Depression Among Women:Focus on Perinatal Depression

Diana Cheng, M.D.Medical Director, Women’s Health

Maryland Department of Health and Mental HygieneMarch 22, 2007

Incidence of Depression, U.S.

• Annual - 12 % of women (6% men) will experience a depressive disorder during a one year period

• Lifetime - 20% of women (10% of men) will experience depression

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Depression Across the Female Lifespan

Birth DeathMenarche Menopause

PremenstrualPregnancy/Postpartum

Peri-menopause

Postpartum Depression• Affects 1 out of every 8 postpartum women• Begins 2 weeks – 1 year postpartum• Symptoms

– Depression, anhedonia– Emotional stress, helplessness, irritability, anger– Inability to do normal everyday tasks– Appetite changes, sleeping too much/ too little– Thoughts of self-harm or suicide– Overly intense worries about baby– Lack of interest or fear of harming baby

Postpartum Thyroiditis• 5–10 % during 1st postpartum year• Thyrotoxicosis (destruction-induced), onset 1-4 months

• Fatigue, palpitations, psychosis (rare)• 30% develop hypothyroidism

• Hypothyroidism, onset 4-8 months• 40% require treatment• 30% go on to permanent hypothyroidism • Fatigue, cold intolerance, weight gain, depression

Depression During Pregnancy

• Pregnancy is not protective against depression

• Affects 10-15% of pregnant women• Begins any trimester

Maternal Depression: Effects on Infant and Child

• Poor pregnancy outcomes– PTL, LBW, SGA, RDS, ?PIH ?SAb

• Poor mother-infant attachment– Irritable, lethargic, poor sleep

• Language delays• Behavioral difficulties• Lower cognitive performance• Mental health disorders• Attention problems

Kahn, et al. AJPH 2002;92:1312-1318

Bonari et al. Can J Psychiatry 2004;49:726-735

•Infant Behav Dev 2004;27:216-229

•Psychiatry 2004;67:63-80

Maternal Effects of Untreated Depression

• Poor prenatal behaviors– Nutrition, prenatal care, substance abuse

• Poor parenting behaviors• Longer persistence of symptoms• Increased risk of postpartum depression• Increased risk of relapse

Risk Factors for Maternal Depression

• Prior depression (30%)• Prior postpartum depression (50%) or psychosis (70%)• Depression during pregnancy• Prior PMDD (premenstrual dysphoric disorder)• Family history of depression or bipolar disorder• ?Teens, not married, low income• Recent stressful events

– marital/partner discord, loss of loved one, family illness, premature birth

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Postpartum Period, Maryland PRAMS 2001-2003

Annual household

incomeAgeRace and ethnicity Marital status

Edinburgh Postnatal Depression Scale

• Created for postpartum women– Can also be used during pregnancy– Less emphasis on physical symptoms

• Takes < 5 minutes to complete• Self-administered• Validated screening tool• Useful in primary care settings• Rates intensity of depressive symptoms

– 10 questions, each worth 0-3 points– Score >12 (out of 30) indicates likely depression

Treatment for Depression• Support

– Support groups (facilitated), family, friends, help lines

• Counseling– Cognitive behavioral / interpersonal therapy

• Other treatments– light, alternative medicines – ECT

• Antidepressants– SSRIs

Maternal DepressionGetting Help

Treated

Undiagnosed80%

Diagnosed20%

State Programs: DepressionDATA to Action

State Programs: Depression• Data

– PRAMS – BRFSS– HSCRC– Vital Records – Medical Examiner– Case Reviews

• Maternal mortality review

Data ACTION• Maternal Depression Team (multidisciplinary)

• Providers (ob,ped, CNM, FP, psych, nursing, social work, public health)

• Health care coverage (Insurance/medicaid)• Organizations (WIC, academic/community, women’s health,

daycares, churches)

• Representation/Advocacy – other committees• Professional education and Outreach• Legislation• Direct Services - Title X Family Planning• Grants

WELL Project“Women Enjoying Life Longer”

A Women’s Health Program in 3 Title X Baltimore County Family Planning Sites

Eastern Family Resource Center

Essex Health Center Dundalk Health Center

• 1-800-PPD-MOMS Helpline• Website (www.healthynewmoms.org)

– Provider CMEs (www.perinataldepression.org), screening scale, brochure, resource list

• Media messages– Posters, Video PSAs, Radio Ads

• Local partnership grants• Provider training

– Information Packets– Education

www.healthynewmoms.org

Maternal Depression

Common DisorderUnder-diagnosed, under-treated

Adverse effects on mother, fetus, infant, familyEffective treatment availableUniversal ScreeningNeed for Education, Capacity, ResearchCommunity Support Eliminate Stigma