In addition to my work on MyndPlan, I keep busy in my role as a psychologist in a family health team. This is a pretty sweet job, because it lets me test out a lot of my ideas in a real life setting, plus I learn new things every day from my clients and colleagues. Occasionally, I’ll discover a gap in our service, and set out to fix it. A recent example involved screening for postpartum depression. You might be surprised to learn that depression is a very common problem for pregnant women and new moms.
Close to 10% of women who are pregnant or postpartum suffer from major depressive disorder. Despite this fact, it is a problem that often goes undiagnosed.
Depression can have serious consequences for both the new mother and her child, since the symptoms can be very disabling. Furthermore, we know there are some very effective treatments for depression. If these were available to every mom who ran into some difficulty, it could save a lot of misery and unhappiness.
Seems obvious doesn’t it?
In 2009 the US Preventative Services Task Force published recommendations based on research that showed screening for depression in the general population can be helpful. But despite a plethora of studies since the report was released, up till now no one could say for sure whether screening pregnant or postpartum women actually resulted in benefits such as reduced symptoms of depression or improved quality of life. Nor did we know which screening measures were the best for this particular group of people, who are very different from, say, middle aged unemployed men. Then there was the question of potential harm. For example, if some women are misdiagnosed and then treated unnecessarily, we might be putting them under a lot of stress and worry, not to mention exposing them to questionable treatments. Which gets us to the final question.
Even if we could figure out all these unknowns, there is still a lot of debate about whether the available treatments work for pregnant and postpartum women.
New Findings Have Emerged
Whew! That is a lot of unknowns and uncertainties. Which is the reason why a team led by Dr. Elizabeth O’Connor has trying to bring some clarity to the issue. Thankfully, they’ve recently published their report in the Journal of the American Medical Association that gives us some straight answers. I’ve just finished going over their findings, and I think that you’ll be interested to hear what they found.
Should We Screen?
Let’s start with the first question: Should we use screening measures at all for detecting depression in pregnant and postpartum mothers, and if so, which ones? Right now in our clinic we use a scale called the PHQ9. It’s a 9 item questionnaire that we use as a quick screen for anyone who seems even remotely sad. There are some other versions that are even shorter, including one with only 2 items. However, the PHQ measures are originally designed for the general population, and they have the unfortunate habit of catching people who might not be very depressed – or may not be depressed at all. That’s because the items making up the PHQ9 tend to emphasize physical symptoms that everyone – most notably pregnant women – will get when they are simply feeling physically unwell. Symptoms like excessive fatigue, or sleep problems. The other measure that Dr. O’Connor and her team looked at was more specialized. It’s called the Edinburgh Postnatal Depression Scale. Like the PHQ scales, it is short, but it has the advantage of being specifically designed to identify women who have PPD.
It turns out that the PHQ scales have not been applied consistently to the problem of PPD, whereas many dozens of studies have looked closely at the use of the Edinburgh measure. In the case of the latter measure, results gathered from studies involving over five-thousand pregnant or postpartum women suggest that it can catch between 80 and 90% of cases when a cutoff score of 13 is used.
More intriguing is the fact that even though no formal treatment was offered to many of the women in these studies, the results suggest that just being screened resulted in fewer depressive symptoms and improved quality of life at follow up.
Of course, most of these studies would have included some sort of informal follow up. Nevertheless, the fact that significant improvement was observed under these conditions is pretty encouraging. Furthermore, though only one fairly large study looked at potential harms of screening, the results suggest that they are safe.
What About Treatment?
Okay, so now I’m feeling pretty sure that I’m going to recommend we use the Edinburgh scale to screen women in our clinic. But then what? Which treatments for depression in pregnant or postpartum women help? And are there any risks associated with them?
Dr. O’Connor and her team were able to find studies involving a total of 1638 pregnant or postpartum women who screened positive for depression and got one of two types of treatment. Some of them received CBT, a type of psychotherapy that helps you understand how certain thoughts and behaviors can fuel depressive feelings, and shows you ways to turn this around. Others received medication, usually a type of antidepressant called an SSRI. When we look at the results of women who received CBT their symptoms of depression were reduced and their likelihood of remission improved significantly.
However, no consistent evidence either way was available for women with postpartum depression who received medication. And when we look at results for pregnant women, it turns out that using antidepressants might actually be associated with a slight increase in risk for some negative outcomes.
Medication Risks Are Small, But Significant
I wasn’t entirely surprised to read these last findings. I’ve learned in my work with clients who take these medications that they occasionally cause some troubling side effects. Women who are pregnant face a lot more demands on their bodies, making the likelihood of these unwanted effects even greater. But the effects that antidepressants can cause for pregnant moms, though infrequent, are more serious than most of the typical side effects I usually hear about. They include a doubling of risk for preeclampsia, higher rates of post-partum hemorrhage, and greater risk of miscarriage. There are also increased risks to the baby. These range from higher rates of preterm births to respiratory distress.
Keep in mind that these kinds of problems are rare most of the time,
If you are a pregnant or postpartum mom and are taking antidepressant medication, there is no reason to panic. These are population based risks. To prevent just one woman from having most of the common negative outcomes you would have to take hundreds off their medication. The risk to any one person is very small. Even doubling the rate might mean a difference in risk going from 1 in 300 to just 2 in 300 cases for more serious outcomes. Furthermore, depression has some pretty serious risks, so leaving it untreated is dangerous.
A Surprising Bonus
There was one more unexpected finding revealed by the report. It turns out that some of the women who were picked up by the screen were depressed before they were pregnant. At first this was taken as a problem. After all, the study meant to look at depressed pregnant and postpartum women, not depressed women in general. The screen was specifically built to detect postpartum symptoms, and it’s use in medical clinics and other settings was expressly intended for this purpose. But let’s think about it for a minute. If these already depressed women are being picked up by the screen, this means that their depression would otherwise have been missed. How many women are there out there that are depressed and not getting treatment? Or getting treatment that is not effective? In the end, catching these women this way is a positive thing. It shows that the use of screening can catch more than just depressed pregnant or postpartum women, and it reveals that we should be looking more closely at depression in women in general. The fact of the matter is that depression in general is missed more often than it is detected in our society. That is a familiar problem in my world as a psychologist, and one of the reasons I began working on MyndPlan. I had learned that having effective treatments for depression is only half the solution – they are no good at all if we can’t spot the problem early enough.
What Does It All Mean?
In the end, I’m glad I looked into this question. We really should be doing more in our clinic, and I’m willing to bet that many more across North America can do better. The results are pretty clear:
- Screening for depression in women who are pregnant or postpartum is effective, and it has a positive effect.
- Most women who are pregnant or postpartum will benefit from CBT if they are depressed.
- Antidepressants are probably not the first choice treatment for pregnant women.
- Many women who are depressed before getting pregnant or having a child are still depressed and not getting effective treatment. We can do more to help these women too.
Cox, J.L., Holden, J.M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. B J Psychiatry. 150, 782-6.
O’Connor, E., Rossom, R.C., Henninger, M., Groom, H.C., Burda, B.U. (2016). Primary care screening for and treatment of depression in pregnant and postpartum women: Evidence report and systematic review for the US preventive services task force. JAMA. 315(4), 388-406.
Wisner, K.L., Parry, B.L., & Piontek, C.M. (2002). Postpartum Depression. N Engl J Med. 347(3), 194-9.
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