Depression: Reflection on treatment

The experience of depression is both traumatic and challenging to the individual at any stage of life. However, the physiological, social and role changes that accompany pregnancy and the birth of a new baby may have severe additional ramifications for the well‐being of the mother‐to‐be or new mother. Antenatal and postnatal depression rates are significant and remain a cause of concern for all those professionally involved in the delivery of care (Borri et al., 2008; Dennis, 2009; Jomeen & Martin, 2008). Many papers report the salient issues involved in effective screening for depression during pregnancy and in the postnatal period, a number of which have been published in the journal (Ingram and Taylor, 2007; Mc Vey and Tuohy, 2007). The goal of effective and reliable screening is of course to facilitate identification of depression and consequently provide an avenue for evidenced‐based and therapeutic intervention. An uncomfortable tension in both the research literature and the provision of care concerns treatment and the question of what is the most appropriate therapeutic option in the event of formally diagnosed depressive disorder in this group of women. Recent evidence has queried the therapeutic efficacy of anti‐depressant medication including selective serotonin reuptake inhibitors (SSRI's) for the treatment of moderate depression (Kirsch et al., 2008). Guidelines suggest that the use of anti‐depressant medication such as SSRI's during pregnancy and postnatally should be based on a comprehensive risk‐benefit analysis taking into account factors such as breast‐feeding and previous history and experience. It it is not uncommon for SSRI's to be prescribed even when other therapeutic approaches such as counselling and cognitive behavioural therapy (CBT) are available. Any pharmacotherapy such as antidepressant medication is not without hazard and the emerging evidence base highlights far‐reaching concerns about the use of this kind of treatment (Gentile & Bellantuono, 2009).

One potential barrier to the use of alternatives to antidepressant medication such as CBT (Milgrom et al., 2005) or counselling (Holden et al., 1989) is the integration of such therapies within a formal structure of service provision. Guidelines can inform the service provider as to what may be an effective intervention, however guidelines will not necessarily describe the way services should be provided, which can lead to variable quality and availability in service provision locally and nationally. Which intervention an individual receives will thus, in part, be mediated by factors unrelated to optimal treatment selection. Given that the battery of interventions available is fairly limited in number and scope, and that within the options available some treatments are particularly controversial, for example electroconvulsive therapy (ECT), innovation in the development of new approaches with noteworthy clinical efficacy is long over due. A relatively recent treatment innovation that may find application for the treatment of both antenatal and postnatal depression is transcranial magnetic stimulation (TMS). TMS is a non‐invasive approach that delivers magnetic pulses to the surface of the brain. A number of studies have shown that TMS is effective in the treatment of major depression (Klirova et al., 2008; Loo et al., 2008; Nahas et al., 1999) and it is likely that the approach will be evaluated in antenatal and postnatal depression some time in the near future within the context of a major clinical trial. However, like ECT, the exact modus operandi of TMS is not currently clearly understood and the basic principles underpinning the treatment approach are not entirely clear. For example, the depth to which the magnetic pulses penetrate the brain is not easily controlled or measured. The non‐invasive aspects of TMS may make it an attractive proposition, as does the consensus in the literature that the approach appears to be ‘safe’ in other groups experiencing depression. TMS as a treatment innovation may yet prove to be an effective addition to the array of therapeutic interventions, an assortment that is currently depleted in terms of both variety and innovation. The potential use of TMS also provides an opportunity to reflect on what is currently on offer, the contemporary concerns of clinical effectiveness and choice of treatment, the theoretical rationale of current treatments for antenatal and postnatal depression currently and their effectiveness in practice, both clinically and from the women's own perspective. Perhaps the arrival of TMS serves to remind us that the time has come to review comprehensively and meticulously, the relative benefits of each treatment approach currently available against what is understood about it's mechanism of action and the risks associated with the intervention? This may go some way toward ensuring that women experiencing depression may be able to make a more informed choice about the range, risk and benefits of available treatments.

Depression and associated mental health and wellbeing issues are factors considered in many of the papers in this edition of the journal in relation to infertility, parenting, couple relationships and being a parent of a preterm infant. While the current guidelines (NICE, 2007) have adopted a pragmatic attitude and are relying on two and possibly three questions to be put to women antenatally and postnatally, it is critical that researchers continue to focus on the complexities associated with possible causal pathways and methods of prediction of this particular condition and its symptoms.