Depression During Pregnancy

Heather A. Bennett; Adrienne Einarson; Anna Taddio; Gideon Koren; Thomas R. Einarson

Clin Drug Invest. 2004;24(3)

Epidemiology of Depression during Pregnancy

Published reports of the prevalence of depression during the gestational period have increased dramatically over recent years. Eight studies were published between 1985 and 1995, compared with 21 between 1996 and 2003. Despite increased research into the epidemiology of this disorder, there is still considerable uncertainty as to the numbers of women affected. Rates determined by structured interview have ranged from 2 to 21%^[13,62,63] and up to 38% for women of low SES.^[20] Estimates derived from self-report questionnaires have ranged from 8 to 31%^{[11,12,14,16,18,64,65,66,67,68,69,70]} and 20 to 51%,^[21,71,72] respectively. Table II summarises studies that have estimated the prevalence of depression during pregnancy.

To obtain an explanation for such a wide variation, it is necessary to consider the methods used within the original articles. Researchers have used a variety of instruments to detect depression and depressive symptoms. Not all have been validated for pregnancy. It is possible that the use of such instruments may have measured pregnancy-related somatic symptoms as well as the depression itself. Furthermore, researchers have used modified instruments and varying cutoff scores. Rates derived from the use of such instruments may not provide a 'true' estimate of prevalence in this population. However, the consequences of such use are unknown and may in part contribute to the variation in observed rates.

Another reason for the discrepancies between study outcomes may be that estimates have been determined at different stages of pregnancy. The progression of pregnancy may have an impact upon depression status. If so, it would be necessary to specify the time of the prevalence measurement relative to the stage of pregnancy. In addition, although the prevalence of depression has not been shown to be dependent on race,^[81] it has been shown to be negatively correlated with SES.^[35] Therefore, it is important that data from patients with low SES be analysed separately.

To ensure adequacy of healthcare resources, a more precise estimate of the number of women with prenatal depression is required. Systematically combining the available studies based on: (i) the SES of the participants and (ii) the method of determination of depression may provide such an estimate. To date, no such research has been identified.

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This project was unfunded, and the authors have no conflicts of interest.

Cite this: Depression During Pregnancy - Medscape - Mar 01, 2004.

Abstract and Introduction
Clinical Spectrum of Depression
Epidemiology of Depression during Pregnancy
Outcomes Associated with Prenatal Depression
Treatment of Depression during Pregnancy
Reasons for Inadequate Antidepressant Treatment
Conclusions
References

Table I. Screening Instruments Used to Identify and Quantify Depression During Pregnancy
Instrument	Timeframe of questions	No. of items	Total possible score	Cutoff score (level of depression)
BDI^[39]	Today	21	63	≤10 (mild) ≤20 (moderate) ≤30 (severe)
CES-D^[40]	Past week	20	60	≥16
DACL-Form C^[41]	Present time	32		≥14
EPDS^[42]	Past week	10	30	≥12
PRIME-MD, PHQ^[43]	Past 2 weeks	?9	78	≤4 (none) 59 (mild) 1014 (moderate) 1519 (major) 2027 (severe)

BDI = Beck Depression Inventory; CES-D = Center for Epidemiological Studies Depression Scale; DACL = Lubin Depression Adjective Checklist; EPDS = Edinburgh Postnatal Depression Score; PRIME-MD, PHQ = Primary Care Evaluation of Mental Disorders Patient Health Questionnaire.

Table II. Summary of Studies That Have Estimated the Prevalence of Depression in Pregnancy
Author	Country	Year	No. invited to participate	Instrument (cutoff score)	% of patients depressed
Affonso et al.^[62]	US	1990	224	SADS (na)^a	2
Andersson et al.^[73]	Sweden	2001	1 795	PRIME-MD, PHQ (na)^a	10
Areias et al.^[74]	Portugal	1996	65	SADS (na)	18
Birndorf et al.^[75]	US	2002	69	BDI (≥10)	25
Bolton et al.^[68]	England	1996	492	EPDS (>15)	24
Chung et al.^[76]	Hong Kong	2001	959	BDI (>14.5)	10
Da Costa et al.^[18]	Canada	1999	100	DACL (≥14)	30
Da Silva et al.^[77]	Brazil	1998	32	EPDS (>13)	38^b
Dayan et al.^[16]	US	2002	767	EPDS (≥15)	11
Evans et al.^[14]	England	2001	13 799	EPDS (≥13)	14
Gotlib et al.^[12]	Canada	1989	363	BDI (≥10)	26
Hobfoll et al.^[20]	US	1995	192	RDC (na)	38^b
Hoffman & Hatch^[66]	US	2000	876	CES-D (≥16)^a	31
Johanson et al.^[11]	UK	2000	417	EPDS (>14)	10
Josefsson et al.^[69]	Sweden	2000	1 489	EPDS (>10)	17
Kelly et al.^[15]	US	2001	186	PRIME-MD, PHQ (na)	21
Kitamura et al.^[63]	Japan	1993	134	SADS (na)	16
Kurki et al.^[65]	Finland	2000	652	BDI (≥3)^a	30
Marcus et al.^[70]	US	2003	3 472	CES-D	20
Matthey et al.^[78]	Australia	2000	166	BDI (>9)	12
McKee et al.^[19]	US	2001	114	BDI-II (≥14)	51^b
O'Hara^[13]	US	1985	106	SADS (na)^a	9
O'Heron^[79]	US	2000	108	SCID-I (na)	14
Orr & Miller^[21]	US	1995	2 000	CES-D (≥16)	50^b
Pajulo et al.^[64]	Finland	2001	391	EPDS (>12)	8
Salamero et al.^[48]	Spain	1994	976	BDI (>10)	35
Seguin et al.^[71]	Canada	1995	55	BDI (≥15)	20^b
Verdoux et al.^[80]	France	2002	598	EPDS (>12)	5
Wu et al.^[67]	US	2002	3 873	CES-D (≥16)	16
Total			32 765		18.3 ^c

^aInstrument modified by researcher.
^bAll participants of low socioeconomic status.
^cAverage percentage of depressed patients weighted by size of study.
BDI = Beck Depression Inventory; CES-D = Center for Epidemiological Studies Depression Scale; DACL = Lubin Depression Adjective Checklist; EPDS = Edinburgh Postnatal Depression Score; na = not applicable; PRIME-MD, PHQ = Primary Care Evaluation of Mental Disorders Patient Health Questionnaire; RDC = Research Diagnostic Criteria; SADS = Schedule for Affective Disorders and Schizophrenia; SCID-I = Structured Clinical Interview for Axis 1 disorders.

Table III. The Canadian Psychiatric Association and Canadian Network for Mood and Anxiety Treatments (CANMAT) Recommendations for the Treatment of Depression During Pregnancy ^a
Treatment level	Medication
First-line	Fluoxetine
Second-line	Citalopram, fluvoxamine, paroxetine, sertraline
Third-line	Tricyclic antidepressants, electroconvulsive therapy, interpersonal therapy (short-term treatment focused on improving interpersonal relationships and communication skills)

^aFrom the paper by the CANMAT Depression Work Group.^[177]

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Depression During Pregnancy

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