Heather A. Flynn

Depressive symptoms among pregnant women screened in obstetrics settings.

OBJECTIVES This study aimed to describe the prevalence of depressive symptomatology during pregnancy when seen in obstetric settings, the extent of treatment in this population, and specific risk factors associated with mood symptoms in pregnancy. METHODS A total of 3472 pregnant women age 18 and older were screened while waiting for their prenatal care visits in 10 obstetrics clinics using a brief (10 minute) screening questionnaire. This screen measured demographics, tobacco and alcohol (TWEAK problem alcohol use screening measure), and depression measures, including the Center for Epidemiological Studies-Depression scale (CES-D), use of antidepressant medications, past history of depression, and current treatment (i.e., medications, psychotherapy, or counseling) for depression. RESULTS Of women screened, 20% (n = 689) scored above the cutoff score on the CES-D, and only 13.8% of those women reported receiving any formal treatment for depression. Past history of depression, poorer overall health, greater alcohol use consequences, smoking, being unmarried, unemployment, and lower educational attainment were significantly associated with symptoms of depression during pregnancy. CONCLUSIONS These data show that a substantial number of pregnant women screened in obstetrics settings have significant symptoms of depression, and most of them are not being monitored in treatment during this vulnerable time. This information may be used to justify and streamline systematic screening for depression in clinical encounters with pregnant women as a first step in determining which women may require further treatment for their mood symptoms. As elevations in depressive symptomatology have been associated with adverse maternal and infant outcomes, further study of the impact of psychiatric treatment in gravid women is essential.

Risk factors for depressive symptoms during pregnancy: a systematic review

The purpose of this study was to evaluate risk factors for antepartum depressive symptoms that can be assessed in routine obstetric care. We evaluated articles in the English-language literature from 1980 through 2008. Studies were selected if they evaluated the association between antepartum depressive symptoms and > or =1 risk factors. For each risk factor, 2 blinded, independent reviewers evaluated the overall trend of evidence. In total, 57 studies met eligibility criteria. Maternal anxiety, life stress, history of depression, lack of social support, unintended pregnancy, Medicaid insurance, domestic violence, lower income, lower education, smoking, single status, and poor relationship quality were associated with a greater likelihood of antepartum depressive symptoms in bivariate analyses. Life stress, lack of social support, and domestic violence continued to demonstrate a significant association in multivariate analyses. Our results demonstrate several correlates that are consistently related to an increased risk of depressive symptoms during pregnancy.

Preferences and Perceived Barriers to Treatment for Depression during the Perinatal Period

BACKGROUND AND METHODS Little is understood about why few women during the perinatal period will use depression treatment. In particular, beliefs and barriers related to depression treatment use have not been studied. In this study, African American and white pregnant women (n = 108) who screened > or =10 on the Edinburgh Postnatal Depression Scale (EPDS) were asked about recent formal and informal treatment use in prenatal care settings. Confidence in the helpfulness of treatment, providers, and settings and perceived barriers to treatment were assessed and compared between African American and white women. RESULTS Pregnant women overall reported low rates of formal treatment use but frequently sought help from informal sources, such as friends, family, and printed materials. All women expressed greatest confidence in psychosocial treatments and lowest confidence in antidepressants. African American women reported less confidence in advice from family and friends and in antidepressants than did white women. Women expressed greatest confidence in treatments delivered by mental health professionals and religious leaders. African American women sought help more frequently and had significantly more confidence in religious leaders as treatment deliverers than white women. Women had greatest confidence in treatments delivered in professional and home settings, with African American women expressing greater confidence in religious settings than white women. All women reported greatest concern with structural barriers, compared with attitudinal and knowledge barriers. CONCLUSIONS Understanding patterns of treatment use, beliefs, and barriers to depression treatment provides important information for tailoring and improving appropriate use of mental health treatment in women during the perinatal period.

Depression after alcohol treatment as a risk factor for relapse among male veterans

We examined the association between relapse-to-drinking and depressive symptomatology measured during inpatient treatment for alcohol disorder and 3 months posttreatment. Data were obtained from 298 veterans who completed 21-day inpatient treatment. Follow-up interviews were conducted at 3, 6, 9, and 12 months posttreatment. We used multiple logistic regression to assess the association between relapse and baseline/3-month posttreatment measures of depression (Beck Depression Inventory; BDI), controlling for important covariates. Our results showed that (a) the mild-to-moderately symptomatic participants (BDI = 14-19) at 3 months posttreatment were on average 2.9 times more likely than the nondepressed to have relapsed across follow-ups, and (b) the severely symptomatic participants (BDI = 20+) at 3 months posttreatment were on average 4.9 times more likely to have relapsed across follow-ups. Other analyses revealed that those with persistent depressive symptomatology reported at both baseline and 3 months posttreatment did not experience worse outcomes that those who reported symptomatology at 3 months posttreatment alone.

Patient perspectives on improving the depression referral processes in obstetrics settings: A qualitative study

OBJECTIVES Although depression screening in obstetrics settings has been recommended, little research exists to guide strategies for screening follow up and depression referral. The purpose of this qualitative study was to inform recommendations for depression screening follow up and referral in obstetrics settings based on responses from a key sample of women about influences on depression treatment use and engagement. METHODS A stratified purposeful sampling based on pregnancy, socioeconomic status and depression severity was used to identify 23 women who completed semistructured interviews that centered on their beliefs about what would prevent or facilitate entry into depression treatment in the context of obstetrical care. We conducted a thematic analysis through an iterative process of expert transcript review, creation of and refining codes and identifying themes. RESULTS Two broad themes influencing depression treatment usage emerged including practical and psychological factors. Among practical factors, women reported a strong preference for treatment provided in the obstetric clinic or in the home with a desire for a proactive referral process and flexible options for receiving treatment. Psychological factors included differing conceptualizations of depression, knowledge about severity and treatment and issues of stigma. CONCLUSIONS This study suggests that the current standard practice of depression screening and referral to specialty treatment does not match with perceived influences on treatment use among our sample of perinatal women. Recommendations derived from the results for improving follow up with screening and depression referral in obstetrics settings are provided as a platform for further research.

Interpersonal Goals and Change in Anxiety and Dysphoria in First-Semester College Students

Two longitudinal studies examined the associations between interpersonal goals (i.e., self-image and compassionate goals) and anxiety and dysphoria (i.e., distress). In Study 1, 199 college freshmen (122 women, 77 men) completed 12 surveys over 12 weeks. Compassionate goals predicted decreased distress, and self-image goals predicted increased distress from pretest to posttest when distress was assessed as anxiety, dysphoria, or a composite, and when the goals were worded as approach goals, avoidance goals, or a composite. In Study 2, 115 first-semester roommate pairs (86 female and 29 male pairs) completed 12 surveys over 12 weeks. Compassionate and self-image goals predicted distress in same-week, lagged-week, and pretest-to-posttest analyses; effects of compassionate goals remained significant when the authors controlled for several known risk factors. Having clear goals consistently explained the association between compassionate goals but not self-image goals and distress. Results supported a path model in which compassionate goals predict increased support given to roommates, which predicts decreased distress. Results also supported a reciprocal association; chronic distress predicted decreased compassionate and increased self-image goals from pretest to posttest, and weekly distress predicted decreased compassionate goals the subsequent week. The results suggest that compassionate goals contribute to decreased distress because they provide meaning and increase support given to others. Distress, in turn, predicts change in goals, creating the potential for upward and downward spirals of goals and distress.

Relationships between stigma, depression, and treatment in white and African American primary care patients.

Although many depressed patients are treated in primary care, depression in these settings has been underdetected and undertreated, which may be influenced by mental health beliefs such as stigma. This study examined the relationships among depression, mental health stigma, and treatment in African American and white primary care patients. Data were collected at 3 primary care settings from 1103 patients who completed surveys measuring depression, stigma, and treatment use. Overall, African American patients reported greater mental health stigma than whites. African American women reported greater stigma than white women. White patients were found to be more likely to use depression treatment than African American patients. Multivariate analyses showed that greater depression severity fully mediated the relationship between stigma and treatment use, and that patients with the highest depression scores had significantly higher stigma scores as well. These results suggest that greater severity of depressive symptoms may override stigma and other beliefs about mental health in determining treatment use, but may be important to address for patients with more moderate levels of symptomatology.

A PILOT RANDOMIZED CONTROLLED TRIAL OF COGNITIVE BEHAVIORAL THERAPY FOR PERINATAL DEPRESSION ADAPTED FOR WOMEN WITH LOW INCOMES

Perinatal women with identified depression in prenatal care settings have low rates of engagement and adherence with depression‐specific psychotherapy. We report the feasibility and symptom outcomes of Cognitive Behavioral Therapy (CBT) modified (mCBT) to address the needs of perinatal, low‐income women with Major Depressive Disorder (MDD).

Treatment guidelines for depression in pregnancy

Depression is a ubiquitous disorder in childbearing women with up to 10% of women experiencing depression in pregnancy. Postpartum depression occurs in 12–16% of pregnancies making it a common complication. Moreover, these illnesses are frequently underdiagnosed in obstetric settings, and a recent report of the Surgeon Generals Office confirms that many women do not access services, or receive treatment of inadequate intensity or duration. This paper provides current treatment guidelines to aid in appropriate diagnosis and treatment of depression in pregnancy and postpartum. Review of current literature on psychotropic medication use in pregnancy is also provided.

Relationships Among Depression, Anxiety, and Insomnia Symptoms in Perinatal Women Seeking Mental Health Treatment

BACKGROUND Depression and anxiety symptoms are commonly experienced by women during the perinatal period. Changes in sleep and sleep quality are typical throughout pregnancy and early postpartum. However, little is known about relationships between insomnia symptoms and psychiatric symptoms in perinatal women. The objective of the present study is to characterize the burden of insomnia symptoms in perinatal women seeking outpatient psychiatric treatment and to examine relationships between insomnia and symptoms of depression and anxiety. METHODS Data from 257 pregnant or postpartum women who sought outpatient psychiatric treatment at a university hospital-affiliated clinic were extracted from an existing clinical management database. Data included validated self-report measures assessing insomnia (Insomnia Severity Index [ISI]), mood (Edinburgh Postnatal Depression Scale [EPDS]), and generalized anxiety (Penn State Worry Questionnaire [PSWQ]). RESULTS Fifty-two percent of women reported symptoms of insomnia, 75% reported symptoms of depression, and 61% reported symptoms of generalized anxiety. After controlling for PSWQ, the partial correlation between EPDS and ISI was 0.15 and 0.37 for pregnant and postpartum women, respectively. After controlling for EPDS, the partial correlation between PSWQ and ISI was 0.20 and 0.12 for pregnant and postpartum women, respectively. Women with clinically significant ISI scores had significantly higher odds for reporting symptoms consistent with depression (odds ratio [OR] 7.7) and generalized anxiety (OR 2.55) compared to women with lower ISI scores. CONCLUSIONS Insomnia symptoms affected a significant proportion of the perinatal women in this sample. These symptoms are linked to symptoms of depression and anxiety in treatment-seeking pregnant and postpartum women. Perinatal women seen in psychiatric treatment settings should be routinely screened for sleep problems.