Identifying Depression during Pregnancy and Early Postpartum

To read more of the ANGELS Update, please click here.

 

By Jessica L. Coker, MD, Assistant Professor, Departments of Psychiatry and OB/GYN

In November 2018, the American College of Obstetricians and Gynecologists (ACOG) issued a revised committee opinion on screening for perinatal depression (ACOG 2018). The prevalence of depression during pregnancy is as high as 25% with prevalence increased in younger pregnant women (Pearson 2018). Utilizing the Pregnancy Risk Assessment Monitoring System (PRAMS), the Centers for Disease Control estimated that in 2012 the overall prevalence of postpartum depressive symptoms was 11.5% with the greatest prevalence among Arkansas women (20.1%) compared to 26 other states (Ko 2017). Risk factors for postpartum depressive symptoms included: 1) younger (less than 24 years old), 2) American Indian/Alaska Natives or Asian/Pacific Islanders, 3) less than high school education, 4) unmarried, 5) smokers, 6) three or more stressful life events in the year before birth, 7) term, low-birthweight infants, and 8) infants requiring NICU admission at birth (Ko 2017). Depressive symptoms during pregnancy and postpartum can have devastating effects on mothers, their families and their children. Mother-infant bonding and breastfeeding success are often impacted by depressive symptoms, and suicide is the third leading cause of death among early and late postpartum women (Wallace 2016).

ACOG recommends the following for all obstetricians-gynecologists and other obstetric care providers:

  1. Screen patients at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool.
  2. Complete a full assessment of mood and emotional well-being during the comprehensive postpartum visit for each patient. This is in addition to any screening that was completed during pregnancy.
  3. When indicated, providers should initiate medical therapy or refer patients to appropriate behavioral health resources, or both.

Common, validated screening tools for depression include the Edinburgh Postnatal Depression Scale (EPDS), Postpartum Depression Screening Scale, and Patient Health Questionnaire 9. The EPDS was developed in the 1980s and is frequently used in both pregnant and postpartum populations (Cox 1987). The scale has 10 items that takes less than five minutes for a patient to complete. A score of 10 or greater is suggestive of possible depression. Of note, it is also important to review question #10 of all completed scales as this assesses self-harm thoughts.

Recent recommendations from the US Preventive Services Task Force (USPSTF) suggest that counseling-based interventions may be effective in preventing perinatal depression in women at increased risk (O’Connor 2019); however, counseling options, specifically in more rural areas, continue to be sparse. The ANGELS guidelines provide evidence based treatment recommendations for depression during pregnancy and the postpartum period. It is also of note that the Women’s Mental Health Program (Drs. Jessica Coker and Shona-Ray Griffith) at UAMS provides 24/7 phone consultation for obstetrical providers throughout the State for questions regarding diagnosis and/or treatment as well as referral sources.

In conclusion, depressive symptoms during pregnancy and the postpartum period are common and can have negative obstetrical and neonatal consequences. The first step in attenuating these consequences is by effective screening and identification.

 

Selected References

  1. American College of Obstetricians and Gynecologists. (2018). Screening for perinatal depression. ACOG Committee Opinion No. 757. Obstet Gynecol, 132, e208-12.
  2. Cox, J.L., Holden, J.M., and Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782-786.
  3. Ko, J.Y., Rockhill, K.M., Tong, V.T., Morrow, B., Farr, S.L. (2017). Trends in Postpartum Depressive Symptoms –27 States, 2004, 2008, and 2012. MMWR Morb Mortal Wkly Rep, 66, 153-158.
  4. O’Connor, E., Senger, C.A., Henninger, M.L., Coppola, E., and Gaynes, B.N. (2019). Interventions to prevent perinatal depression: evidence report and systematic review of the US Preventative Services Task Force. JAMA, 321(6), 588-601.
  5. Pearson, R.M., Carnegie, R.E., Cree, C., Rollings, C., Rena-Jones, L., Evans, J. et al. (2018). Prevalence of Prenatal Depression Symptoms Among 2 Generations of Pregnant Mothers: The Avon Longitudinal Study of Parents and Children. JAMA network open, 1(3), e180725-e180725.
  6. Wallace, M.E., Hoyert, D., Williams, C., & Mendola, P. (2016). Pregnancy-associated homicide and suicide in 37 US states with enhanced pregnancy surveillance. American journal of obstetrics and gynecology, 215(3), 364-e1.