Perinatal Depression: How do we
Respond?
Meeting the Mental Health Needs of Texans
(and others)
Michael W. O’Hara
Department of Psychology
The University of Iowa
mike-ohara@uiowa.edu
Iowa Depression and Clinical
Research Center Team in Iowa City
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Sarah Bell
Jen Bowman-Reif, MS
Melissa Buttner, MA
Jane Engeldinger, MD
Sheehan Fisher, PhD
Rebecca Grekin
Corinne Hamlin, MAT
Robin Kopelman, MD
Jennifer McCabe
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Michelle Miller
Kimberly Nylen, PhD
Michael O’Hara, PhD
Jennifer Richards, MSW
Heather Rickels, MA
Lisa Segre, PhD
Scott Stuart, MD
J Austin Williamson, MA
Outline of Presentation
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Burden of Depression
What is Postpartum/Perinatal Depression
Risk Factors
Prevalence
Screening
Treatment: Impact on mother
Treatment: Impact on infant
Summary
Burden of Depression in Women
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Second leading cause of disability (lost years of
healthy life) among women in the world aged 15
to 44 years
In the U.S. depression is the leading cause of
non-obstetric hospitalizations among women
aged 18-44
Sources: The World Health Report 2001, Geneva: WHO; Jiang et al. 2000 ‘Care of
Women in U.S. Hospitals, 2000.’
Burden of Perinatal Depression
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For mother
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Personal suffering, continued depression, poor health
For the child
Delayed prenatal care, shorter gestation
 Fussiness, feeding problems, poor weight gain
 Delays: cognitive skills, social skills, language
 Behavioral problems, insecure attachment
 Later depression
 For the family – marital discord, divorce
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Perinatal Depression: Definition
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Major or minor depression that begins or
continues in pregnancy and the postpartum
period (usually up to one year after delivery)
DSM-IV criteria – postpartum onset
Does not include:
Postpartum blues
 Postpartum psychosis
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Often co-morbid with anxiety disorders or
significant anxiety symptoms
Criteria for Diagnosing Depression
Symptoms (at least one of first two and total of five)
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Depressed mood
Loss of interest or pleasure
Significant weight or appetite change
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or inappropriate guilt
Impairment in thinking, concentration, or decisions
Recurrent thoughts of death or suicide
Causal/Risk Factors for PPD
O’Hara et al. (1982 – 2007)
Several prospective and cross-sectional studies
 Outcomes: Depression diagnosis and symptoms
 Predictors of PPD
Past depression (level, diagnosis, past history) ++
 Ψ vulnerability ±
 Life events (incl. childcare, obstetric) ++
 Social support (incl. marital, non-marital) ++
 Low income + (…but only in cross-sectional studies
 Hormones –
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Meta-Analytic Findings
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Past depression or anxiety disorder
Life stress
Unplanned/unwanted pregnancy, obstetrical
 Losses (e.g., housing, job, divorce/separation)
 Conflicts with family, co-workers, friends, children
 Natural disasters (e.g., fires, floods, tornadoes)
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Poor social support (from partner, family, friends)
Socioeconomic disadvantage
O’Hara & Swain, 1996; Beck, 2001; Robertson et al., 2004
Prevalence of Perinatal Depression
Prospective studies (O’Hara et al., 1984; 1990)
 Pregnant/Postpartum women
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Non-pregnant/postpartum controls
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8-9% pregnancy; 10-12% post partum
5.6% pregnancy; 7.8% post partum (NCB)
Childbearing and non-childbearing rates
were not different
What the literature suggests
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O’Hara & Swain (1996)
54 studies; 12,910 subjects
 13% prevalence rate for postpartum period
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Gavin et al. (2005)
28 studies (all based on diagnosis)
 18.4% pregnancy period prevalence
 19.2% postpartum period (first 3 months)
 No evidence of increased risk over other times
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Recent Large Scale Study
Vesga-Lopez et al. (2008)
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National representative survey
13,025 non-pregnant; 994 post partum
 Adjusted odds ratio for postpartum women
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1.52 (1.07-2.15) Depression
 .55 (.31-.96) Receiving treatment
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Women are at increased risk for depression in the
postpartum period
 …but are less likely to be treated.
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Implications or What’s so special
about perinatal depression?
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It is prevalent during pregnancy and the
postpartum period
Women suffer
Negative consequences for women, their
children, and families
Often are not treated
…but women have frequent contact with health
care providers during and after pregnancy
Role of the PCP in
Detecting Depression
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Recommendations of U. S. Preventive Services
Task Force (2009)
Recommendations of ACOG Committee on
Obstetric Practice (2010)
Recommendation of the USPSTF
“The U.S. Preventive Services Task Force
recommends screening adults for depression
when staff-assisted depression care supports are
in place to assure accurate diagnosis, effective
treatment, and follow-up (Grade B)”
Source: U.S. Preventive Services Task Force. (2009). Screening for depression in
adults: U.S. Preventive Services Task Force recommendation statement,
Annals of Internal Medicine, 151, 784-792.
ACOG – Committee on Obstetric
Practice Recommendations
“Depression is very common during pregnancy and the postpartum
period. At this time there is insufficient evidence to support
a firm recommendation for universal antepartum or
postpartum screening. There are also insufficient data to
recommend how often screening should be done. However,
screening for depression has the potential to benefit a
woman and her family and should be strongly considered.
Women with a positive assessment require follow-up evaluation and
treatment if indicated. Medical practices should have a referral
process for identified cases. Women with current depression or a
history of major depression warrant particularly close monitoring
and evaluation.”
Committee on Obstetric Practice. (2010). Screening for depression during and after
pregnancy. Obstetrics and Gynecology, 115, 394-395
PPD Screening
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Screening is feasible (Gordon et al., 2006; Segre, Brock,
O’Hara, Gorman & Engeldinger, 2010; Yonkers et al., 2009)
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Primary care providers can be trained quickly and
effectively (Baker, Kamke, O’Hara, & Stuart, 2009)
Both on-line and in-person trainings are available
(Baker et al., 2009; Segre et al., 2010; Wisner et al., 2008)
What needs to be in Place
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A tool for detection
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EPDS; PDSS; PHQ-9; Two question screen
A decision rule for further assessment
An approach to physician evaluation of possible
depression
Referral, treatment, follow-up protocols
Following up on Positive Screens
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Follow-up with positive items on screen
Understand the context
More formally assess and possibly diagnose
depression
Rule out alternative medical explanations
Ask about concerns or preferences for treatment
Initiate treatment or referral
Physician’s Role
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Medication management
Refer for medication management
Refer for counseling/psychotherapy
Refer for social services
Treatment
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Medication
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TCA; SSRI; SNRI; Mood Stabilizer
Psychotherapy
Interpersonal Psychotherapy (IPT)
 Cognitive-Behavioral Therapy (CBT)
 Listening Visits
 Group Therapy
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Treatment
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Complementary and Alternative Approaches
Bright Light Therapy
 Exercise, Nutrition
 Herbals, Acupuncture, Yoga
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Peer Support and Education
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Postpartum Support International
Evaluating IPT for Postpartum
Depression (O’Hara et al., 2000)
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120 postpartum depressed women
DSM-IV major depression
 Recruited from the community
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12 sessions IPT or 12 weeks of waiting
Treatment provided by community clinicians
Assessments included depression, social
adjustment, infant behavior, and mother-infant
interaction
Also followed a cohort of nondepressed
mothers and infants
IPT for Postpartum Depression:
Hamilton Rating Scale for
Depression (HRSD)
25
20
15
IPT
WLC
10
5
0
Pre-therapy
4-Wks
8-Wks
12-Wks
IPT for Postpartum Depression:
Major Depression at 12 week
Assessment
70
60
50
%
40
69%
30
20
10
12 %
0
MDE at 12 Week Assessment
IPT
WLC
Wait List Group after IPT (N=47)
HRSD
18
16
14
12
10
WLC
8
6
4
2
0
Pre-therapy
4-Wks
8-Wks
12-Wks
Relapse and Recovery
Nylen, O’Hara et al. (2008)
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Relapse following IPT
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Recovery for treatment non-responders
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12 months - 42%; 18 months - 48%
84% of women not recovered with treatment
recovered over 18 months
Proportion of month depressed during follow-up
Month six post-treatment
 Month twelve post-treatment
 Month eighteen post-treatment
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39%
35%
26%
Evidence for Treatment Efficacy
Empirical validation
 General population
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Medication and psychotherapy
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….but, effects for mild to moderate depression may be no
greater than placebo
Postpartum women
Numerous RCTs demonstrate efficacy of
psychotherapy for postpartum depression
 Relatively few studies of antidepressant medication,
mostly positive, but mostly uncontrolled
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Impact of treatment on offspring
(Forman, O’Hara et al., 2007)
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Little impact on infant behavior
Mothers reported less parenting stress
18 months later treated depressed mothers
(compared to non-depressed mothers) rated their
children as:
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lower in attachment security; higher in negative
temperament & behavior problems
…all of this suggests that parenting behaviors
should be a target of therapy
Parenting Interventions
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Lynne Murray & Peter Cooper (2003)
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CBT, psychodynamic, and non-directive counseling
approaches to PPD and altering the M-I relationship
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“Indications of a positive benefit were limited.”
Roseanne Clark (2003; 2008)
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Mother-Infant Therapy Group for PPD and M-I
relationship
Intensive 12 week treatment including mothers’ group,
infants’ group, and mother-infant group.
 Relative to WLC, M-I group found infants more
reinforcing, and more positive in interactions
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Conclusions and Next Steps for
Parenting Interventions
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Little evidence that treatment for PPD improves
parenting
Modest evidence that focus on parenting in context of
PPD treatment is efficacious
Most parenting interventions with infants have been
driven by infant rather than maternal problems
New interventions, possibly introduced during
pregnancy must be developed in increase sensitivity in
at risk and depressed mothers in pregnancy and the
postpartum period.
Take Home Messages
Perinatal Depression:
 Prevalent
 Significant mental health problem
 Consequences extend to offspring and family
 Detection in Ob-Gyn and primary care settings
 Professional treatments effective…but
 Coordination of care and uptake of services
remain challenges
 Interventions that target the M-I relationship