Depression Among Women:Focus on Perinatal Depression
Diana Cheng, M.D.Medical Director, Women’s Health
Maryland Department of Health and Mental HygieneMarch 22, 2007
Incidence of Depression, U.S.
• Annual - 12 % of women (6% men) will experience a depressive disorder during a one year period
• Lifetime - 20% of women (10% of men) will experience depression
6.6
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Dep
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Causes of Depression
geneticsenvironment
hormones
Depression Across the Female Lifespan
Birth DeathMenarche Menopause
PremenstrualPregnancy/Postpartum
Peri-menopause
Postpartum Depression• Affects 1 out of every 8 postpartum women• Begins 2 weeks – 1 year postpartum• Symptoms
– Depression, anhedonia– Emotional stress, helplessness, irritability, anger– Inability to do normal everyday tasks– Appetite changes, sleeping too much/ too little– Thoughts of self-harm or suicide– Overly intense worries about baby– Lack of interest or fear of harming baby
Postpartum Thyroiditis• 5–10 % during 1st postpartum year• Thyrotoxicosis (destruction-induced), onset 1-4 months
• Fatigue, palpitations, psychosis (rare)• 30% develop hypothyroidism
• Hypothyroidism, onset 4-8 months• 40% require treatment• 30% go on to permanent hypothyroidism • Fatigue, cold intolerance, weight gain, depression
Depression During Pregnancy
• Pregnancy is not protective against depression
• Affects 10-15% of pregnant women• Begins any trimester
Maternal Depression: Effects on Infant and Child
• Poor pregnancy outcomes– PTL, LBW, SGA, RDS, ?PIH ?SAb
• Poor mother-infant attachment– Irritable, lethargic, poor sleep
• Language delays• Behavioral difficulties• Lower cognitive performance• Mental health disorders• Attention problems
Kahn, et al. AJPH 2002;92:1312-1318
Bonari et al. Can J Psychiatry 2004;49:726-735
•Infant Behav Dev 2004;27:216-229
•Psychiatry 2004;67:63-80
Maternal Effects of Untreated Depression
• Poor prenatal behaviors– Nutrition, prenatal care, substance abuse
• Poor parenting behaviors• Longer persistence of symptoms• Increased risk of postpartum depression• Increased risk of relapse
Risk Factors for Maternal Depression
• Prior depression (30%)• Prior postpartum depression (50%) or psychosis (70%)• Depression during pregnancy• Prior PMDD (premenstrual dysphoric disorder)• Family history of depression or bipolar disorder• ?Teens, not married, low income• Recent stressful events
– marital/partner discord, loss of loved one, family illness, premature birth
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Marrie
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arrie
dPe
rcen
t dep
ress
edPercentage of Mothers Who Reported Being at Least Moderately Depressed in the
Postpartum Period, Maryland PRAMS 2001-2003
Annual household
incomeAgeRace and ethnicity Marital status
Edinburgh Postnatal Depression Scale
• Created for postpartum women– Can also be used during pregnancy– Less emphasis on physical symptoms
• Takes < 5 minutes to complete• Self-administered• Validated screening tool• Useful in primary care settings• Rates intensity of depressive symptoms
– 10 questions, each worth 0-3 points– Score >12 (out of 30) indicates likely depression
Treatment for Depression• Support
– Support groups (facilitated), family, friends, help lines
• Counseling– Cognitive behavioral / interpersonal therapy
• Other treatments– light, alternative medicines – ECT
• Antidepressants– SSRIs
Maternal DepressionGetting Help
Treated
Undiagnosed80%
Diagnosed20%
State Programs: DepressionDATA to Action
State Programs: Depression• Data
– PRAMS – BRFSS– HSCRC– Vital Records – Medical Examiner– Case Reviews
• Maternal mortality review
Data ACTION• Maternal Depression Team (multidisciplinary)
• Providers (ob,ped, CNM, FP, psych, nursing, social work, public health)
• Health care coverage (Insurance/medicaid)• Organizations (WIC, academic/community, women’s health,
daycares, churches)
• Representation/Advocacy – other committees• Professional education and Outreach• Legislation• Direct Services - Title X Family Planning• Grants
WELL Project“Women Enjoying Life Longer”
A Women’s Health Program in 3 Title X Baltimore County Family Planning Sites
Eastern Family Resource Center
Essex Health Center Dundalk Health Center
• 1-800-PPD-MOMS Helpline• Website (www.healthynewmoms.org)
– Provider CMEs (www.perinataldepression.org), screening scale, brochure, resource list
• Media messages– Posters, Video PSAs, Radio Ads
• Local partnership grants• Provider training
– Information Packets– Education
www.healthynewmoms.org
Maternal Depression
Common DisorderUnder-diagnosed, under-treated
Adverse effects on mother, fetus, infant, familyEffective treatment availableUniversal ScreeningNeed for Education, Capacity, ResearchCommunity Support Eliminate Stigma
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