Perinatal Depression: How do we Respond?

Michael W. O’HaraDepartment of

PsychologyThe University of Iowa

Meeting the Mental Health Needs of Texans (and others)

mike-ohara@uiowa.edu

Iowa Depression and Clinical Research Center

Team in Iowa City Sarah Bell Jen Bowman-

Reif, MS Melissa Buttner,

MA Jane

Engeldinger, MD Sheehan Fisher,

PhD Rebecca Grekin Corinne Hamlin,

MAT Robin

Kopelman, MD Jennifer McCabe

Michelle Miller Kimberly Nylen,

PhD Michael O’Hara,

PhD Jennifer

Richards, MSW Heather Rickels,

MA Lisa Segre, PhD Scott Stuart, MD J Austin

Williamson, MA

Outline of Presentation

Burden of Depression What is Postpartum/Perinatal

Depression Risk Factors Prevalence Screening Treatment: Impact on mother Treatment: Impact on infant Summary

Burden of Depression in Women

Second leading cause of disability (lost years of healthy life) among women in the world aged 15 to 44 years

In the U.S. depression is the leading cause of non-obstetric hospitalizations among women aged 18-44

Sources: The World Health Report 2001, Geneva: WHO; Jiang et al. 2000 ‘Care of Women in U.S. Hospitals, 2000.’

Burden of Perinatal Depression

For mother Personal suffering, continued depression,

poor health For the child

Delayed prenatal care, shorter gestation Fussiness, feeding problems, poor weight

gain Delays: cognitive skills, social skills,

language Behavioral problems, insecure

attachment Later depression

For the family – marital discord, divorce

Perinatal Depression: Definition

Major or minor depression that begins or continues in pregnancy and the postpartum period (usually up to one year after delivery)

DSM-IV criteria – postpartum onset Does not include:

Postpartum blues Postpartum psychosis

Often co-morbid with anxiety disorders or significant anxiety symptoms

Criteria for Diagnosing Depression

Symptoms (at least one of first two and total of five)

Depressed mood Loss of interest or pleasure

Significant weight or appetite change Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or

inappropriate guilt Impairment in thinking, concentration,

or decisions Recurrent thoughts of death or suicide

Causal/Risk Factors for PPD

O’Hara et al. (1982 – 2007)Several prospective and cross-

sectional studies Outcomes: Depression diagnosis and

symptoms Predictors of PPD

Past depression (level, diagnosis, past history) ++

Ψ vulnerability ± Life events (incl. childcare, obstetric) ++ Social support (incl. marital, non-marital)

++ Low income + (…but only in cross-

sectional studies Hormones –

Meta-Analytic Findings

Past depression or anxiety disorder Life stress

Unplanned/unwanted pregnancy, obstetrical

Losses (e.g., housing, job, divorce/separation)

Conflicts with family, co-workers, friends, children

Natural disasters (e.g., fires, floods, tornadoes)

Poor social support (from partner, family, friends)

Socioeconomic disadvantage

O’Hara & Swain, 1996; Beck, 2001; Robertson et al., 2004

Prevalence of Perinatal Depression

Prospective studies (O’Hara et al., 1984; 1990)

Pregnant/Postpartum women 8-9% pregnancy; 10-12% post

partum Non-pregnant/postpartum

controls 5.6% pregnancy; 7.8% post

partum (NCB) Childbearing and non-

childbearing rates were not different

What the literature suggests

O’Hara & Swain (1996) 54 studies; 12,910 subjects 13% prevalence rate for postpartum

period Gavin et al. (2005)

28 studies (all based on diagnosis) 18.4% pregnancy period prevalence 19.2% postpartum period (first 3

months) No evidence of increased risk over

other times

Recent Large Scale StudyVesga-Lopez et al. (2008)

National representative survey 13,025 non-pregnant; 994 post partum Adjusted odds ratio for postpartum

women 1.52 (1.07-2.15) Depression .55 (.31-.96) Receiving treatment

Women are at increased risk for depression in the postpartum period

…but are less likely to be treated.

Implications or What’s so special about

perinatal depression? It is prevalent during pregnancy and

the postpartum period Women suffer Negative consequences for women,

their children, and families Often are not treated …but women have frequent contact

with health care providers during and after pregnancy

Role of the PCP inDetecting Depression

Recommendations of U. S. Preventive Services Task Force (2009)

Recommendations of ACOG Committee on Obstetric Practice (2010)

Recommendation of the USPSTF

“The U.S. Preventive Services Task Force recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up (Grade B)”

Source: U.S. Preventive Services Task Force. (2009). Screening for depression in adults: U.S. Preventive Services Task Force recommendation statement, Annals of Internal Medicine, 151, 784-792.

ACOG – Committee on Obstetric Practice Recommendations“Depression is very common during pregnancy and

the postpartum period. At this time there is insufficient evidence to support a firm recommendation for universal antepartum or postpartum screening. There are also insufficient data to recommend how often screening should be done. However, screening for depression has the potential to benefit a woman and her family and should be strongly considered. Women with a positive assessment require follow-up evaluation and treatment if indicated. Medical practices should have a referral process for identified cases. Women with current depression or a history of major depression warrant particularly close monitoring and evaluation.”

Committee on Obstetric Practice. (2010). Screening for depression during and after pregnancy. Obstetrics and Gynecology, 115, 394-395

PPD Screening

Screening is feasible (Gordon et al., 2006; Segre, Brock, O’Hara, Gorman & Engeldinger, 2010; Yonkers et al., 2009)

Primary care providers can be trained quickly and effectively (Baker, Kamke, O’Hara, & Stuart, 2009)

Both on-line and in-person trainings are available (Baker et al., 2009; Segre et al., 2010; Wisner et al., 2008)

What needs to be in Place

A tool for detection EPDS; PDSS; PHQ-9; Two question

screen A decision rule for further

assessment An approach to physician evaluation

of possible depression Referral, treatment, follow-up

protocols

Following up on Positive Screens

Follow-up with positive items on screen

Understand the context More formally assess and possibly

diagnose depression Rule out alternative medical

explanations Ask about concerns or preferences

for treatment Initiate treatment or referral

Physician’s Role

Medication management Refer for medication management Refer for counseling/psychotherapy Refer for social services

Treatment Medication

TCA; SSRI; SNRI; Mood Stabilizer Psychotherapy

Interpersonal Psychotherapy (IPT) Cognitive-Behavioral Therapy (CBT) Listening Visits Group Therapy

Treatment

Complementary and Alternative Approaches Bright Light Therapy Exercise, Nutrition Herbals, Acupuncture, Yoga

Peer Support and Education Postpartum Support International

Evaluating IPT for Postpartum Depression (O’Hara et al., 2000)

120 postpartum depressed women DSM-IV major depression Recruited from the community

12 sessions IPT or 12 weeks of waiting

Treatment provided by community clinicians

Assessments included depression, social adjustment, infant behavior, and mother-infant interaction

Also followed a cohort of nondepressed mothers and infants

IPT for Postpartum Depression:

Hamilton Rating Scale for Depression (HRSD)

Pre-therapy 4-Wks 8-Wks 12-Wks0

5

10

15

20

25

IPT

WLC

IPT for Postpartum Depression:

Major Depression at 12 week Assessment

12 %

69%

0

10

20

30

40

50

60

70

%

MDE at 12 Week Assessment

IPTWLC

Wait List Group after IPT (N=47)HRSD

Pre-therapy 4-Wks 8-Wks 12-Wks0

2

4

6

8

10

12

14

16

18

WLC

Relapse and RecoveryNylen, O’Hara et al. (2008)

Relapse following IPT 12 months - 42%; 18 months - 48%

Recovery for treatment non-responders 84% of women not recovered with

treatment recovered over 18 months Proportion of month depressed

during follow-up Month six post-treatment

39% Month twelve post-treatment 35% Month eighteen post-treatment

26%

Evidence for Treatment Efficacy

Empirical validation General population

Medication and psychotherapy ….but, effects for mild to moderate

depression may be no greater than placebo

Postpartum women Numerous RCTs demonstrate efficacy of

psychotherapy for postpartum depression

Relatively few studies of antidepressant medication, mostly positive, but mostly uncontrolled

Impact of treatment on offspring(Forman, O’Hara et al., 2007) Little impact on infant behavior Mothers reported less parenting

stress 18 months later treated depressed

mothers (compared to non-depressed mothers) rated their children as: lower in attachment security; higher in

negative temperament & behavior problems

…all of this suggests that parenting behaviors should be a target of therapy

Parenting Interventions Lynne Murray & Peter Cooper

(2003) CBT, psychodynamic, and non-directive

counseling approaches to PPD and altering the M-I relationship

“Indications of a positive benefit were limited.”

Roseanne Clark (2003; 2008) Mother-Infant Therapy Group for PPD

and M-I relationship Intensive 12 week treatment including

mothers’ group, infants’ group, and mother-infant group.

Relative to WLC, M-I group found infants more reinforcing, and more positive in interactions

Conclusions and Next Steps for Parenting

Interventions Little evidence that treatment for PPD

improves parenting Modest evidence that focus on parenting

in context of PPD treatment is efficacious Most parenting interventions with infants

have been driven by infant rather than maternal problems

New interventions, possibly introduced during pregnancy must be developed in increase sensitivity in at risk and depressed mothers in pregnancy and the postpartum period.

Take Home Messages

Perinatal Depression: Prevalent Significant mental health problem Consequences extend to offspring

and family Detection in Ob-Gyn and primary

care settings Professional treatments effective…

but Coordination of care and uptake of

services remain challenges Interventions that target the M-I

relationship