Prenatal Depression in Women Hospitalized for Obstetric Risk<\/a><\/div>\n
by Anna R. Brandon<\/a>, Madhukar H. Trivedi, Linda S. Hynan, Paula D. Miltenberger, Dana Broussard Labat, Jamie B. Rifkin, and C. Allen Stringer<\/div>\n
Journal of Clinical Psychiatry<\/font><\/strong>. 2008 69[4]: 635–643.<\/div>\n
[full text on-line<\/a>] <\/div>\n
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Objective<\/font><\/strong><\/u>: 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.<\/div>\n
Method<\/font><\/strong><\/u>: 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.<\/div>\n
Results<\/font><\/strong><\/u>: 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<\/em>=−0.33, p<\/em>< 0.001]; those reporting interpersonal relationship dissatisfaction on the DAS endorsed higher depressive severity [rho<\/em>=−0.21, p<\/em>=0.02]. Severity of obstetric risk was unrelated to depression but, one complication, incompetent cervix, was positively associated with level of depressive symptomatology.<\/div>\n
Conclusion<\/font><\/strong><\/u>: 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.<\/div>\n<\/blockquote>\n
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:<\/div>\n![](\"http:\/\/1boringoldman.com\/images\/trevidi-preg-1.gif\")
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<\/div>\nAnd here’s the consort and flow through the study [modified to fit your screen]:<\/div>\n![](\"http:\/\/1boringoldman.com\/images\/trevidi-preg-2.gif\")
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<\/div>\nThe findings were:<\/div>\n
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- \n"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]<\/em>"<\/div>\n<\/li>\n
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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.<\/em>" <\/div>\n<\/li>\n<\/ul>\nIn case you haven’t noticed, this is not a candidate for study of the year. They’re using a questionnaire for predicting post<\/u>-partum depression to screen for pre<\/u>-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<\/em> – referenced but with findings not shown except in summary:<\/div>\n\n\n
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.<\/em><\/div>\n<\/blockquote><\/div>\nThey seem to know that it’s a shambles, saying:<\/div>\n\n
"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.<\/em>"<\/div>\n<\/blockquote>\nFortunately, 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<\/a>, has a list of publications including looking into psychotherapeutic interventions<\/a> 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:<\/div>\n\n
"Corroborating previous work, prenatal depression is significantly associated with psychiatric history, lower maternal fetal attachment, and higher relationship dissatisfaction.<\/em>"<\/div>\n<\/blockquote>\nIt’s the phrase "met the DSM-IV criteria for Major Depressive Disorder [MDD]<\/font><\/strong><\/em>" 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<\/em>" at the end of their pregnancy. That means:<\/div>\n\n
"… 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."<\/em><\/div>\n<\/blockquote>\nIn 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: <\/div>\n\n
"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<\/font><\/strong>.<\/em>"<\/div>\n<\/blockquote>\nIn fact, in this cohort, there were more cases of women who lost their babies than women where they could document the "MDD<\/font><\/strong>" they were looking for with a structured interview: <\/div>\n![](\"http:\/\/1boringoldman.com\/images\/trevidi-preg-3.gif\")
<\/div>\nCall it The Depression of Dire Straits<\/font><\/strong> or The Understandable Misery of carrying a Pregnancy that Might Go Very Badly<\/font><\/strong>, but not Major Depressive Disorder. We used to call it Reactive Depression<\/font><\/strong>. I liked that term because it was the truth. What about patients who really do have a Melancholic Depression<\/font><\/strong> 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<\/u><\/font><\/strong> 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<\/em>. But even though this group didn’t go down the antidepressant path, here’s an example of what is happening in the real world:<\/div>\n\n
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