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Take prenatal vitamins. Don't eat sushi or drink alcohol.

Oh, and have you been feeling sad?

For many pregnant women across Canada, questions about their mental health are becoming a mainstay of prenatal visits to the doctor.

As recently as a few years ago, pregnant women may not have been treated for depression until it showed up after baby was born -- if they were treated at all.

Fuelled by new research, experts are now broadening the definition of postpartum depression to include moms-to-be. In response, new, more extensive treatment programs are springing up across the country to help women during pregnancy and after.

For women who experience prenatal or postpartum depression - between 10 and 20 per cent of those who give birth - experts say the experience is more than a brief blip near childbirth. It may be part of a lifelong battle with a mood disorder.

But even a short period of depression can have lasting effects for a new mother and her family.

Armed with this view, doctors are now seeking to identify women who are in danger long before they deliver.

"One of the biggest risk factors for postnatal depression is prenatal depression," says psychiatrist Eileen Sloan, a specialist in perinatal mood disorders at Toronto's Mount Sinai Hospital.

And the fix may not be as simple as undergoing talk or drug therapy, experts say.

"Women who are depressed need support in their role as mothers," says Concordia University psychologist David Forman, who recently studied the negative effects of postpartum depression on mothers' relationships with their babies. "It's not just a momentary or passing problem of her mood that can somehow get fixed by quick, symptom-relieving treatment."

His conclusion was echoed by many participants at a conference last week in Toronto on the topic of maternal health run by York University's Association for Research on Mothering.

New tools include offering help with social supports such as child care in addition to the standard arsenal of antidepressants and talk therapy. Some centres are offering drop-in services for mother and baby, parenting lessons and family and group therapy.

A postpartum depression support group staffed by a social worker at Toronto's St. Joseph's Hospital became a lifeline for new mother Tania Jivraj when her condition deteriorated.

Ms. Jivraj, now 35, enrolled after her baby was born because of the strain the birth had placed on her relationship with her husband. But one day, when a woman on the street stopped to admire her nine-month-old baby, Ms. Jivraj found herself having a strange idea: She thought the woman was going to kill her child. And her immediate thought was to wrap the baby in her plastic stroller covering and "hide" her in a nearby garbage can.

A line from the St. Joseph's social worker rang through her head: "You could be right, but you're probably wrong."

She called the social worker for support. "It saved my life," she says.

Reaching women like Ms. Jivraj before they find themselves in trouble is becoming a priority during many prenatal doctors' visits.

At Mount Sinai, some women believed to be at risk during pregnancy are eligible for an initiative called the five-day, five-night program when they deliver. Mothers stay in hospital for five days after delivery, adjusting to life with baby and getting some sleep.

Sleep in the early days is believed to help protect at-risk women. "It's been shown to be effective," Dr. Sloan says.

For Lisa Held, who was depressed after the birth of both her children, sleep was part of the solution. Ms. Held, whose children are 10 and 6, did not take antidepressants, but after giving birth the second time, found relief when her nanny took the baby two nights a week.

"As soon as I was catching up on sleep, it was a huge weight lifted," Ms. Held says.

In Vancouver, if a mom has a severe case of depression for which she needs to be hospitalized, she can be offered a "swing" bed to share with her baby while undergoing treatment at the BC Women's Hospital.

The hospital was one of the main partners in the publication last year of a B.C.-wide framework to identify and treat depression throughout and after pregnancy.

The hospital is now working on creating a cognitive behaviour therapy tool specifically to teach depressed mothers how to banish negative thought patterns. The hospital is even using baby massage to help moms bond with their children, says Diana Carter, a psychiatrist in the reproductive mental health program at BC Women's Hospital.

Bonding is one of the chief worries about depressed new mothers.

In a recent study, Concordia's Dr. Forman found that the 120 women who underwent 12 weeks of interpersonal psychotherapy for postpartum depression six months after giving birth did not get back on track in their relationships with their babies even after they recovered. At nine and 18 months later, they continued to report negative feelings about their babies and a failure to bond with them.

Further study is needed to understand the results, Dr. Forman says.

He added that it could be because "they met their baby when they were already depressed."

His findings, he says, back up the therapies being deployed on the front lines of maternal depression and confirm that if a woman is depressed when she has a young baby, "she should get help and support in her role as a mother, in addition to symptom relief."

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Mood disorders

In recent years, the term postpartum depression has given way to the umbrella term postpartum mood disorders, to include such problems as anxiety. The newest term, perinatal mood disorders, covers a wider range of disorders and a longer period of time.

The American Psychiatric Association added postpartum depression to its widely used diagnostic and statistical manual of mental disorders in 1994. The condition is described as depression with postnatal onset, and symptoms include extreme feelings of guilt and helplessness, fatigue, change in sleep patterns or appetite, irritability and thoughts of death or suicide.

In extreme and rare cases, women can suffer postpartum psychosis, in which a mother is at high risk of harming herself and her baby.

Many new mothers hesitate to seek help because of the stigma still attached to the problem. "You're supposed to be going through a period of life that's wonderful," says Carol Kauppi, program co-ordinator of Laurentian University's school of social work, which is conducting a two-year study of postpartum depression in the North, of women's reluctance to admit a problem.

Many health-care providers and researchers cite Brooke Shields' public admission of her struggles with postpartum depression - never mind her being skewered by Tom Cruise for taking antidepressants - as a positive example of awareness-raising.

For many women, the problem doesn't come out of the blue. A recent study has raised questions about the links between perinatal depression and pre-existing mood disorders.

According to the study out of California-based Kaiser Permanente Center for Health Research and the U.S. national Centers for Disease Control and Prevention, three-quarters of women who experienced postpartum depression were also depressed before becoming pregnant.

The study, published in this month's American Journal of Psychiatry, went back to look at women nine months before they became pregnant, followed them during pregnancy and then for nine months after birth.

Some researchers continue to probe whether postpartum depression is actually triggered by the birth process at all.

"It doesn't look like there's this unique condition, postpartum depression," says CDC epidemiologist Patty Dietz, one of the authors of the Kaiser Permanente paper.

"When women first get pregnant, think about depression now," Dr. Dietz says. "It's really important to ask women how they're doing and continue to ask during the pregnancy, and after. You will continue to capture women when you ask the questions."

Tralee Pearce