a 50 per cent increased risk of giving birth to a child with developmental delay, compared to pregnant women without symptoms of depression.
Dr Chua Tze Ern, an associate consultant at KKH Mental Wellness Service, cited a 2008 United States study which showed that women who were depressed delivered their babies two weeks earlier and their babies weighed significantly less than babies whose mothers were not depressed. She said: “A pregnant woman who is depressed may not eat or rest well, or may indulge in drinking or smoking to cope with her depression, any of which may have a lasting impact on her baby.” Dr Chen added that antenatal depression can be a predictor of postnatal blues and about half of those who are depressed while pregnant will continue to be depressed after giving birth. The earlier the woman is given help, the better the outcome.
A study by KKH showed that with medication or counselling or both, about 80 per cent of antenatal patients recover from their depression within eight months. Mothers are screened once every trimester and once after birth. At SGH, the obstetrician takes the patient through a questionnaire adapted from the Edinburgh Postnatal Depression Scale and fills in her verbal responses. At NUH, the woman completes the form in English, Chinese, Malay or Tamil on her own. This questionnaire has been shown to be effective as a screening tool for antenatal women as well. At both hospitals, the screening is offered to all mothers and not just firsttime mothers, as studies show both groups are equally likely to suffer from depression. Those who have high scores are given an appointment with a psychiatrist. Both hospitals have case managers, who may be nurses or medical social workers, to follow up with these women.
SGH also stations a psychiatrist at its obstetrics and gynaecology clinic twice every month. There are logistical advantages to screening mothers while they are pregnant, said Dr Cornelia Chee, a consultant psychiatrist and the director of the NUH Women’s Emotional Health Service. She said: “Women are more likely to return for their antenatal appointments, rather than their postnatal ones. After giving birth, they are more likely to be caught up with taking care of the baby.” A pregnant woman may need to see the doctor about 10 times during her pregnancy and a couple more times after she has given birth.
Of the 12,000 women screened by NUH since 2008, more than 9,000 were screened during their pregnancies. The hospital identified one in three, or about 3,300, who were at risk. But in a sign of how unacceptable depression is, only two thirds – or about 2,200 – agreed to return for further assessment. Of these, a third or 800 were found to have depression. Two thirds have since recovered while the rest are still being followedup. Dr Chee said: “There is still a stigma attached to seeing the psychiatrist. It is not acceptable in society to seek help for a mental problem.”
Another hurdle may be the cost. While it is free to fill out the questionnaire, seeing a psychiatrist is not. Doctors urge women not to take their symptoms lightly. Dr Chua said that because antenatal and postnatal depression revolve around motherhood, the conditions are potentially dangerous. She said: “The mother can have thoughts of harming the baby or even suicide.” Although tragedies are uncommon, they can be averted if the signs are recognised and heeded. Ideally, fathers, too, should be screened for depression. Said Dr Chee: “After all, having a child is a family affair.” But due to the lack of manpower, any plans to screen fathers have to be shelved for now.
The Edinburgh Postnatal Depression Scale
This questionnaire has been shown to be effective in screening women for depression during pregnancy and after they give birth. It is used in at least three hospitals here. Please choose the answer that comes closest to how you have been feeling in the past seven days and not just today. The number in brackets is the score for each answer. Add up the numbers for all 10 questions to get your final score.
1. I have been able to laugh and see the funny side of things.
- As much as I always could. (0) Not quite so much now. (1)
- Definitely not so much now. (2)
- Not at all. (3)
2. I have looked forward with enjoyment to things.
- As much as I ever did. (0) Rather less than I used to. (1)
- Definitely less than I used to. (2)
- Hardly at all. (3)
3. I have blamed myself unnecessarily when things go wrong.
- Yes, most of the time. (3)
- Yes, some of the time. (2)
- No, not very often. (1)
- No, never. (0)
4. I have felt worried and anxious for no very good reason.
- No, not at all. (0)
- Hardly ever. (1)
- Yes, sometimes. (2)
- Yes, very often. (3)
5. I have felt scared or panicky for no very good reason.
- Yes, quite a lot. (3)
- Yes, sometimes. (2)
- No, not much. (1)
- No, not at all. (0)
6. Things have been getting on top of me.
- Yes, most of the time I haven’t been able to cope at all. (3)
- Yes, sometimes I haven’t been coping as well as usual. (2)
- No, most of the time I have coped quite well. (1)
- No, I have been coping as well as ever. (0)
7. I have been so unhappy that I have had difficulty sleeping.
- Yes, most of the time. (3)
- Yes, sometimes. (2)
- Not very much. (1)
- No, not at all. (0)
8. I have felt sad or miserable.
- Yes, most of the time. (3)
- Yes, quite often. (2)
- Not very often. (1)
- No, not at all. (0)
9. I have been so unhappy that I have been crying.
- Yes, most of the time. (3)
- Yes, quite often. (2)
- Only occasionally. (1)
- No, never. (0)
10. The thought of harming myself has occurred to me.
- Yes, quite often. (3)
- Sometimes. (2)
- Hardly ever. (1)
- Never. (0)
If your score is 13 and above, you are likely to be suffering from depression of varying severity. You should confirm your diagnosis with a psychiatrist.
Source: National University Hospital
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