Postpartum Depression Underidentified, Undertreated

One in 7 Women Positive for Recurrent Episodes of Major Depression

Deborah Brauser

March 21, 2013

Postpartum depression is increasingly common, new research suggests.

In a study of 10,000 women who had recently given birth, 14% — or roughly 1 in 7 — screened positive for recurrent episodes of major depression. And of these, more than 19% reported having considered harming themselves.

"The rate of postpartum depression was not surprising and [was] consistent with other estimates that have been developed from smaller samples of patients," lead author Katherine L. Wisner, MD, professor of psychiatry and behavioral sciences and of obstetrics and gynecology, and director of the Asher Center for the Study and Treatment of Depressive Disorders at Northwestern University Feinberg School of Medicine in Chicago, Illinois, told Medscape Medical News.

The largest-scale depression screening of postpartum women, the study marks the first time a full psychiatric assessment was done in this patient population.

"Although this is a bit of a controversial subject, we were able to show that women will accept these types of screenings. But where we need a lot more work is how to get those who screen positive to treatment," added Dr. Wisner.

The study was published online March 13 in JAMA Psychiatry.

Dr. Katherine Wisner

A second study also conducted by Dr. Wisner and colleagues and published online March 20 in the American Journal of Psychiatry showed that infant growth during the first 12 months is unaffected by prenatal exposure to antidepressants or by maternal depression.

Although the 2 studies are very different, Dr. Wisner noted that they both highlight the importance of screening women both before and after giving birth and to discuss treatment options.

"I've been doing this for about 30 years, and I'm still really troubled by the number of women who are pregnant or postpartum and depressed and not identified. And I just want them to know that they don't have to feel like that. Don't suffer, get some help!"

Huge Public Health Problem

In the study on postpartum depression, the investigators aimed to screen for the disorder, determine the timing of episode onset, and evaluate the possibility of thoughts of self-harm.

"In the US, the vast majority of postpartum women with depression are not identified or treated even though they are at higher risk for psychiatric disorders," said Dr. Wisner in a release.

"It's a huge public health problem. A woman's mental health has a profound effect on fetal development as well as her child's physical and emotional development."

The researchers evaluated 10,000 women older than 18 years who underwent screenings 4 to 6 weeks after delivery at Magee-Womens Hospital in Pittsburgh, Pennsylvania.

Results showed that 1396 of the women screened positive for depression, as shown by a score of 10 or higher on the Edinburgh Postnatal Depression Scale (EPDS), and 19.3% of these women reported having thoughts of self-harm.

Seven percent of the positive-screening women had a score of 13 or higher on the EPDS, and of these, 30% reported self-harm ideation.

Of the 1396 women, 826 (59.2%) received full psychiatric assessments during at-home visits, and 147 (10.5%) underwent a diagnostic interview by telephone.

"Most of these women would not have been screened and therefore would not have been identified as seriously at risk," said Dr. Wisner.

High Rate of Bipolar Disorder

In addition, 26.5% of the women who screened positive and had an in-home assessment reported having depression prior to their pregnancy, 33.4% had first-episode onset during pregnancy, and 40.1% had first onset postpartum. More than two thirds reported a comorbid anxiety disorder.

"Clinicians need to know that the most common clinical presentation in the postbirth period is more complex than a single episode of depression," said Dr. Wisner. "The depression is recurrent and superimposed on an anxiety disorder."

Interestingly, 68.5% of the women had unipolar depressive disorders, and 22.6% had bipolar disorder.

"That's a very high rate of bipolar disorder that has never been reported in a population screened for postpartum depression before. It is significant because antidepressant drug treatment alone can worsen the course of [this] disorder," added Dr. Wisner.

Overall, she noted that screenings are very important for this patient population. In fact, she reported that screenings for perinatal mental health disorders are now mandatory in the state of Illinois.

However, "if we identify patients, we must have treatment to offer them. If you try to refer them from an obstetrical setting to a mental health setting, because of stigma and other barriers, that's very difficult," said Dr. Wisner.

"So the newer models are treatment in the obstetrical or primary practice settings — so it's like 1-stop shopping. We need to integrate our system more. If we identify these women, then we have the responsibility to provide accessible treatment. And we aren't doing so good at that right now as a society."

Infant Growth Unaffected

For the second study, the investigators evaluated 3 groups of pregnant women between the ages of 15 and 44 years: those who did not use selective serotonin reuptake inhibitors (SSRIs) and did not have depression (n = 97), those who did not use SSRIs but did have major depression (n = 31), and those who used SSRIs and had major depression (n = 46).

All were assessed at 20, 30, and 36 weeks' gestation. In addition, pairs of mothers and infants were evaluated at 2, 12, 26, and 52 weeks postpartum.

Results showed that neither maternal major depression or SSRI exposure was significantly associated with infant weight, length, or head circumference. This nonsignificance continued even after evaluating prepregnancy body mass index.

In addition, the observed infant values were comparable with population statistics from the Centers for Disease Control and Prevention.

"Use of SSRIs is widespread, and women who stop taking them near the time of conception have a high relapse rate," said Dr. Wisner. "Given that depression has its own negative consequences, it's important to know the effects of both treatment and the lack of treatment."

The investigators note that larger studies are now needed.

"The effect of SSRI dose or, more directly, maternal serum drug also needed to drive the process of risk-benefit decision making to a new level of sophistication," they write.

Gold Standard Research

In an accompanying editorial, Barbara L. Parry, MD, from the Department of Psychiatry at the University of California, San Diego, agrees that clinicians who manage major depression during pregnancy and lactation must weigh both the risks and benefits of prescribing antidepressants.

Although previous studies have suggested that prenatal depression is associated with increased risk for preterm birth and low birth weight and that use of antidepressants during pregnancy is linked to several adverse outcomes, Dr. Parry noted that much of that research was limited because of the exclusion of specific participants — and by not assessing longer-term outcomes.

She notes that "the distinguishing feature of the current study" is its examination of the 3 distinct groups of pregnant women.

"Other strengths of the study include its prospective design, thorough participant (mother and child) assessments of clinical history, and physical examinations by raters blind to the condition," said Dr. Parry.

"Thus, this study sets the gold standard as to how to conduct sound methodological investigations in this field so that clinicians and patients have the necessary information to make informed decisions about reproductive choices."

Both studies were supported by grants from the National Institute of Mental Health. The study authors have reported several relevant financial relationships, which are fully listed in the original articles. Dr. Parry has reported no such financial relationships.

JAMA Psychiatry. Published online March 13, 2013. Abstract

Am J Psychiatry. Published online March 20, 2013. Abstract, Editorial