Perinatal depression is not being well addressed, putting mothers and families at risk

Role of psychologists in improving depression diagnosis and management in obstetrical and family practices.

By Anne W. Riley, PhD, and Nomi Weiss-Laxer

Anne W. Riley Nomi Weiss-Laxer
Decades of research demonstrates that maternal depression has a triple impact, on the woman herself, the family and her children. But what is almost overlooked, is that depression is the most common serious condition affecting pregnant women and new mothers. It is under-identified, and even when identified, often inadequately treated. Among the almost four million women who give birth annually in the United States at least 13 percent experience a major depressive disorder (Bennett et al., 2004), with many more having significant symptoms that compromise their ability to care for themselves and their families. Among low-income women, these rates are much higher (Grote et al., 2010). Although 94 percent of new mothers have a postpartum visit, 47 percent see their family doctor rather than an obstetrician (Declercq, et al., 2008).  

Psychologists can play a much more active role in this public health crisis. By working with obstetricians, family physicians and obstetric nurses, psychologists can help improve the detection, evaluation and management of depressive symptoms among pregnant and post-partum women. Pregnant women are screened for many disorders, none of which are as common as depression, and some of which are not as pernicious (Perry, et al., 2011). The American College of Obstetricians and Gynecologists advises that depression contributes to the occurrence of low-birth weight and preterm birth (ACOG, 2006), but it is still not routinely assessed, even in our most prestigious teaching hospitals.  

Opportunities for Psychologists in Obstetrical and Family Practices 

Effective and acceptable models and tools for depression screening exist (Hewitt, et al., 2009). Many practices have an electronic medical record (EMR), which may include a depression screener. Two widely used screens are the Edinburgh Postnatal Depression Scale (EPDS) and the Post-partum Depression Screening Scale (PPDS). The EPDS asks 10 questions about the woman’s depression symptoms over the past 7 days, excluding somatic symptoms (e.g., appetite and sleep changes) that are common in the perinatal period. Another valid approach is to administer two screening questions in routine visit interviews or on the initial check-in form:  (1) ‘During the past month, have you often been bothered by feeling down, depressed or hopeless?’ and (2) ‘During the past month, have you often been bothered by little interest or pleasure in doing things?’ A positive screen (“Yes” to either question) means the woman needs a careful evaluation. Psychologists can assist with this. Medical providers may want to learn how to evaluate for the presence of depression and to inquire about the most powerful risk factors for depression, such as prior experiences of depression, serious anxiety, inadequate support and major life stresses or events (Milgrom & Gimmill, 2014). Or they may prefer to make a referral for a depression evaluation. Either way, psychologists can provide approaches to address the depressive symptoms and help the mother carry the baby to a healthy full-term delivery. Importantly, a simple referral to a mental health provider is insufficient for most depressed women. Much research demonstrates that at a minimum a ‘liaison’ is needed who actively coordinates between medical and mental health providers to ensure patients get into recommended treatment (Perry, et al., 2011). 

Women with multiple depressive symptoms, even if not clinically depressed, should be actively monitored and involved in preventive interventions to help them and their families understand depression experiences, the importance of treatment, and ongoing management to prevent a full (or recurrent) episode. 

By working together, psychologists can help nurses, obstetricians and family physicians implement routine screening for depression and develop the procedures needed to ensure adequate diagnosis and management. Table 1 summarizes some key issues. Such efforts require a clear commitment and resources to provide education and guidance for obstetric providers to be able to care for women who have positive screens as well as education, support and referrals for the women themselves (Howell, et al., 2012). Such collaborations can expand the ‘reach’ of psychologists to provide early and preventive interventions, to involve partners and family members who are powerfully affected by a mother’s depression, and help assure that a system of care exists to meet the needs of all pregnant women and new mothers.

Table 1. Psychologists working to improve public health
Provider education High prevalence; effects of depression on birth outcomes, family health, and child development; effectiveness and safety of depression treatments; potential for positive impact
Screening Brief, reliable, valid tools. Screening in isolation not effective; need diagnostic confirmation, active monitoring, referral resources
Management in OB or referral to behavioral health treatment Depression information to be integrated into prenatal, postpartum and pediatric care
Family support and intervention Critical to involve partner and family members to improve communication, and prevent negative family effects
Prevention of recurrence Patient and family education

References

American College of Obstetrics and Gynecology (ACOG). (2006). ACOG Committee Opinion No. 343: psychosocial risk factors: perinatal screening and intervention. Obstet Gynecol., 108(2):469-477.

Bennett HA, Einarson A, Taddio A, Koren G, & Einarson TR. (2004). Prevalence of depression during pregnancy: systematic review. Obstet Gynecol.,103(4):698-709.

Declercq E, Sakala C, Corry MP, & Applebaum S. (2008). New Mothers Speak Out: National Survey Results Highlight Postpartum Experiences. New York: Childbirth Connection.

Grote NK, Bridge JA, Gavin AR, Melville JL, Iyengar S, & Katon WJ. (2010). A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Archives of General Psychiatry, Oct;67(10):1012-24. doi: 10.1001/archgenpsychiatry.2010.111.

Hewitt C, Gilbody S, Brealey S, et al. (2009). Methods to identify postnatal depression in primary care: an integrated evidence synthesis and value of information analysis. Health Technology Assessment Journal. 2009 Jul;13(36):1-145, 147-230. doi: 10.3310/hta13360.

Howell EA, Balbierz A, Wang J, Parides M, Zlotnick C, & Leventhal H. (2012). Reducing postpartum depressive symptoms among black and Latina mothers: A randomized controlled trial. Obstet Gynecol, May;119(5):942-9. doi: 10.1097/AOG.0b013e318250ba48.

Milgrom J & Gemmill AW. (2014). Screening for perinatal depression. Best Practice and Research Clinical Obstetrics and Gynaecology, Jan;28(1):13-23. doi: 10.1016/j.bpobgyn.2013.08.014. 

Perry DF, Nicholson W, Christensen AL, & Riley, AW. (2011). A Public Health Approach to Addressing Perinatal Depression. International Journal of Mental Health Promotion, Aug;13(3):5-13.