Pregnancy is a time when most women are eagerly anticipating and preparing for the birth of their child (or children), so it is surprising to note that approximately 10% of pregnant women may experience a depressive disorder during pregnancy. What is even more heartbreaking is the fact that as many as 2.6% of pregnant women may have thoughts of suicide. In pregnant women with major depression, the rates of suicidal ideation can reach nearly 30%. It is well known that major depression is associated with significant disease co-morbidity and mortality. Clinicians must know which women are at highest risk for depressive disorders yet screen all their patients for depressive disorders at regular intervals during their prenatal care and provide treatments and/or resources when needed.

Jennifer Melville, MD, MPH, an associate professor in the Department of Obstetrics and Gynecology at the University of Washington School of Medicine, Seattle, WA sought to estimate the prevalence of depressive disorders during pregnancy in her 2004-'09 study, Depressive Disorders During Pregnancy: Prevalence and Risk Factors in a Large Urban Sample . Melville and her colleagues also wanted to know if there are identifiable risk factors that make certain women more likely to develop depressive disorders than others. The results of this prospective study of 1,888 pregnant women over a five-year period have been published in the current issue of Obstetrics and Gynecology.

A Look at the Research

The methodology used in this study to determine major and minor depression was based on patient responses to the Patient Health Questionnaire and in accordance with criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), as follows:

'In our study, women meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for major or minor depression on the Patient Health Questionnaire were classified as experiencing current depression. The DSM-IV criteria for major depression on the Patient Health Questionnaire require the participant to have, for at least 2 weeks, five or more depressive symptoms present for more than half the days, with at least one of these symptoms being depressed mood or anhedonia. The criteria for minor depression (or depression not otherwise specified) require the participant to have, for at least 2 weeks, two to four depressive symptoms present for more than half the days, with at least one of these symptoms being depressed mood or anhedonia. The criteria for panic disorder require affirmative answers to all five panic symptoms and follow the DSM-IV.'

A summary of the Melville et. al study findings includes:

• Antenatal depressive disorders were present in 9.9% of study participants and 5.1% of those identified also met the criteria for probable major depression; 4.8% met the criteria for probable minor depression.
• 3.2% of women had probable panic disorder and of those, 52.5% had co-morbid depression (31% major and 21% minor). 47.5% had isolated panic disorder. 19.6% of women with probable major depression had panic disorder while 14.4% of women with probable minor depression had panic disorder.
• Suicidal ideation was present in 2.6% of the women studied, but of those with major depression, 29.5% reported suicidal ideation.

Melville and her colleagues found that antenatal depressive disorders are more prevalent in younger, less educated, single women. Other aggravating factors that heightened a woman's risk of antenatal depression included:

• women with two or more co-morbidities
• prior pregnancy complications (including medically required bed rest)
• psychosocial stressors (lower socioeconomic status and limited resources)
• domestic violence
• Asian, African American and Hispanic ethnicity

Discussion

First and foremost, we have to recognize that pregnancy is not a welcomed event for all women. And, even in women for whom pregnancy is a welcomed event, antenatal mood disorders can still develop. In fact, many people remain unaware of the prevalence of antenatal depressive disorders - including some clinicians. The first step to combating this problem is through creating heightened awareness. With evidence-based training (utilizing studies like Melville's) and implementation of universal screening and intervention protocols during prenatal visits, diagnosing and treating these pregnancy-related mood disorders can become a widespread reality.

If a clinician suspects a prenatal depressive disorder in one of their patients, she must be ready to provide not only prescriptions for medical therapy (if indicated) but also address other medical and social issues contributing to the condition. For women with underlying co-morbidities, clinicians must identify and treat these conditions accordingly. Challenges to this might include maintaining frequency and consistency in prenatal care: socioeconomic, geographic, and patient age issues can sometimes prompt less-than-optimal attendance of regular prenatal office visits. Also, for women whom English is not their first language or for whom American culture and medical care are unfamiliar, a similar deleterious effect on prenatal care consistency might be observed. In these cases, clinicians may need to invite the assistance of social workers, other support services, family members and/or friends of the patient to both educate her as well as increase her access to appropriate care.

Melville's study confirms what other research had already identified: domestic violence bears a hefty association with antenatal depressive disorders (odds ratio = 3:45). While some clinicians may experience discomfort in questioning their patients about the possibility of domestic violence, the data suggests this line of questioning should be imperative. If a clinician suspects or confirms a case of abuse he must be prepared to immediately provide appropriate resources to his patient in the form of patient education pamphlets, hotline phone numbers, shelter information and counseling resources. Alternatively, a trained individual within the practice can also act as a liaison between the patient and appropriate resources, along with maintaining follow- up with the patient at each subsequent prenatal visit. Because domestic violence happens to women of all ages, races and ethnicities and in all socioeconomic brackets, clinicians must screen all their prenatal patients for this antenatal mood disorder risk factor.

Antenatal depressive disorders are more common than most people realize and they are a real challenge for clinicians to manage. Melville and her colleagues have provided a useful set of identifiable risk factors that can alert clinicians to patients with potential problems. My greatest concern is that this data may lead some clinicians to screen only those women who have one of the herein analyzed risk factors or who appear to fit the criteria and ignore the potential for antenatal depressive disorders in other women. The researchers acknowledge that this study has limitations despite being carried out on a large sample and producing data very similar to previous studies. Therefore, they recommend that further studies be conducted to determine if the risk factors identified for antenatal depressive disorders are applicable to a wider subset of patients. I commend Melville, et. al for their work and for acknowledging the study's limitations.All pregnant women are at risk for antenatal depressive disorders, with some possessing a greater risk than others. As such, it behooves clinicians to make the extra effort to screen all antenatal women at regular intervals during pregnancy for depressive disorders.

Posted by: Darline Turner-Lee, BS, MHS, PA-C,

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