Smith, Denise C. CNM; Munroe, Michelle L. CNM; Foglia, Lisa M. MD; Nielsen, Peter E. MD; Deering, Shad H. MD
At the end of 2008, approximately 150,000 members of the U.S. Armed Forces were deployed to Iraq or Afghanistan, and for many of them, not for the first time.1 As 54.7% of the U.S. Army is reported as married, the military family takes on new significance and bears much of the strain of being a nation at war.2 Families are often required to relocate and are thus isolated from usual sources of social support such as extended family, friends, and familiar surroundings. Additionally, given the continuing conflict overseas, their spouses are often called upon to deploy for long periods of time, sometimes as long as 15 months. By the very nature of the military lifestyle, military spouses and children cope with higher levels of stress that is uncommon in the general population during their lives.3,4
The importance of screening, diagnosing, and treating depression in pregnancy and the postpartum period has been well documented in the literature.5,6 Risk factors for postpartum depression include a history of depression, depression during pregnancy, poor marital relationship, low social support, and stressful life events.7 Experiencing multiple deployments, not knowing when their spouse's unit might deploy again, fears of safety for their loved one, and strain on spousal relationships are all stressors that one might reasonably expect to increase a woman's risk for depression in pregnancy and postpartum.8,9,10
To date, only a small number of studies exist estimating the prevalence of postpartum depression or depression during pregnancy in military communities.10–13 Considering that the U.S. Army comprises the majority of combat troops, this population bears special attention. The purpose of this study was to estimate the relationship of high-risk depression screen scores to deployment status.
MATERIALS AND METHODS
This study was approved by the Madigan Army Medical Center Institutional Review Board. Use of screening tools for depression has become an accepted practice in determining which patients need further evaluation or referral for diagnosis and treatment of postpartum depression. The Edinburgh Postnatal Depression Scale is a screening tool for depression that uses a 10-item Likert-type scale. It can be completed in less than 5 minutes and has been clearly established as a reliable tool for detecting those patients at high risk for depression. Scores range from 0 to 30 with higher scores being more concerning for and associated with postpartum depression. Scores of 14 or greater have been determined to be the most predictive in diagnosing depression.11
Although the Edinburgh Postnatal Depression Scale was developed for screening depression in the postpartum population, it has also been shown to effectively screen for depression in the antenatal period.12 Furthermore, the scale has been shown to effectively screen for antenatal anxiety, which has been shown to be associated with postpartum depression.7,12
In 2007, Madigan Army Medical Center modified and implemented the Edinburgh Postnatal Depression Scale for routine screening for depression during pregnancy and in the postpartum period. The obstetric population at Madigan Army Medical Center consists of active-duty soldiers and their family members, which can include spouses and adolescent children. Screening was performed at the initial obstetric visit, between 28 and 32 weeks of gestation, and 6–8 weeks postpartum. If a patient transferred care to our institution, screening was performed at the first patient visit, regardless of gestational age. Patients had the right to decline the survey. Scores of 10 or greater required further evaluation and were documented in the patient record. A score of 14 or greater was considered an indicator of a patient at high risk for having depression. In addition to the 10-question Likert-scale, the Edinburgh Postnatal Depression Scale screening questionnaire was modified to include an assessment of the spouse's deployment status. The question asked if the spouse was “Preparing to deploy, Deployed, Just returning from Deployment, Not applicable, no deployment planned.” The results of all surveys were entered into an electronic database, which was queried for the study period of January 2007 to June 2009.
Surveys that were not completed or that lacked information regarding the time period and visit at which they were given were excluded. Additionally, if the question regarding deployment status was not answered, the survey was excluded.
Participants who answered “Not applicable, no deployment planned” were considered to represent the control group for purposes of comparison. Survey results with scores of 14 or higher from the three different time periods were grouped according to time point collected, then compared with the control group with χ2 analysis, with P<.05 considered significant.
A total of 5,950 surveys were completed during the study period. Among those, 610 were either patients who transferred care and were not in one of the specific time periods where screening was usually performed or the time period was not specified. Another 1,369 did not answer the question related to deployment, and 15 women declined to complete the survey leaving a total of 3,956 (66%) surveys available for analysis. Of the surveys available for analysis, 2,061 (52%) were collected at the initial obstetric appointment, 563 (14%) at the 28–32-gestational week visit, and 1,332 (34%) at the postpartum appointment. Of the included surveys, 653 patients filled out the survey at two different times during their pregnancy, and 40 patients at all three time intervals.
The baseline risk of an elevated Edinburgh Postnatal Depression Scale score of 14 or higher was between 4% and 8% in all three time periods. This level did not differ significantly between the different visit times which were analyzed.
At the initial obstetric visit, the prevalence of an elevated Edinburgh Postnatal Depression Scale score was more than double the baseline rate for the control group patients with a partner returning from deployment (6% compared with 14%, P=.002) but was not significantly different for patients whose partner was currently deployed (6% compared with 5.6%, P=.83) (Table 1).
At the 28–32-gestational week visit, the prevalence of a positive score was significantly higher for patients with partners who were deployed or returning from deployment as compared with the control group (Table 2). This risk was 20.8% in the group with spouses returning from deployment and 13.1% for those whose partner was currently deployed compared with only 4.3% in the control group.
In the postpartum time frame, the only group with an elevated risk of a positive screen was the group whose partner was currently deployed (16.2% compared with 8.1%, P=.006) (Table 3).
A summary graph of elevated Edinburgh Postnatal Depression Scale screening scores by spousal deployment status across the time periods can be seen in Figure 1.
Deployment status of the spouse appears to be a significant factor in the prevalence of elevated Edinburgh Postnatal Depression Scale scores in pregnant and postpartum women. When considering that American soldiers have been engaged in armed conflict in Iraq and Afghanistan for the last 8 years and that this is likely to continue, the effects of deployment on depression during and after pregnancy is an important issue that needs to be further studied.
A review of the studies completed on postpartum depression suggests that rates of depression are between 6% and 13% in the general population, which is similar to the baseline rate of elevated screening results in our study (4–8%).5,7 Of the studies available examining the rates of positive depression screens in military populations, rates ranging from 11% to 24% have been reported.13–15 The largest study identified was a retrospective chart review of 415 women at Naval Medical Center San Diego, who were surveyed using the Edinburgh Postnatal Depression Scale at 6 weeks postpartum.16 This study reported that women who had a spouse deployed during pregnancy were at an increased risk for postpartum depression. Data collected in this study included the additional questions “Is your spouse/partner currently deployed?” and “Did your spouse deploy during your pregnancy?” Spousal deployment was not clearly defined as a combat or noncombat deployment, nor was length or location of deployment assessed. Women whose spouses were deployed during pregnancy were reported to have a mean Edinburgh Postnatal Depression Scale score of 7.36 compared with 4.81 for those whose spouses were not deployed (odds ratio 2.79, P<.001). Spousal deployment during pregnancy was found to increase the risk of a score 12 or higher (n=90, odds ratio 2.79, P=.002). Neither deployment during or after pregnancy was found to increase the risk of suicidal ideation or suicide. While this is an important study with useful information, typical deployments for the Navy, with the exception of the Marines, involve several months deployed at sea. The exposure to daily hostile operations and deployment lengths are vastly different than for U.S. Army personnel, thus these data may not be representative of the Army population.
Fort Lewis, the U.S. Army garrison where Madigan Army Medical Center is located, is the home to more than 29,000 soldiers. Since 2003, Fort Lewis Soldiers have maintained a continuous cycle of deployments to theaters of war in both Iraq and Afghanistan. During the interval for this study, the operational tempo remained high. Mid-year to late 2008 saw the return of approximately 6,500 soldiers from theater, the end of the publicized Iraq “surge” of 2007.17,18 Deployment tour length varies depending on the capacity in which a soldier deploys, but over the time period of the study, 12–15 months was the most common deployment duration.
In this study, deployment status significantly affected the prevalence of positive screens for depression in pregnant women. It is interesting to note that having a spouse return from deployment during pregnancy was associated with a much higher risk for a positive depression screen at both the initial and 28–32-gestational week visits but not in the postpartum period. We hypothesize contrary to the expected joyful reunion, the return of a spouse during pregnancy may involve an increased level of stress as military couples may find that the relationship has become strained with the separation and there is a time period over which roles are relearned, communication restarted, and cohabitation reestablished. This reintegration can further be complicated if the returning spouse has psychological disorders, such as Posttraumatic Stress Disorder. Conversely, in the postpartum period, the feeling that the returning spouse might provide additional help and support may offer more reassurance.
The principal strength of this study is the large number of data points with more than 3,900 surveys available for review. The surveys were completed at multiple points throughout pregnancy and at the postpartum visit. This allowed for evaluation of depression screening scores across the full antenatal spectrum.
A limitation of this study is that it is retrospective in nature. Because of this, we were unable to control for a previous history of depression or the number of previous deployments, and patient age and parity were not collected. We were also not able to determine or account for the number of our patients who left the area to go back home during their spouse's deployment, which is not uncommon in our population. In addition, our database did not include information about the patient's gravidity and parity or whether or not the patient was active duty.
Our population is representative of the U.S. Army in its current state, with multiple and prolonged deployments expected to continue for the foreseeable future. The impact on obstetric patients is not completely unexpected given the significant stressors, highlighting the need to focus on ways to assist a vulnerable population.
Given our findings, we recommend that all pregnant women be screened for depression in the antenatal and postpartum periods, and particular attention must be paid to those women whose spouses are deployed, have recently returned from deployment, or are preparing to deploy. The highest risk group appears to be women whose spouses return from deployment during the antepartum period when the risk of a positive score was 20%. Screening should not be limited to only military treatment facilities that care for these patients. Since many women choose to return to their hometown or to another family member's home for care during the time of their spouse's deployment, civilian providers need to understand the unique stressors military families are enduring.
As a result of our screening process and these findings, the Department of Obstetrics and Gynecology partnered with the Department of Behavioral Health and placed a psychologist within the obstetrics and gynecology clinic for same-day referrals and follow-up consultation.
Further study in this high-risk population is imperative. Subsequent studies should include determining the number of women who require formal treatment for depression in pregnancy and postpartum and evaluating the effectiveness of treatment. It is also important to examine if differences exist between patients whose spouses undergo multiple deployments compared with first deployment and whether the length of deployment is related to rates of depression. Additionally, evaluation of the stressors facing a dual military couple during the child bearing years should be explored.
3. Ryan-Wenger NA. Impact of the threat of war on children in military families. J Pediatr Health Care 2002;16:245–52.
4. Birgenheier PS. Parents and children, war and separation. Pediatr Nurs 1993;19:471–6.
5. Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol 2005;106:1071–83.
6. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000.
7. O'Hara MW, Swain AM. Rates and risk of postpartum depression: a meta analysis. Int Rev Psychiatry 1996;8:37–54.
8. McLeland KC, Sutton GW, Schumm WR. Marital satisfaction before and after deployments associated with the Global War on Terror. Psychol Rep 2008;103:836–44.
9. Haas DM, Pazdernik LA, Olsen CH. A cross-sectional survey of the relationship between partner and deployment and stress in pregnancy during wartime. Womens Health Issues 2005;15:48–54.
10. Sayers SL, Farrow VA, Ross J, Oslin DW. Family problems among recently returned military veterans referred for a mental health evaluation. J Clin Psychiatry 2009;70:163–70.
11. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782–6.
12. Kim JJ, Gordon TE, La Porte LM, Adams M, Kuendig JM, Silver RK. The utility of maternal depression screening in the third trimester. Am J Obstet Gynecol 2008;199:509.e1–5.
13. Appolonio KK, Fingerhut R. Postpartum depression in a military sample. Mil Med 2008;173:1085–9.
14. O'Boyle AL, Magann EF, Ricks RE Jr, Doyle M, Morrison JC. Depression screening in the pregnant soldier wellness program. South Med J 2005;98:416–8.
15. Rychnovsky J, Beck CT. Screening for postpartum depression in military women with the Postpartum Depression Screening Scale. Mil Med 2006;171:1100–4.
16. Robrecht DT, Millegan J, Leventis LL, Crescitelli JB, McLay RN. Spousal military deployment as a risk factor for postpartum depression. J Reprod Med 2008;53:860–4.
© 2010 by The American College of Obstetricians and Gynecologists.