by Anna R. Brandon, Madhukar H. Trivedi, Linda S. Hynan, Paula D. Miltenberger, Dana Broussard Labat, Jamie B. Rifkin, and C. Allen StringerJournal of Clinical Psychiatry. 2008 69[4]: 635–643.
Objective: Little is known about depression during pregnancy in women with high maternal or fetal risk, as this population is often excluded from research samples. The aim of this study was to evaluate depressive symptoms and known risk factors for depression in a group of women hospitalized with severe obstetric risk.Method: In the antenatal unit, 129 inpatients completed the Edinburgh Postnatal Depression Scale [EPDS], the Dyadic Adjustment Scale [DAS], and the Maternal Antenatal Attachment Scale [MAAS] from October 2005 through December 2006. A subset of women were administered the Mood Disorder module of the Structured Clinical Interview for DSM-IV Axis I Disorders [SCID] based upon a score of ≥11 on the EPDS. Obstetric complications were classified according to the Hobel Risk Assessment for Prematurity.Results: Fifty-seven of the 129 women [44.2%] scored 11 or greater on the EPDS, and at least 25/129 [19%] met the DSM-IV criteria for Major Depressive Disorder [MDD]. Mothers reporting high attachment to the fetus on the MAAS reported lower severity of depressive symptoms [rho=−0.33, p< 0.001]; those reporting interpersonal relationship dissatisfaction on the DAS endorsed higher depressive severity [rho=−0.21, p=0.02]. Severity of obstetric risk was unrelated to depression but, one complication, incompetent cervix, was positively associated with level of depressive symptomatology.Conclusion: Findings indicate a higher prevalence rate of MDD in women with severe obstetric risk than that reported in low-risk pregnancy samples, suggesting the need for routine depression screening to identify those who need treatment. Fewer depressive symptoms were reported by mothers reporting strong maternal fetal attachment and greater relationship satisfaction.
First, the study: Women with high risk pregnancies are usually admitted to the hospital for observation. Here’s a table from the article with the specific risk factors. The study consisted of the subjects completing a group of self report questionnaires. Those with a score of > 11 on the Edinburgh Postnatal Depression Scale [EPDS] had a SCID structured Interview as a marker for the presence of Major Depressive Disorder [MDD]. Here’s the table of reasons for admission from the article:
And here’s the consort and flow through the study [modified to fit your screen]:
The findings were:
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"Fifty-seven of the 129 women [44.2%] scored 11 or greater on the EPDS, and at least 25/129 [19%] met the DSM-IV criteria for Major Depressive Disorder [MDD]"
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"… the data indicated the proportion of those with MDD was at least 19%, higher than reported in other studies of perinatal women."
In case you haven’t noticed, this is not a candidate for study of the year. They’re using a questionnaire for predicting post-partum depression to screen for pre-natal depression. The fall-off in the flow chart is impressive and with the likelihood of non-random missingness, who knows what the numbers mean. Their control group is other studies – referenced but with findings not shown except in summary:
the best estimate of point prevalence for MDD at any time during pregnancy is 12.7%, with as many as 18.4% reporting major or minor depression.
They seem to know that it’s a shambles, saying:
"Conducting pure research in a hospital unit such as the setting for this study and with a population such as this one is a challenging task. The process of pregnancy and childbirth has always been unpredictable, which is illustrated by the rate of exclusions that occurred because mothers either delivered or were discharged within 72 hours of admission, even when this was not expected."
Fortunately, the fact that it’s so uninterpretable doesn’t interfere with the reason I’m talking about it. It’s not even my more usual reason for looking at such studies: trolling for patients to put on antidepressants. In the conclusion and the implications for further research, they don’t even suggest antidepressants – to their credit. In fact, the first author, Dr. Anna R. Brandon, has a list of publications including looking into psychotherapeutic interventions for depressed pregnant patients because they were afraid to take antidepressants. Good for her, and good for them. Nor is this posted here because the results are obvious:
"Corroborating previous work, prenatal depression is significantly associated with psychiatric history, lower maternal fetal attachment, and higher relationship dissatisfaction."
It’s the phrase "met the DSM-IV criteria for Major Depressive Disorder [MDD]" that got it on the record of this blog. These are women towards the end of their pregnancies who found themselves hospitalized for "high risk" at the end of their pregnancy. That means:
"… a pregnancy may be defined “high risk” on the basis of an increased probability of fetal anomaly, compromises to maternal or fetal health, or significant risk for maternal or fetal demise."
In my book, that’s a stress of major proportions. Were I capable of being in that situation, I’m sure I’d be pretty damned unhappy. The authors knew that. In discussing the difficulties of doing their study, they said:
"The protocol required two face-to-face interviews and the completion of a packet of self-report measures, a process that may have seemed overwhelming to patients already overwhelmed with the implications of their obstetric complications and the effect of hospitalization upon their spouses and families."
In fact, in this cohort, there were more cases of women who lost their babies than women where they could document the "MDD" they were looking for with a structured interview:
Call it The Depression of Dire Straits or The Understandable Misery of carrying a Pregnancy that Might Go Very Badly, but not Major Depressive Disorder. We used to call it Reactive Depression. I liked that term because it was the truth. What about patients who really do have a Melancholic Depression either unrelated to the pregnancy or precipitated by the pregnancy? You don’t need a screening instrument for that. The clerk doing the intake can see it with the naked eye. If Major Depressive Disorder is a Disorder, don’t stick women in this situation with that label. All you’ll do is muck up their insurance premiums in perpetuity. But even though this group didn’t go down the antidepressant path, here’s an example of what is happening in the real world:
by Jeffrey R. Lacasse and Joanne CacciatoreDeath Studies doi:10.1080/07481187.2013.820229
To examine psychiatric prescribing in response to perinatal/neonatal death, we analyzed data from a cross-sectional survey of 235 bereaved parents participating in an on-line support community. Of the 88 respondents prescribed medication, antidepressants were most common [n = 70, 79.5%] followed by benzodiazepines/sleep aids [n = 18, 20.5%]. Many prescriptions were written shortly after the death [32.2% within 48 hours, 43.7% within a week, and 74.7% within a month]. Obstetrician/gynecologists wrote most prescriptions given shortly after loss. Most respondents prescribed antidepressants took them long-term. This sample is select, but these data raise disturbing questions about prescribing practices for grieving parents.
The current usage of the diagnosis Major Depressive Disorder [MDD] trivializes human experience by implying that very unhappy or symptomatically depressed is a disease or a disorder. This is a case where Thomas Szasz is totally correct. When the DSM-III conflated the magnitude of the felt symptoms with the presence of psychiatric conditions that are, in fact, clinical entities with unique histories and course, the framers made an error that has had widely felt consequences that we’re all aware of – popularized by some psychiatrists [one of whose names in on this paper – Madhukar Trevidi]. I’ve been convinced by others that this was not Robert Spitzer’s intent, but it doesn’t change today’s problematic reality. Likewise, the widely used term antidepressants for certain of our medications seems benign, but it’s not. In general medicine, that means "give them to unhappy sad depressed people" [we don’t call antihistamines anti-sneezers, or antacids anti-upset-tummiers]. The antidepressants are not effective in helping people with the human responses to adversity, at least not in my hands or in our literature. But they can, at times, add to the burden.
If the intent of the authors of the first paper is to highlight the fact that the threat of fetal loss is a big deal in the life of a mother, even a reluctant mother, more power to them. I’d only suggest they find another term for it. As to the second paper, it highlights the epidemic of inappropriate uses of psychiatric medications everywhere, and the even worse fact that routinely, their use becomes long term. I’ll probably get myself in trouble with the authors saying this, but in acute bereavement, sometimes the most helpful thing in the world is a few good nights of sleep – even that is with the accent on "a few." But a third of them on antidepressants? Absurd.
Fetal or neonatal death, or even its threat, can be a life altering event. What is easily overlooked is that for the mother-to-be, attachment well antedates birth, and it’s an unusual attachment because it’s to what the child will be, what the child will be like in the life of the mother. The well known worried preoccupation of the healthy new mother has been understood as the mother’s adapting to the reality of the child they actually have, transitioning from a relationship with the virtual child. Whatever the meanings, it’s an attachment and a loss like no other, understood best by people who know it from experience, either their own or long exposure to others. And while this is not the format to discuss it, even the threat of a lost pregnancy can have long range consequences for a mother/child pair persisting long after the danger has passed, worthy of exploration beyond symptoms…
And don’t forget the hormonal tides that accompany pregnancy and miscarriage.
A lot of people find merely visiting a hospital depressing!
Whether the authors are trolling for antidepressant customers or not, they’re trolling for people they can diagnose with psychiatric disorders. This is empire-building, and too often women are the building blocks.
And then there are parents who have lost a baby….
Simply appalling. I’d ask “have they no shame?” but it’s clear they’re beyond that.
At least three UT Southwestern PhD candidates used data from this study for their dissertations:
Brandon, A. R. (2006). Maternal and fetal representations, dimensions of personality, and prenatal attachment in women hospitalized with high risk pregnancy. Unpublished doctoral dissertation, University of Texas Southwestern Medical Center.
http://tinyurl.com/no4fqnp
Broussard Labat, D. (2007). Predictors and correlates of anxiety in women hospitalized with high-risk pregnancy. Unpublished doctoral dissertation, University of Texas Southwestern Medical Center.
http://tinyurl.com/ovoxofm
Keller, M.J. (2009) Object representation, relationship satisfaction, maternal-fetal attachment, and depression in high risk pregnancy. Unpublished doctoral dissertation, University of Texas Southwestern Medical Center.
http://tinyurl.com/oa8zo3l
Interestingly, Trivedi (second author of the published paper) is not mentioned in the original research paper.
Hi Nancy. Those actually sound kind of interesting. It’s a reasonable thing to study, what a threat in pregnancy does to prenatal attachment. But they didn’t seem to spend any time talking to their subjects! And it’s a pity they had to muck it all up by turning it into MDD. I’m not surprised that MT signed on. He’ll sign anything these days…
Wow. You are not such a boring old man. But some of your details are wrong and there may not be room enough here for me to clarify.
1. The EPDS has been validated for prenatal and postpartum depression and is the most commonly used SCREENING instrument around the world. There are 124 references in PubMed if you want to check this out.
2. Yes, this was a graduate student project in a hospital that sorely needed free clinicians. What the paper doesn’t say is that we all met with the women who were struggling weekly until they delivered or were discharged, and some of them maintained treatment afterwards.
3. All of my later work (this was done in 2006 and published in 2008) highly emphasizes nonpharmacological approaches to depression, particularly this review: Brandon, A. R. and Freeman, M. P. (2011). When she says “no” to medication: Psychotherapy for antepartum depression. Current Psychiatry Reports, 13 (6), 459-466. PMID:21877161.
4. Only those who concretely met the criteria for MDD were classified as such, and this requires more than 2 weeks of symptoms. They were interviewed within their first few days in the hospital, so the symptoms preceded the undeniably high stress of hospitalization.
5. My real interest was in the attachment process. The attachment people were not interested in my work because in their strict evolutionary way of thinking attachment doesn’t happen until the birth of the baby! They suggested I try to find another word for it, like “bonding.”
6. Oh you boring old man please don’t be so mean. Graduate students have to begin somewhere, and hey, I actually published part of my dissertation! And I can remember what I studied so hard. ;-} Second, it’s hell out here for psychotherapy researchers. In fact, after three years of being unsuccessful at getting follow-up funding for my Partner-Assisted Interpersonal Psychotherapy, I’m packing away the research career and going to what I love the most, helping new moms get through stressful times in my new private practice in Dallas.
7. Thank you for reading our article so well. It warms my heart and brings a smile to my face. I didn’t think anyone would remember this one.
8. To all of you, our society makes childbearing more stressful than it has ever been in the past (for moms and dads). I would love to take the label of depression away. If we do, moms who need psychosocial support will not have it covered by their insurance, it won’t get noticed by OBs, gynecologists, pediatricians, and other health care providers. We can’t throw the baby out with the bathwater…
Anna,
Oh, I’m not that mean. I’m actually a retired psychoanalyst psychiatrist with a major interest in attachment theory. I think I smelled graduate student before Nancy told me, and as a veteran of similar hospitals in Memphis and Atlanta, I even had a bit of a shudder at the thought of getting that sheath of questionnaires filled out in the world of a busy hospital. My reaction was what I said It’s the phrase “met the DSM-IV criteria for Major Depressive Disorder [MDD]” that got it on the record of this blog. In real life, that’s what gets people put on too much medication as that second study shows rather than the kind of supporting and exploratory care that’s needed. I expect you know that. The issue of insurance coverage requiring labeling is a Faustian bargain – and I’m glad you know that too.
What I was alluding to in that last paragraph was experiences with mother/child pairs where scares like admission for “high risk” or bleeding during pregnancy with threatened abortion were associated with self protective detachment from the infant that had persistent consequences long after birth with ramifications for the child lasting into adult life.
And I will readily admit that Dr. Trevidi is no favorite with his concrete interpretations of MDD and antidepressants…
Have a good career!…
Iron and b-deficiencies should be tested for in women who have just gone through a difficult birth, and— as Altostrata pointed out— testing for hormone imbalance.
You know what would be superior to am antidepressant? Friends who would help the woman through the ordeal by being supportive and offering her the gifts of support and real help with the new baby. Cooking and shopping for her. Doing some of her housework. Helping with the baby. Helping with other children. Getting the mother and the baby out of the house.
For a woman who loses a baby, it’s pure grief of a very personal nature. No one else knew her baby like she did. Once a woman decides to take a pregnancy full term, she is likely to love what is growing in her more and more as it develops into a viable fetus. It’s a close and unique relationship with the baby and between the woman and her own body. Treating grief after a still birth as a malfunctioning brain is obscene.