Screening for depression before, during and after pregnancy can help
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Amber cried a lot after the birth of her first child, a son.
"Small things upset me -- not to the angry point, but to the confused point," said the 26-year-old part-time preschool teacher from northern Ohio.
This is just how confused:
She showed up at her obstetrician's office for her eight-week, post-delivery checkup at the wrong time on the wrong day. "That was very odd for me," Amber said.
"The final straw that told me I needed help was when I was driving home from that and thought what would happen if I put my car into a tree," she added. "When I went back the next day [for the real appointment] I told him, 'There's something wrong.' "
She voiced her concerns and filled out a form, and the doctor told her she needed more help than he could provide. He suggested she contact Dr. Katherine Wisner at the University of Pittsburgh about getting into one of the studies of postpartum depression at Magee-Womens Hospital of UPMC.
She qualified for a National Institute of Mental Health-funded study of a form of the hormone estrogen called estradiol to treat postpartum depression through skin patches.
It is a study of which the American College of Obstetricians and Gynecologists would approve.
Postpartum depression, which the college says affects an estimated 5 percent to 25 percent of women, is one-half of the so-called "hot-button issue" for that group right now. Gerald F. Joseph, president of the physicians group, made screening women for depression both during and after pregnancy the theme of his 2009-2010 initiative.
Screening for both also was the topic of an opinion piece in the February issue of the group's journal, Obstetrics & Gynecology.
In a statement about its editorial, the OB/GYN group said depression can lead to preeclampsia, preterm delivery and low birth weight. It also can affect an infant's cognitive, neurologic and motor skill development and the mental health and behavior of older children, the statement said.
There are signs for doctors to look for before an infant is born. According to the U.S. Department of Health and Human Services, pregnant women with depression tend to eat poorly, not gain enough weight, have trouble sleeping, miss prenatal visits, have difficulty following medical instructions and use harmful substances such as tobacco, alcohol or illegal drugs.
Though it did acknowledge there is insufficient evidence to support a "firm recommendation" for screening in pregnant and postpartum women, the physicians' group said it "should be strongly considered."
And so it has been for quite a while at Magee.
"A federal grant allows me to offer screening [for depression] to every woman who delivers at Magee," said Dr. Wisner.
There also is a treatment study for patients who, like Amber, did not give birth at Magee.
"We have been screening at Magee almost four years now," added Dr. Wisner, an investigator at Magee Womens Research Institute and a multidisciplinary professor at the University of Pittsburgh.
"What we found is roughly 14 percent are positive for [postpartum] depression, so that's our rate in Pittsburgh, actually 14.1 percent," Dr. Wisner said.
"Of women that were in that 14.1 percent, when we talked to them and asked when did [the depression] begin, it began post-birth in a third of them, during pregnancy in a third, and before pregnancy in the other third."
The results were even more startling in a collaborative screening program Magee has with DuBois Regional Medical Center, located about 100 miles northeast of Pittsburgh. "Their postpartum depression rate is 20 percent now," she said. The DuBois center screens for depression during pregnancy, as well, and those numbers are even more troublesome than those of depressed women postpartum: 29 percent during the first prenatal visit.
"Again the rural area has a higher rate of positive screens," Dr. Wisner said. "Some population groups are going to have a higher rate, so it's a big problem."
For example, according to the University of Pittsburgh Office of Child Development, the rate of depression is higher among low-income families and more prevalent among parents who did not earn a high school diploma.
Depression can interfere with a woman's ability to care for her child. Interaction between mother and child can enhance a child's development if it is stimulating and responsive and nurturing.
"There is no question that if the mother is dealing with depression that you are going to have greater neonatal adaptation for the baby. There we're talking about what people typically refer to as bonding," said Ronald Thomas, director of the Division of Maternal-Fetal Medicine for the West Penn Allegheny Health System.
A doctor's ability to detect depression has limitations, according to neonatologist Nilima T. Karamchandani, chief of the Division of Neonatology, and medical director, of the Infant Apnea Center, both at the Western Pennsylvania Hospital.
Mother-infant bonding can be hard to measure, she said: "It is subjective to a certain point."
Entire families are affected, said Dr. David Wolfson, medical director of Children's Community Pediatrics, a network of pediatric practices and 104 pediatricians in the greater Pittsburgh area. It is affiliated with Children's Hospital.
"The issue is identifying these kids who are at risk because of parental depression. ... Anybody who thinks they're not seeing these families is just not recognizing [them]."
Each Children's Community practice either has access to, or has its own, behavioral therapist to provide family, child-centered, care.
The network also is planning a joint conference with women's health care specialists to learn more about postpartum depression and how to conduct screening. Dr. Wisner is among the speakers.
The local experts agreed more study was needed but that it shouldn't get in the way of screening and care.
"We know depression is not a good thing for the mother at least and probably not for the whole family, so let's give them the care while we do the research," Dr. Wolfson said.
Screening of pregnant and postpartum women can be as simple as observing their behavior, asking some questions, or administering any of several screening forms available for that use.
One commonly used form is the Edinburgh Postnatal Depression Scale. It asks the woman to use a scale of 0 to 3 to respond to statements such as "I have blamed myself unnecessarily when things went wrong," "I have felt scared or panicky for no very good reason," and "The thought of harming myself has occurred to me."
Treating depression in a pregnant woman is more problematic, especially since the use of psychotropic medications remains controversial. A review of multiple studies that Dr. Wisner helped to write said, for example, "both depressive symptoms and antidepressant exposure are associated with fetal growth changes and shorter gestations."
"Some [women] have strong opinions on what they will accept as treatment. Some are opposed to medications and some are opposed to therapy. ... So it really depends upon her sense of what's best for her," Dr. Wisner said.
"I think for mild to moderate depression that's new, the start is psychotherapy and social services and efforts to address social circumstances, some of the stresses that potentially lead to depression," Dr. Thomas said. "For patients that have severe symptoms that very clearly are better managed with medications, I think those patients are best served by seeing a psychiatrist for psychotropic medication."
Dr. Karamchandani said exposure to antidepressives can cause side effects -- tremors and poor feeding -- in newborns, but "the benefits of antidepressants may still outweigh the risks for some women. ...
"We watch [the newborns] in neonatal care and, after five days, symptoms [usually] have resolved."
It is not that simple for women whose depression has not been recognized and treated.
What causes it?
Hormonal changes can be a culprit, but other factors also can be to blame: family pressures; the stresses of trying to be the perfect mother; genetics; and previous history of depression.
"It's never quite that simple in that it may not simply be a change in hormones. It may be a change in her relationship with her husband, the stress of having a preterm baby, or simply how having a baby changes your life," Dr. Thomas said.
And, like mothers who are candidates for gestational hypertension or diabetes, he added, "pregnancy may bring out a diagnosis of depression in a patient who has that baseline risk, anyway."
That does not seem to be the case for Amber, who is feeling fine a couple of months following her participation in the Magee study.
"The treatment was taking one pill a day and wearing four small patches," she said. "I didn't know which it was [patches of estradiol or the pill] or if either one was active -- both could have been placebos. But I knew it would not harm the baby."
Her course of participation ended after about 15 weeks, when the researchers told her what was in her patches and pills.
"Within the first week or two of taking the medications I did start feeling better," she said. But because the study will be enrolling for three more years, Amber is not allowed to tell anyone what her study drug was.
Women need not to have delivered their baby at Magee to qualify for the postpartum depression treatment study. To find out more, call 800-436-2461.
First Published March 3, 2010 12:00 am
