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Perinatal Depression: How do we Respond?
Michael W. O’HaraDepartment of
PsychologyThe University of Iowa
Meeting the Mental Health Needs of Texans (and others)
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
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