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Study Finds 1 in 7 New Mothers Depressed Before, During, and After Pregnancy CME/CE News Author: Marlene BuskoCME Author: Charles Vega, MD

Complete author affiliations and disclosures, and other CME information, are available at the end of this activity.

Release Date: October 3, 2007; Valid for credit through October 3, 2008

Credits AvailablePhysicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™ for physicians;Family Physicians - up to 0.25 AAFP Prescribed credit(s) for physicians;Nurses - 0.25 nursing contact hours (None of these credits is in the area of pharmacology)

All other healthcare professionals completing continuing education credit for this activity will be issued a certificate of participation.Physicians should only claim credit commensurate with the extent of their participation in the activity.

October 3, 2007 — A study of a large healthcare database found that approximately 1 in 7 new mothers are identified as having depression during at least 1 phase of pregnancy: 8.7%, 6.9%, and 10.4% of the women had a record of depression before, during, or after pregnancy.

The study, led by Patricia M. Dietz, DrPH, at the Centers for Disease Control and Prevention in Atlanta, Georgia, is published in the October issue of the American Journal of Psychiatry.

"It is the first study to take a comprehensive look across this time period for women," study author Evelyn P. Whitlock, MD, MPH, at Kaiser Permanente in Portland, Oregon, told Medscape Psychiatry. "I think it was a bit surprising that there was as high a prevalence of depression before and during as there was after pregnancy," she added. "There was a fair amount of depression at all 3 time points."

The group writes that given recent concerns about the risk for harm to the fetus from antidepressants and the overall increase in the use of these agents in the United States, they aimed to estimate the prevalence of antidepressant use before, during, and after pregnancy.

Fair Amount of Depression at All 3 Time Points

The investigators examined data from 4398 women who gave birth between 1998 and 2001 and who were continuously enrolled in the Kaiser Permanente Northwest health plan from 39 weeks before the pregnancy, during the pregnancy, and 39 weeks after childbirth.

They found that about 1 in 7 women had been identified with depression during the study period. Of the women diagnosed with postpartum depression, 54.2% were also identified as being depressed either before or during pregnancy.

"The fact that [depression] is similar between those 3 time points reinforces the fact that depression is something that happens relatively commonly in reproduction-aged women and can be exacerbated during pregnancy," said Dr. Whitlock.

Although postpartum depression clearly is an important concern, we also need to consider the mental health and treatment needs of the many women who are depressed right before or during their pregnancies, Dr. Whitlock observed, in a press release issued by Kaiser Permanente.

She commented to Medscape that the study looked at data from 1998 to 2001, when some of the more recent information about the use of selective serotonin reuptake inhibitors (SSRIs) in pregnancy was not available, but nonetheless, 4% of women were using SSRIs during their pregnancy.

"It's a tricky area and some of the medications are studied better in terms of breast-feeding vs use during pregnancy, for example, so women need to work carefully with an informed clinician and have a discussion about the risks and benefits of whatever treatment seems appropriate for the severity of their depression," she noted.

Challenges of Treating Pregnant or Breast-feeding Women With Depression

Because it is neither ethical nor practical to randomize pregnant women to antidepressant agents vs placebo to obtain information about treating depression, clinicians must rely on observational, cohort studies and reports that use administrative databases, Kimberly A. Yonkers, MD, at the Yale University School of Medicine in New Haven, Connecticut, points out in an accompanying editorial. She believes that the study by Dietz and colleagues exhibits the advantages and disadvantages of the studies with use of databases. "Administrative databases provide the largest sample size and the most power, but the cost of this is a lack of precision regarding information about possible confounders, such as health habits and illness characteristics," she writes. "But we must use the information that we have and hope for increased opportunities to enhance that database with future, rigorously controlled studies," she concludes.

The Centers for Disease Control and Prevention and America's Health Insurance Plans funded this study. The study authors have disclosed no relevant financial relationships.

Am J Psychiatry. 2007;164:1457-1458, 1515-1520.

Learning Objectives for This Educational ActivityUpon completion of this activity, participants will be able to:

1. Identify a potential complication of using selective serotonin reuptake inhibitors during pregnancy.

2. Describe the epidemiology of depression at the time of pregnancy.

Clinical ContextAlthough the prevalence of depression has been demonstrated to be approximately 10% during any trimester of pregnancy, clinicians should exercise some caution in initiating antidepressants for pregnant women diagnosed with depression. A study by Chambers and colleagues, which appeared in the February 9, 2006, issue of The New England Journal of Medicine, compared 377 women whose infants had persistent primary pulmonary hypertension of the newborn with 836 matched control women and their infants. The researchers found that infants exposed to SSRIs after the 20th week of gestation had an adjusted odds ratio of 6.1 for persistent pulmonary hypertension vs control infants. However, use of SSRIs, or use of any other antidepressant class, before the 20th week of gestation did not increase the risk for pulmonary hypertension.

The current study by Dietz and colleagues seeks to understand more regarding the risk for depression during pregnancy and how it relates to prepartum and postpartum depression. In addition, the study authors examine factors that increase the risk for depression during the time of pregnancy.

Study Highlights Data were drawn from a database of patients in the Kaiser Permanente Northwest health

maintenance organization. Researchers examined all pregnancies that ended in a live birth in this patient cohort between 1998 and 2001. Only mothers who were enrolled in the health plan for 39 weeks before and 39 weeks after the pregnancy were included in the present analysis.

The study authors used International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify depression during the period from 39 weeks before pregnancy to 39 weeks after delivery. Patients with a code for depression or who were found to have received antidepressant medications during this period were considered to have depression.

The main outcomes of the study were the prevalence of depression before, during, and after pregnancy as well as the association of maternal characteristics to the prevalence of depression.

4398 women were included in the analysis, 79% of subjects were white, and 76% of women were married.

15.4% of subjects had depression at some point in the study. The prevalence rates of depression before, during, and after pregnancy were 8.7%, 6.9%, and 10.4%, respectively.

Most women were diagnosed with depressive disorder not otherwise specified, whereas 20.6% had a code for major depression. Anxiety was a comorbid condition in 17.5% of women with depression.

Among women with depression before pregnancy, 56.4% had a diagnosis code for depression during pregnancy.

Rates of visiting a mental health specialist or receiving an antidepressant were 66.7% and 74.9%, respectively, among women with depression. SSRIs were the most commonly prescribed antidepressants. Rates of filling a prescription for an antidepressant before, during, and after pregnancy were 77.4%, 67.2%, and 81.5%, respectively.

Primary care clinicians identified the highest percentage of cases of depression, followed by mental health clinicians and obstetrician-gynecologists.

Variables associated with a higher rate of depression included white race, unmarried status, having 3 or more children before the incident pregnancy, smoking cigarettes during pregnancy, and having health coverage through Medicaid. However, age, educational level, and trimester of entry into prenatal care were not related to the risk for depression.

Pearls for Practice A previous case-control study by Chambers and colleagues found a link between the maternal

use of SSRIs after the 20th week of gestation and the risk for persistent pulmonary hypertension of the newborn.

The current study by Dietz and colleagues finds that depression affected 15% of women before, during, or after pregnancy. More than half of women with depression diagnosed before pregnancy continued to carry a diagnosis of depression during pregnancy, but the use of antidepressants was lowest during the time of pregnancy.

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News Author

Marlene Buskois a staff journalist for Medscape Psychiatry.

Disclosure: Marlene Busko has disclosed no relevant financial relationships.

CME Author

Charles P. Vega, MDAssociate Professor; Residency Director, Department of Family Medicine, University of California, Irvine

Disclosure: Charles Vega, MD, has disclosed an advisor/consultant relationship to Novartis, Inc.

Brande Nicole Martinis the News CME editor for Medscape Medical News.

Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

Medscape Medical News 2007. ©2007 Medscape

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