Back in 2016, the US Preventive Services Task Force (USPSTF) recommended that all adults, including pregnant and postpartum women, should be screened for depression; the task force has extended those recommendations by stating that all pregnant and postpartum women should be evaluated in order to determine risk for depressive illness and recommends that women at increased risk for perinatal depression should be referred for counselling. The overarching goal is to prevent perinatal depression, and this recommendation is based on the review carried out by O’Connor and colleagues which indicates that certain types of psychotherapy, including interpersonal psychotherapy and cognitive behavioral therapy, may be useful for reducing the risk of perinatal depression in certain populations of women. (Much less study has been devoted to the use of pharmacotherapy in this setting.)
After so many years of advocating for women with perinatal mood and anxiety disorders, we certainly welcome this increase in attention to identifying and caring for this vulnerable population. However, we must acknowledge that there are still some rather daunting obstacles to overcome, as outlined in the commentaries by Drs. Marlene Freeman and Lee Cohen. While we have demonstrated that we can screen for and identify women with perinatal depression, we have learned that identification does not necessarily result in treatment. Pregnant and postpartum women faces many obstacles when it comes to receiving psychiatric care; limited access to trained providers, long waiting lists, inadequate insurance coverage, and stigma are all factors that contribute to low levels of mental health treatment in this population.
Dr. Freeman notes, “While there are challenges, optimism is warranted, as an increasing number of studies and programs are assessing the delivery of therapies using technology and social media, which hold the promise of delivering care to a diverse population of women. If the health care delivery system can make the necessary investment to implement these recommendations, they may return great dividends in the form of enhanced well-being of mothers and their offspring.”
Ruta Nonacs, MD PhD
US Preventive Services Task Force, Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, Davidson KW, Doubeni CA, Epling JW Jr, Grossman DC, Kemper AR, Kubik M, Landefeld CS, Mangione CM, Silverstein M, Simon MA, Tseng CW, Wong JB. JAMA. 2019 Feb 12;321(6):580-587.
The USPSTF recommends that clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions.
O’Connor E, Senger CA, Henninger ML, Coppola E, Gaynes BN. JAMA. 2019 Feb 12;321(6):588-601.
Fifty studies (N?=?22?385) were identified. Counseling interventions were the most widely studied interventions. Compared with controls, counseling interventions were associated with a lower likelihood of onset of perinatal depression (pooled risk ratio [RR], 0.61 [95% CI, 0.47-0.78]; 17 RCTs [n?=?3094]).
Freeman MP. JAMA. 2019 Feb 12;321(6):550-552.
Commentary on the recommendations of the USPSTF.
Preventing postpartum depression: Start with women at greatest risk.
Cohen LS. Ob-Gyn News. 2019 January 31.
Commentary on the recommendations of the USPSTF.
Bina R. Women Birth. 2019 Feb 1.
Service use for postpartum depression is a function of a woman’s predisposition to use mental health services; individual, familial, and communal factors which enable or pose barriers to use of mental health services; and the woman’s perceived or evaluated need for treatment. In addition, societal determinants impact the woman’s decision to seek help directly or through impacting the health and mental health care service system’s resources and organization.
Lawson A, Dalfen A, Murphy KE, Milligan N, Lancee W. Psychiatr Serv. 2019 Feb 5:
Of 937 participants, 126 (13%) screened positive. Agreement between the texted screen and the Edinburgh Postnatal Depression Scale was moderate (?=0.45), with good sensitivity (0.90, 95% confidence interval [95% CI]=0.81-0.96) and specificity (0.82, 95% CI=0.79-0.85). Nine hundred thirty (99%) participants responded to at least one of the six texted screens, whereas 632 (67%) responded to all six. Of the 589 (63%) who responded to the satisfaction survey, 459 (78%) recommended that all women be screened for postpartum depression via text messaging and that all women in the postpartum period be sent information texts about postpartum depression (N=504, 91%).
Torres A, Gelabert E, Roca A, Navarro P, Plaza A, Subirà S, Martin-Santos R, Ascaso C, Garcia-Esteve L. J Affect Disord. 2019 Feb 15;245:965-970.
The probability of recovering was 30.2% (95% CI: 22.1%-37.4%) at 6 months of follow-up, 66.3% (95% CI: 57.4%-73.4%) at 12 months of follow-up, and 90.3% (95% CI: 79.8%-95.4%) at 24 months of follow-up. The mean time to full remission was 49.4 weeks (95% CI: 44.0-59.8).
Cannon C, Nasrallah HA. Ann Clin Psychiatry. 2019 Feb 1;30(1):e1-e6.
Most of the studies showed that African American and Hispanic women had a higher odds ratio of reported postpartum depression due to lack of social support, access, trust, past depression, and other factors. One study found that although African Americans are more likely to report symptoms of postpartum depression, they are less likely to seek treatment due to cultural stigma regarding mental illness.
Osnes RS, Roaldset JO, Follestad T, Eberhard-Gran M. J Affect Disord. 2019 Jan 28;248:155-165. Free Article
Anxiety late in pregnancy was also associated with postpartum depression.
Wikman A, Axfors C, Iliadis SI, Cox J, Fransson E, Skalkidou A. J Neurosci Res. 2019 Feb 5.
Nulliparity, instrumental delivery, or a negative delivery experience was associated with early onset postpartum depression. Postpartum factors (e.g., infantile colic, lack of sleep, low partner support, and bonding difficulties) were associated with early and late postpartum onset, as well as chronic depression.
Koch S, De Pascalis L, Vivian F, Meurer Renner A, Murray L, Arteche A.
Infant Ment Health J. 2019 Feb 5.
Fathers with postpartum depression exhibited worse patterns of interaction with their infants on measures of responsiveness, mood, and sensitivity; they also had greater difficulty in recognizing happy adult faces, but greater facility in recognizing sad adult faces.
Stewart DE, Vigod SN. Annu Rev Med. 2019 Jan 27;70:183-196.