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Study finds depression in pregnancy, postpartum is overlooked and undertreated
About 10 to 20 percent of women suffer from new-onset depression during pregnancy or after giving birth. Untreated, the impact of such illness can be profound, ranging from substance abuse, poor prenatal care, and miscarriages to impaired infant bonding and developmental delays.
But a new study comparing the medical records of more than 6,000 such perinatal women—both during their pregnancies and postpartum—to those of about 57,000 non-pregnant women of the same ages (18 to 39 years) has found the perinatal group was significantly less likely to be diagnosed with depression.
In addition, even when the pregnant women were diagnosed with depression, the study found fewer than half received any treatment, versus 72 percent receiving treatment in the non-pregnant control group. Women suffering post-partum depression were similarly undertreated.
The study analyzed three years’ worth of data—2006 through 2009—from the California State Medicaid (Medi-Cal) program which, while rendered individually anonymous, included demographic, medical service, and prescription information.
The new findings provide key follow-up to a 2009 report by the Institute of Medicine (IOM) of the National Academies of Science, which concluded that the risks of untreated depression far exceeded those of antidepressant medications, both during pregnancy and postpartum. The IOM report called treatment rates for new mothers “alarmingly low,” but allowed that the evidence in that area was based on older data and small sample sizes.
Along with the overall shortfalls in care, the researchers analyzed demographics and found that perinatal depression detection and treatment was notably lower for women of Hispanic descent, under age 25, and/or living in a rural setting. Those disparities suggest the need for specific research into barriers to care and ways to address them, the study authors concluded.
Journal citation: Geier ML, Hills N, Gonzales M, Tum K, and Finley PR, “Detection and treatment rates for perinatal depression in a state Medicaid population,” CNS Spectrums, November 2014; Vol. 13, p. 1-9.
Q & A with faculty member Patrick Finley, PharmD
Your paper notes that the Medi-Cal study population consisted primarily of urban Hispanic women—so the results are not necessarily generalizable to all pregnant women in the United States. Is there any reason you would expect there to be significant differences?
It’s possible that women with private insurance would be receiving better care and more likely to have depression diagnosed and appropriately treated. The same might be said of women from different socioeconomic or educational backgrounds.
While the [2009 Institute of Medicine (IOM) report] [link defunct] concludes that benefits of treatment far outweigh risks of untreated depression both during pregnancy and postpartum, to what extent do you think physician concerns about drug safety in utero and postpartum play a role in the undertreatment you found even when depression was diagnosed?
There is no question that the safety of antidepressants in pregnancy and postpartum continues to be controversial and misunderstood in the lay press as well as among clinicians.
Part of the problem is that it is not ethical to conduct randomized control trials [in which patients are randomly assigned to two groups, one of which receives a drug and the other a placebo] with antidepressants in pregnant women to assess safety. So we are forced to rely on observational data to evaluate safety and there are inherent biases in these study designs. For instance, depression itself has been associated with many enhanced risks to the mother and offspring, so it is difficult to determine if it is the antidepressant or the depression [that is causing a problem].
I should also mention that the conclusions of the IOM report were strongly supported by a subsequent [U.S. Agency for Healthcare Research and Quality report] [link defunct] released in July, which concluded there is minimal risk with most commonly prescribed antidepressants.
Given your findings, why do you think depression in perinatal women is being overlooked and undertreated?
There are many reasons. New mothers often have a difficult time admitting or recognizing their depression and are reluctant to seek treatment. They may feel shame that they are not excited and content at this time of their life. Or they may be wary of treatments used to relieve depressive symptoms. Also, depression is still not routinely screened for in most health care systems, and it may be unrealistic to expect non-psychiatric health professionals to accurately diagnose it. This is in addition to the misconceptions about the safety of antidepressants.
Another problem exists during the postpartum period: Women generally have their last visit with their obstetrician/gynecologist at six weeks—the well-baby visit—and may not be seen by any other health professionals for many months afterward.
How do you think the health care system can address this issue?
Kaiser Permanente and other health care systems are now requiring depression screening twice during pregnancy and once postpartum. But research has shown that this approach is only effective if a reliable and efficient system for treating or referring depressed patients is in place. The continuity of care available in the medical home model [in which health care is delivered by a physician-led team] may also improve outcomes in this population, as will integrating mental health professionals into the primary care, pediatric, and women’s health settings.
About the School: The UCSF School of Pharmacy is a premier graduate-level academic organization dedicated to improving health through precise therapeutics. It succeeds through innovative research, by educating PharmD health professional and PhD science students, and by caring for the therapeutics needs of patients while exploring innovative new models of patient care. The School was founded in 1872 as the first pharmacy school in the American West. It is an integral part of UC San Francisco, a leading university dedicated to promoting health worldwide.