Psychiatry and Primary CareRates and predictors of depression treatment among pregnant women in hospital-affiliated obstetrics practices
Introduction
Detection and adequate treatment of antenatal depression are a critical public health issue for researchers, clinicians and policymakers to address. Antenatal depression affects between 10% and 15% of women [1] and represents the strongest risk factor for postpartum depression [2]. Depression in pregnancy has been associated with poor maternal functioning and birth outcomes [3], [4], [5], [6], [7], yet most depressed pregnant women are not detected or treated [8]. Despite the important growing literature documenting the prevalence of and risk factors for antenatal depression [9], [10], research must also focus its attention on rates and predictors of depression-related treatments being received. Such research is important in determining the degree of undertreatment for such high-risk women and in identifying important factors that are related to whether or not depressed pregnant women seek treatment for their depression. Research on these issues will inform strategies for responding to women positively screened for depression risk in obstetrics settings in order to facilitate treatment seeking.
Prenatal care settings provide an optimal opportunity for identification and treatment of antenatal depression since most women will seek health care at some point during their pregnancy [7]. However, several recent studies of women seeking prenatal care have documented underdetection and undertreatment of depressed pregnant women seen in these settings, with depression detection rates (based on obstetric clinic chart review) to be less than 25% [8], [11], [12], [13], [14]. Factors that have been found to be associated with greater likelihood of detection and referral for psychiatric treatment include higher depression severity scores, being Caucasian, psychiatric comorbidity (i.e., PTSD), previous adverse perinatal outcomes, substance abuse, lifetime history of domestic violence and the presence of an identified mental health care provider [13], [14].
Most of these studies have employed depression screening or symptom measures and have not used validated structured psychiatric interviews to determine treatment rates among women with current and recurrent major depressive disorder (MDD), those most clearly in need of treatment [15], [16]. Also, studies have relied on medical chart review for detection and treatment information. Although this is a valid method for studying rates of medical treatments, health care providers may not consistently note psychiatric treatment information in the medical charts [17]. Finally, although impairment in physical, social and emotional functioning has been documented in depressed, pregnant women [4], the relationship of functional impairment to depression treatment use has not been studied.
This study examined rates of depression treatment, both among pregnant women considered to be at risk for depression according to depression screening and a subset of the sample with MDD diagnosed through clinician-administered structured interview. Such analyses provide not only information regarding rates of treatment associated with at-risk samples defined by relatively standard and efficient screening questions (similar to the approach used in other studies) but also information regarding rates of treatment for those women with current depression, who are most likely in need for specialized depression treatment interventions. We expected that a minority of the at-risk women, as well as those with current MDD, would be receiving any treatment. This study also examined predictors of depression treatment in a multivariate model. The analysis strategy was designed to examine the impact of demographics (e.g., race), measures of symptom severity and functioning, treatment history and the presence of current MDD on treatment use. It was hypothesized that use of treatment would be associated with greater patient need (i.e., greater symptom severity and poorer functioning) and that, based on prior studies (e.g., Ref. [14]), Caucasian race would be positively associated with depression treatment. Such analyses can provide useful information regarding the most important factors to assess and target in order to facilitate treatment seeking for depressed pregnant women.
Section snippets
Procedures
Participants in this study were 276 pregnant women recruited across five university-hospital-affiliated obstetrics clinics, serving primarily patients with private insurance and Medicaid. All participants were recruited for the present study after being screened for depression and other health behaviors as part of a larger screening study while waiting for their prenatal care visit at the clinic sites. Women who were at least 18 years of age, English speaking and less than 32 weeks pregnant (in
Rates of depression
Among this selected high-risk samples (as defined in Section 2), 17% (n=46) had an SCID-diagnosed current major depressive episode, and an additional 23% (n=62) had a prior history of MDD. Among women with current MDD, 76% (n=35) had a prior history of at least one other MDD episode, with an average of 5.2 prior episodes (S.D.=3.9). Most women with MDD (65%, n=30) reported three or more prior episodes. Among the total high-risk sample (including MDD and non-MDD), 39% (n=107) reported at least
Discussion
Rates of depression treatment among pregnant women with significant depressive symptoms and among women meeting diagnostic criteria for MDD were low. Consistent with previous reports, most depressed women (defined either way) were not receiving any form of depression treatment [8], [1], [12], [13], [14]. The low treatment rates found are particularly compelling for the one in four women overall (regardless of current MDD status) with recurrent MDD, a group most in need of intensive monitoring
Acknowledgments
This work was supported by the University of Michigan Medical School and by the National Institutes of Health (Grant AA11922-02). We also thank Timothy R.B. Johnson, M.D., for study consultation and reviews of portions of this work.
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