Megan V. Smith

Does antidepressant use attenuate the risk of a major depressive episode in pregnancy

Background: Many women become pregnant while undergoing antidepressant treatment and are concerned about continuing antidepressant medication. However, antidepressant discontinuation may increase the risk of a new episode of major depressive disorder. We sought to estimate differences in the risk of developing a new major depressive episode among pregnant and postpartum women with recurrent illness who either did or did not use antidepressants. Methods: Participants were recruited from obstetrical settings; we analyzed a subgroup of 778 women with a history of a depressive disorder. Diagnoses were determined by the Composite International Diagnostic Interview administered twice in pregnancy and once after delivery. We used Cox Regression to model onset of a major depressive episode with a time-dependent predictor of antidepressant use. Results: There was no clear difference in risk of a major depressive episode between women who took antidepressants and women who did not (hazard ratio [HR] = 0.88; 95% CI = 0.51-1.50). After accounting for antidepressant use, clearly hazardous factors included 4 or more depressive episodes before pregnancy (HR = 1.97; 95% CI = 1.09-3.57), black race (HR = 3.69; 95% CI = 2.16-6.30), and Hispanic ethnicity (HR = 2.33; 95% CI = 1.47-3.69). Conclusions: Failure to use or discontinuation of antidepressants in pregnancy did not have a strong effect on the development of a major depressive episode. Women with 4 or more episodes before pregnancy were at high risk of a major depressive episode, independent of antidepressant use. Black and Hispanic women also were at high risk of a major depressive episode, but it is possible that this effect is attributable to unmeasured factors.

Pregnant Women With Posttraumatic Stress Disorder and Risk of Preterm Birth

IMPORTANCE Posttraumatic stress disorder (PTSD) occurs in about 8% of pregnant women. Stressful conditions, including PTSD, are inconsistently linked to preterm birth. Psychotropic treatment has been frequently associated with preterm birth. Identifying whether the psychiatric illness or its treatment is independently associated with preterm birth may help clinicians and patients when making management decisions. OBJECTIVE To determine whether a likely diagnosis of PTSD or antidepressant and benzodiazepine treatment during pregnancy is associated with risk of preterm birth. We hypothesized that pregnant women who likely had PTSD and women receiving antidepressant or anxiolytic treatment would be more likely to experience preterm birth. DESIGN, SETTING, AND PARTICIPANTS Longitudinal, prospective cohort study of 2654 women who were recruited before 17 completed weeks of pregnancy from 137 obstetrical practices in Connecticut and Western Massachusetts. EXPOSURES Posttraumatic stress disorder, major depressive episode, and use of antidepressant and benzodiazepine medications. MAIN OUTCOMES AND MEASURES Preterm birth, operationalized as delivery prior to 37 completed weeks of pregnancy. Likely psychiatric diagnoses were generated through administration of the Composite International Diagnostic Interview and the Modified PTSD Symptom Scale. Data on medication use were gathered at each participant interview. RESULTS Recursive partitioning analysis showed elevated rates of preterm birth among women with PTSD. A further split of the PTSD node showed high rates for women who met criteria for a major depressive episode, which suggests an interaction between these 2 exposures. Logistic regression analysis confirmed risk for women who likely had both conditions (odds ratio [OR], 4.08 [95% CI, 1.27-13.15]). For each point increase on the Modified PTSD Symptom Scale (range, 0-110), the risk of preterm birth increased by 1% to 2%. The odds of preterm birth are high for women who used a serotonin reuptake inhibitor (OR, 1.55 [95% CI, 1.02-2.36]) and women who used a benzodiazepine medication (OR, 1.99 [95% CI, 0.98-4.03]). CONCLUSIONS AND RELEVANCE Women with likely diagnoses of both PTSD and a major depressive episode are at a 4-fold increased risk of preterm birth; this risk is greater than, and independent of, antidepressant and benzodiazepine use and is not simply a function of mood or anxiety symptoms.

Depression Screening of Perinatal Women: An Evaluation of the Healthy Start Depression Initiative

OBJECTIVE To address problems with low rates of detection and treatment of depression of pregnant and postpartum women, many advocate depression screening in obstetrical settings. This study evaluated the Healthy Start depression initiative to assess whether it resulted in diminished rates of depressive symptoms and increased rates of detection, referral, and treatment among pregnant and postpartum women. METHODS Three cohorts were used to examine the program impact: a pre-Healthy Start depression initiative cohort, a post-Healthy Start depression initiative cohort that was enrolled in New Haven Healthy Start, and a post-Healthy Start depression initiative cohort not enrolled in the New Haven program. Participants included 1,336 pregnant and postpartum women receiving obstetrical care at publicly funded health care clinics. Measures included the Primary Care Evaluation of Mental Disorders Brief Patient Health Questionnaire; the PTSD Symptom Scale; a five-item modification of the Conflict Tactics Scale; and questions regarding alcohol, illicit substances, and general medical and obstetrical history. RESULTS The Healthy Start depression initiative changed neither levels of depressive symptoms nor use of depression treatment in unselected populations. The initiative may have decreased the rate of referral for depression in the cohort under study. CONCLUSIONS Universal screening and support for treatment referral by paraprofessionals did not reduce the overall rates of depressive symptoms of perinatal women who received care at publicly funded obstetrical clinics. Future work on depression screening should consider strategies to engage women who are more severely affected by a depressive disorder in behavioral health treatment.

Success of mental health referral among pregnant and postpartum women with psychiatric distress

OBJECTIVE This study measured rates of and determined factors associated with mental health service use among a cohort of 465 pregnant and postpartum women receiving care from publicly funded obstetric clinics. METHODS Women underwent a diagnostic evaluation, were provided with at least one mental health referral and were encouraged to seek treatment; follow-up with provision of additional referrals occurred at 1, 3 and 6 months after the initial assessment. Logistic regression was used to estimate the relationship between clinical and psychosocial factors and self-reported mental health service use. RESULTS Of the referred women, 38.1% attended at least one mental health visit, while only 6% remained in treatment during the entire 6-month follow-up interval. Postpartum women were more likely than pregnant women to attend a mental health treatment visit [odds ratio (OR)=4.17]. Being born in the United States (OR=2.06), being exposed to interpersonal violence (OR=2.52) and being unemployed (OR=2.69) were associated with attending at least one mental health-care visit. Women who received a behavioral health referral to the same site as their prenatal or postpartum care were more likely than those referred offsite to attend a mental health treatment visit (OR=3.23). CONCLUSIONS Despite active follow-up, rates of accessing and particularly continuing in mental health treatment were low. More work is needed to support the integration of specialty behavioral health services in primary care settings accessed by perinatal women.

Symptoms of posttraumatic stress disorder in a community sample of low-income pregnant women

OBJECTIVE The purpose of this study was to examine symptoms of posttraumatic stress disorder (PTSD) in a community sample of low-income pregnant women who met the DSM-IV diagnostic criteria for the disorder. METHOD Pregnant women (N=948) were screened for trauma, PTSD, depression, and co-occurring illicit substance use. PTSD symptoms were compared in traumatized pregnant women and a sample of nonpregnant traumatized women from the National Comorbidity Survey. RESULTS Suicidal thoughts and a high degree of psychiatric comorbidity were common in pregnant women with PTSD. Pregnant women were selectively and significantly less likely to endorse reexperiencing symptoms of PTSD (29.5%, N=82), compared to nonpregnant women (79.4%, N=464). CONCLUSIONS PTSD in pregnancy was associated with comorbidity, poor health behaviors, and lower recall of memory-related PTSD symptoms. Further prospective study is needed.

Do the PHQ-8 and the PHQ-2 accurately screen for depressive disorders in a sample of pregnant women?

OBJECTIVE The aim of this study was to assess the psychometric properties of the Patient Health Questionnaire (PHQ)-8, and the PHQ-2, a two-item version of the PHQ, respectively, in pregnancy. These screeners were compared to a structured diagnostic interview in a cohort of pregnant women attending prenatal care. Based upon studies documenting high sensitivity and specificity on the PHQ-8 and PHQ-2 in the general adult population, we hypothesized that both instruments would be effective in this population. METHODS Two hundred eighteen women, 13 of them depressed, were given the Composite International Diagnostic Interview and the PHQ-8 before 17 weeks of pregnancy. Receiver Operating Characteristic curves determined optimal thresholds and sensitivity and specificity were calculated using both dimensional and categorical approaches. Agreement between the PHQ-2 and PHQ-8 was measured using Cohens kappa. RESULTS Optimal cutoffs for the PHQ-8 and PHQ-2 were 11 and 4, respectively. Using these cutoffs, the PHQ-8 had a sensitivity of 77% and a specificity of 62% while the PHQ-2 had a sensitivity of 62% and a specificity of 79%. The categorical method of scoring the PHQ-8 yielded a sensitivity of 54% and a specificity of 84%. CONCLUSIONS In our sample, the PHQ-8 and PHQ-2 performed almost equally in detecting probable major depressive disorder in a sample of pregnant women. The categorical scoring method for the PHQ-8 had lower sensitivity but slightly higher specificity than the dimensional version. We found the PHQ-8 and PHQ-2 to have lower sensitivity and specificity in our pregnant population as compared to findings in nonpregnant populations; however, characteristics of our sample and choice of diagnostics instrument could explain these discrepant findings.

Perinatal Depression and Birth Outcomes in a Healthy Start Project

Given the risk of adverse perinatal outcomes associated with a depressive disorder, the Health Resources and Services Administration’s (HRSA) Maternal and Child Health Bureau (MCHB) from 2001–2005 devoted resources through the Federal Healthy Start Initiative to screen pregnant women for depression and link them with services. In this report, we present the evaluation of a program that screened for depression and provided services for women with depressive symptoms or psychiatric distress in pregnancy to assess whether the program was associated with a reduction in babies born low birth weight, small for gestational age, or preterm. The program impact was examined among 1,100 women in three cohorts enrolled from 2001–2005 that included: (1) subjects recruited prior to the inception of the Healthy Start Initiative; (2) subjects enrolled in the Healthy Start Initiative; and (3) a comparison group recruited during the project period but not enrolled in the Healthy Start Initiative. After adjustment for covariates, women with probable depression were over one and a half times more likely to give birth to a preterm baby than non depressed women. Neither adjusted nor unadjusted risks for delivery of preterm, low birth weight or small for gestational age infants were significantly lower for women enrolled in Healthy Start as compared to women not enrolled in Healthy Start. However, regardless of enrollment in Healthy Start, women who delivered babies after the Healthy Start program began were 85% less likely to deliver preterm babies than women giving birth before the program began. Depression status conferred increased risk of adverse birth outcomes, results that were not altered by participation in the Healthy Start program. We cannot exclude the possibility that the community activities of the Healthy Start program promoted increased attention to health issues among depressed women and hence enhance birth outcomes.

Sexual Orientation, Adult Connectedness, Substance Use, and Mental Health Outcomes Among Adolescents: Findings From the 2009 New York City Youth Risk Behavior Survey

OBJECTIVES We examined associations between identifying as lesbian, gay, or bisexual (LGB) and lacking a connection with an adult at school on adolescent substance use and mental health outcomes including suicidality. METHODS We analyzed data from the 2009 New York City Youth Risk Behavior Survey (n=8910). Outcomes of interest included alcohol use, marijuana use, illicit drug use, depressive symptomatology, suicide ideation, and suicide attempt. RESULTS The prevalence of each outcome was significantly higher among LGB adolescents than heterosexual adolescents and among those who lacked an adult connection at school than among those who did have such a connection. Even when LGB adolescents had an adult connection at school, their odds of most outcomes were significantly higher than for heterosexual adolescents. Those LGB adolescents who lacked a school adult connection had the poorest outcomes (about 45% reported suicide ideation; 31% suicide attempt). CONCLUSIONS Adolescents who are LGB, particularly those who lack a connection with school adults, are at high risk for substance use and poorer mental health outcomes. Interventions should focus on boosting social support and improving outcomes for this vulnerable group.

Neurobehavioral assessment of infants born at term and in utero exposure to serotonin reuptake inhibitors

BACKGROUND Some studies report neurobehavioral symptoms in neonates exposed to serotonin reuptake inhibitors (SRIs) in utero. However, maternal psychiatric illness during the last trimester of pregnancy, as a confounding factor, has not always been assessed. AIMS In this prospective study we compared neurobehavioral complications among neonates who were born to euthymic women who either took or did not take an SRI during the last trimester of pregnancy. STUDY DESIGN Exposed and unexposed infants were assessed for: 1) temperament as measured by the Neonatal Behavioral Assessment Scale (NBAS); 2) activity via Actiwatch electronic monitoring; 3) sleep state using trained observer ratings; and 4) perinatal complications through medical record review. T-tests, Fishers exact tests, and analyses of covariance were used to assess the relationship between clinical and neurobehavioral factors and exposure status. SUBJECTS 67 infants (61 controls and 6 exposed to SRIs). OUTCOME MEASURES Neonatal Assessment Behavioral Scale, APGAR scores, infant sleep state (% sleep, % wakeful), startles and tremulousness, gestational age, birth weight, and head circumference. RESULTS Infants exposed to SRIs in the third trimester had poorer motor development, lower 5-minute APGAR scores, and shorter mean gestational age as compared to unexposed infants. CONCLUSION Results of this study show differences in autonomic and gross motor activity between neonates who were or were not exposed to SRIs in utero after controlling for active maternal psychiatric illness. Future longitudinal work should compare longer term outcomes of exposed and unexposed infants of depressed mothers.

Ethnically Diverse Mothers’ Views on the Acceptability of Screening for Maternal Depressive Symptoms during Pediatric Well-Child Visits

The under-identification of depressive symptoms among low-income, minority women contributes to disparities in mental health outcomes. Pediatric visits offer a new venue for the identification of such symptoms. We explored women’s views related to depression screening during pediatric well-child visits in interviews conducted with 42 mothers of diverse ethnicities. Women considered their child’s pediatric provider to be an appropriate person with whom to discuss their emotional health and were aware of the inter-relationship between their mood and their child’s well-being. Thus, they felt discussing their emotional health was an acceptable component of pediatric health care. Stigma and fear of child protective services were concerns. Women articulated strategies to improve acceptability of screening, including providing a clear rationale for screening, services available, and child protective service involvement. The perspectives of women of diverse ethnicities provide information that may improve identification of mothers with depressive symptoms and potentially reduce disadvantages in mental health outcomes in minority populations.