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Who is at Risk? A Call for Universal Antenatal Mood Disorder Screening

Pregnancy is a time when most women are eagerly anticipating and preparing for the birth of their child (or children), so it is surprising to note that approximately 10% of pregnant women may experience a depressive disorder during pregnancy. What is even more heartbreaking is the fact that as many as 2.6% of pregnant women may have thoughts of suicide. In pregnant women with major depression, the rates of suicidal ideation can reach nearly 30%. It is well known that major depression is associated with significant disease co-morbidity and mortality.  Clinicians must know which women are at highest risk for depressive disorders yet screen all their patients for depressive disorders at regular intervals during their prenatal care and provide treatments and/or resources when needed.

Jennifer Melville, MD, MPH, an associate professor in the Department of Obstetrics and Gynecology at the University of Washington School of Medicine, Seattle, WA sought to estimate the prevalence of depressive disorders during pregnancy in her 2004-’09 study, Depressive Disorders During Pregnancy:  Prevalence and Risk Factors in a Large Urban Sample . Melville and her colleagues also wanted to know if there are identifiable risk factors that make certain women more likely to develop depressive disorders than others. The results of this prospective study of 1,888 pregnant women over a five-year period have been published in the current issue of Obstetrics and Gynecology.

A Look at the Research

The methodology used  in this study to determine major and minor depression was based on patient responses to the Patient Health Questionnaire and  in accordance with criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), as follows:

“In our study, women meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for major or minor depression on the Patient Health Questionnaire were classified as experiencing current depression.  The DSM-IV criteria for major depression on the Patient Health Questionnaire require the participant to have, for at least 2 weeks, five or more depressive symptoms present for more than half the days, with at least one of these symptoms being depressed mood or anhedonia.  The criteria for minor depression (or depression not otherwise specified) require the participant to have, for at least 2 weeks, two to four depressive symptoms present for more than half the days, with at least one of these symptoms being depressed mood or anhedonia.  The criteria for panic disorder require affirmative answers to all five panic symptoms and follow the DSM-IV.”

A summary of the Melville et. al study findings includes:

  • Antenatal depressive disorders were present in 9.9% of study participants and 5.1% of those identified also met the criteria for probable major depression; 4.8% met the criteria for probable minor depression.
  • 3.2% of women had probable panic disorder and of those, 52.5% had co-morbid depression (31% major and 21% minor).  47.5% had isolated panic disorder. 19.6% of women with probable major depression had panic disorder while 14.4% of women with probable minor depression had panic disorder.
  • Suicidal ideation was present in 2.6% of the women studied, but of those with major depression, 29.5% reported suicidal ideation.

Melville and her colleagues found that antenatal depressive disorders are more prevalent in younger, less educated, single women. Other aggravating factors that heightened a woman’s risk of antenatal depression included:

  • women with two or more co-morbidities
  • prior pregnancy complications (including medically required bed rest)
  • psychosocial stressors (lower socioeconomic status and limited resources)
  • domestic violence
  • Asian, African American and Hispanic ethnicity

Discussion

First and foremost, we have to recognize that pregnancy is not a welcomed event for all women.  And, even in women for whom pregnancy is a welcomed event, antenatal mood disorders can still develop.   In fact, many people remain unaware of the prevalence of antenatal depressive disorders—including some clinicians. The first step to combating this problem is through creating heightened awareness.  With evidence-based training (utilizing studies like Melville’s) and implementation of universal screening and intervention protocols during prenatal visits, diagnosing and treating these pregnancy-related mood disorders can become a widespread reality.

If a clinician suspects a prenatal depressive disorder in one of their patients, she must be ready to provide not only prescriptions for medical therapy (if indicated) but also address other medical and social issues contributing to the condition. For women with underlying co-morbidities, clinicians must identify and treat these conditions accordingly.  Challenges to this might include maintaining frequency and consistency in prenatal care: socioeconomic, geographic, and patient age issues can sometimes prompt less-than-optimal attendance of regular prenatal office visits.   Also, for women whom English is not their first language or for whom American culture and medical care are unfamiliar, a similar deleterious effect on prenatal care consistency might be observed. In these cases, clinicians may need to invite the assistance of social workers, other support services, family members and/or friends of the patient to both educate her as well as increase her access to appropriate care.

Melville’s study confirms what other research had already identified:  domestic violence bears a hefty association with antenatal depressive disorders (odds ratio = 3:45).  While some clinicians may experience discomfort in questioning their patients about the possibility of domestic violence, the data suggests this line of questioning should be imperative.   If  a clinician suspects or confirms a case of abuse he must be prepared to immediately provide appropriate resources to his patient in the form of patient education pamphlets, hotline phone numbers, shelter information and counseling resources.  Alternatively, a trained individual within the practice can also act as a liaison between the patient and appropriate resources, along with maintaining follow- up with the patient at each subsequent prenatal visit.   Because domestic violence happens to women of all ages, races and ethnicities and in all socioeconomic brackets, clinicians must screen all their prenatal patients for this antenatal mood disorder risk factor.

Antenatal depressive disorders are more common than most people realize and they are a real challenge for clinicians to manage.  Melville and her colleagues have provided a useful set of identifiable risk factors that can alert clinicians to patients with potential problems. My greatest concern is that this data may lead some clinicians to screen only those women who have one of the herein analyzed risk factors or who appear to fit the criteria and ignore the potential for antenatal depressive disorders in other women.  The researchers acknowledge that this study has limitations despite being carried out on a large sample and producing data very similar to previous studies. Therefore, they recommend that further studies be conducted to determine if the risk factors identified for antenatal depressive disorders are applicable to a wider subset of patients.  I commend Melville, et. al for their work and for acknowledging the study’s limitations. All pregnant women are at risk for antenatal depressive disorders, with some possessing a greater risk than others. As such, it behooves clinicians to make the extra effort to screen all antenatal women at regular intervals during pregnancy for depressive disorders.

Posted by:  Darline Turner-Lee, BS, MHS, PA-C,

Patient Advocacy, Practice Guidelines, Prenatal Illness, Research , , , , , , , , , , , , , , , , ,

  1. November 29th, 2010 at 23:53 | #1

    Thank you for this article. I appreciate the careful consideration of the topic, and the role of the clinician in screening for ppmad. I would like to encourage all childbirth educators, birth and postpartum doula, and lactation education training organizations to heed your advice, and step into the world with the rest of maternal care by teaching all birth professionals to screen..every woman, every time–not just postpartum doulas. And all doula/cbe organizations should mandate referrals to local resources, publish position papers, and have links to resources on their sites. (ICEA is VERY close to this now!)

    Clinicians and pediatricians are being led by their certifying organizations to screen. Now, we are next! Doulas, CBE’s…it is NOT beyond the scope of practice to screen (not merely teach her how to do it herself postpartum), but to screen using a reliable tool such as the PHQ, or EDS and then REFER to local resources. Use Postpartum Support International’s national resource for care providers and coordinators in your state as a starting point. http://www.postpartum.net; Give every client/student national suicide prevention number.

    Thank you again for the science! Now let’s see if we can ALL be sensible.

  2. avatar
    Lisa
    November 30th, 2010 at 00:06 | #2

    Until the stigma of mental disorders is removed, universal screening is likely to result in some very nasty repercussions for the mother and her baby. Women still have their babies taken for seeking mental health help. How much worse would the reaction be if they aren’t seeking help voluntarily?

  3. November 30th, 2010 at 12:56 | #3

    @Lisa
    I have to respectfully disagree. First, we are talking about women who are depressed before they have the baby. Second, it is a well established fact that depression carries with it significant co-morbidity both for mothers and their children pre and post partum. As this article aptly stated, there are significant numbers of women who are suicidal during pregnancy. It seems to me that a clinician needs to know if her pregnant patient is suicidal and has the professional obligation to intervene. If a clinician suspects that a woman is depressed and does nothing, that does just as much harm as knowing that a patient has high blood pressure yet the clinician does not treat it. (And we never ask patients of we can take their blood pressure, we just do it!)

    The point of suggesting clinicians screen all patients for antenatal depression is to identify women who may be at risk for (or already have) depression, anxiety or suicidal ideation and to get them help before their situations become severe and there is any need to even consider removing children or mama from the home.

  4. avatar
    Dawn
    November 30th, 2010 at 13:04 | #4

    With the reality of reaction to former birth oppression or whatever it is called, I would caution that it may not always be depression that shows but anxiety that comes from fear of a repeat of problems experienced in the former pregnancy and birth. Some of these problems are actually caused by medical staff and a woman’s reaction to the treatment by medical staff.

    Also, I know some medications may be prescribed when not needed. When I had experienced two miscarriages in a row I was offered anti-depressant medications and sleeping pills without only an OB appointment. I believe it was inappropriate to offer me such medication. I was in grief, and soon became pregnant again. What kind of effect could the medication have had on my next baby had I consented and followed the recommended treatment?

    I know you are speaking of disorders that come up unexpectedly, but medical professionals need to be careful.

  5. November 30th, 2010 at 18:36 | #5

    Dawn, you are right that you should have never been prescribed anti-depressants without first being evaluated. Additionally, Anxiety disorders are part of antenatal mood disorders and as such need to be screened for (I’ll refer you to the full text article for more on this!). My hope is that if you had been properly screened, you would have received (or at least been offered) appropriate treatment, which in your case may have been a referral to a therapist to help you cope with your grief as opposed to medication. The point is that clinicians have to be on the look out for the wide variety of antenatal mood disorders, assess their patients regularly during routine prenatal care and then work with their patients to find the most appropriate therapies. This article offered guidelines for such screening measures.

  6. December 1st, 2010 at 13:42 | #6

    I agree with Lisa. This sounds like it will lead to a cascade of interventions that helps a few but harms many more. I also have other issues/concerns that go beyond the scope of a blog comment- mainly overstepping boundaries, using “clinical opinions” as facts, and how this all ties into personal freedoms.

  7. December 1st, 2010 at 15:22 | #7

    I think that you and Lisa have both missed the point. No one is forcing anyone to do anything. This article is asking clinicians to screen, i.e. ask their patients during office visits, if they are experiencing symptoms of depression, anxiety or suicidal ideation. If a patient doesn’t want assistance, they can simply say that they are not in need of assistance. The exception to this rule is that if the clinician notices that the patient is at immediate risk for danger or putting herself in danger, then they have to report the situation to the proper authorities for further investigation. In my experience as a physician assistant, this happened in a case of blatant abuse where the woman was visibly injured at the visit. My obligation was to report the event to the authorities as was required by my medical license, make a note in the chart, refer the patient to the emergency room (don’t know if she went but referred her) and to offer her information on safe houses, counseling, etc.. It was then up to the authorities to follow up and for the patient to determine what she needed.

    You have to understand, a woman can come and cry her eyes out during an office visit and be clearly depressed. The clinician can make the diagnosis of depression or anxiety and offer her treatment but if she refuses, that is the end of it (unless she is in physical danger!)NO ON IS MAKING ANYONE DO ANYTHING.

    The purpose of the article was to raise clinicians’ awareness to antenatal depression and to encourage them to ask patients if they need any assistance in this area. This is medically no different from asking patients if they are constipated and need a laxative or if they are having nausea and need an anti-emetic. However, the potential consequences of not screening for the patient for depression are far more severe. It’s a fine line because if the clinicians do nothing and the patient harms or kills herself or someone else, then people complain, “Why didn’t her doctor do anything? How could she/he not have known or missed this?”

    As a patient, if you don’t want a certain treatment or assessment, all you have to do is say “no”. But if that puts a rift between you and your provider then you have to be prepared to deal with that an perhaps even switch providers. The Clinician/Patient relationship has to be mutual and if one side doesn’t trust the other, it just won’t work. We can all cited examples of this. But again, my experience is that if you can talk openly with your clinician, you are much more likely to get the treatments that you want and need.

  8. December 2nd, 2010 at 15:38 | #8

    I have not missed the point, I just have a different perspective. I can understand what you are saying while still disagreeing with it. That doesn’t mean I don’t understand the logic and motives- it just means my experiences have led me to different conclusions. Such is life.

  9. avatar
    Christie B
    December 6th, 2010 at 22:17 | #9

    I’d be more comfortable with screening if a “diagnosis” of depression (which shouldn’t be made solely on the basis of a screening tool but often is) didn’t mean that a patient would likely have a great deal of difficulty finding insurance on the individual market in the future or might be used against them in custody proceedings or any number of other ways. Maybe this is part of what is making some folks uncomfortable with what would seem like a pretty straightforwardly useful recommendation.

  10. December 6th, 2010 at 23:18 | #10

    Unfortunately as our health care system stands, you can only get health insurance if you aren’t sick. Once you have a pre-existing condition, you are often deemed ineligible. However, with the recently passed Affordable Care Act (aka Obamacare) such practices are no longer legal. Too bad our legislators are chomping at the bit to reverse health care reform.

    As for child custody battles, that is a sticky situation all around. I don’t have enough experience to be able to comment intelligently on the legalities, but I will say that I fear for women who deny themselves treatment for depression fearing that they will lose their children. In my opinion, untreated depression is as grave a medical emergency as a diabetic not taking insulin because she doesn’t want to be seen using needles. Yes, there is a stigma associated with mental health disorders, but the reality is that untreated depression is a health risk as well as a risk for mortal danger(suicide and even homicide) and as great a risk as the diabetic with uncontrolled blood sugars.

    The comments have raised interesting questions regarding our current health care system, women’s rights to obtain complete medical treatment including treatment for mental health disorders and our skewed legal system. While there is much work to be done in all of the aforementioned areas, I still don’t think that leaving depression untreated is the answer.

  11. December 7th, 2010 at 22:12 | #11

    You mention domestic violence as associated with depressive disorders so ithought you might find this post I wrote about domestic violence screening to be useful.

    http://bellywisebirthsupport.blogspot.com/2010/10/healthcare-providers-and-domestic.html

  12. December 8th, 2010 at 08:21 | #12

    Thank you, mrsculpepper, for sharing this link with us–which I commend to everyone here–and for your courage in declaring your personal history with domestic violence, paired with a drive to end this tragic phenomenon. I wish you the best in your endeavors, and invite you back to Science & Sensibility, anytime!

  1. August 26th, 2012 at 08:54 | #1