The U.S. Preventive Services Task Force recently recommended depression screening for all adults with specific mention of pregnant and postpartum women.1 This is of direct relevance to obstetrician–gynecologists (ob-gyns) and comes close on the heels of the American College of Obstetricians and Gynecologists' committee opinion recommending screening for depression and anxiety symptoms at least once during the perinatal period.2 These recommendations are fitting because women are twice as likely to have a lifetime diagnosis of major depression as men.3
Ob-gyns are well placed to detect depression early and to treat before symptoms become chronic with a devastating effect on families and societies. Not only do many women consider their ob-gyn their primary care provider, almost 50% of ob-gyns also consider themselves primary care providers.3 In addition, several gynecologic conditions encountered by ob-gyns, for example, endometriosis,4 polycystic ovarian syndrome,5 infertility, recurrent pregnancy loss,6 and premature ovarian insufficiency,7 are associated with depressive symptoms—either as risk factors or comorbidities (Fig. 1).
SCREENING DURING CRITICAL PERIODS OF VULNERABILITY, AND AT ROUTINE INTERVALS, CAN RESULT IN EARLY DEPRESSION DETECTION, PREVENTION, AND TREATMENT AND CAN PREVENT ASSOCIATED COMORBID CONDITIONS
Prevention goes hand in hand with early detection, because early detection and treatment can help prevent the morbidity associated with the primary disorder and comorbid conditions. Underscoring the importance of prevention, the Affordable Care Act instituted the national prevention strategy. One of six national prevention strategy priority areas is “mental and emotional wellbeing.” The national prevention strategy emphasizes integration of early detection of mental health problems into primary care settings.8 Preventive measures have the highest yield when delivered at routine intervals, for example, at the annual gynecologic examination and at “critical periods” or “windows of vulnerability”—specific periods along the life course when adverse events or exposures have the greatest negative effect.9 In women, specific reproductive stages (eg, adolescence, pregnancy, postpartum, menopause transition) are particularly vulnerable periods when reproductive hormone levels and psychosocial circumstances are in flux. These windows of vulnerability, when appropriately identified, provide opportunities for prevention. Several effective screening and preventive interventions for other conditions commonly treated in obstetric gynecology settings already exist: cervical and breast cancer, hypertension, sexually transmitted infections, and family planning.10,11 However, interventions to promote mental and emotional well-being are not yet systematically offered. Although ob-gyns are aware of the importance of depression screening,3 they may be reticent to make depression screening routine, perhaps as a result of lack of resources and limited clinical time allotment. Additional concerns that may arise relate to the question of necessary follow-up and treatment availability for women who screen positive for depression.12 New treatment models for depression, based in primary care13 and obstetrics and gynecology3,14 clinics, are relatively easy to implement, are effective, and are well accepted by busy practices.
We argue that, given the high prevalence and burden of depression in women, the influence that an ob-gyn might have by identifying and treating depression early is substantial. This should be our new patient care paradigm. We describe the importance of depression screening and early treatment, and summarize models of care that can achieve these goals in an obstetric and gynecology practice setting. Commonly used screening tools such as the nine-item Patient Health Questionnaire are integrated into many electronic health records and are easy for patients to complete in the office. Anxiety is frequently comorbid with depression, particularly in adolescence, but details are beyond the scope of this commentary. We organize our recommendations by focusing on vulnerable periods—adolescence, pregnancy, postpartum, and the menopause transition and conclude with recommendations regarding initiation of treatment. Details of our recommendations and all primary references to those recommendations can be found at www.dawncare.org.
ADOLESCENCE IS A PERIOD OF SOCIAL TRANSITION AND A HIGH-RISK PERIOD FOR BEHAVIORAL AND EMOTIONAL DISORDERS
The increased risk for depression in females begins at puberty. Female adolescents are at a two- to threefold higher risk of major depressive disorder than males and a nearly fourfold higher risk of severe major depressive disorder.15 Adolescents with depressive symptoms are at a higher risk of educational underachievement, unemployment, early parenthood and anxiety disorders, nicotine dependence, alcohol abuse, and suicidality.16 Thirty percent of adolescents with major depressive disorder report suicidality in the past year and 10.8% report a suicide attempt. Centers for Disease Control and Prevention data from 1999 to 2014 demonstrate that suicide rates increased in both men and women of all age groups. In females, the largest increase was in adolescent girls, almost tripling in 15 years.17
We recommend that ob-gyns screen all adolescent patients for depression and anxiety. Further care coordination may be required with the pediatric provider or specialists. Knowledge of the commonly comorbid conditions in depressed adolescents (Fig. 1) can guide further preventive measures. For example, assuring adequate family planning services for teens can prevent subsequent pregnancies, more common in adolescents with depression (49% of depressed adolescent mothers experienced a subsequent pregnancy within 2 years).18 Similarly, adolescents with depression should be screened for sexually transmitted infections, substance abuse, and eating disorders.
MOOD DISORDERS IN PREGNANT AND POSTPARTUM WOMEN HAVE A TREMENDOUS PUBLIC HEALTH EFFECT DUE TO CONSEQUENCES ON CHILDREN AND FAMILIES AND SHOULD BE TREATED EARLY
Reproductive-aged women who are at a high risk for depression constitute the most common age group cared for by ob-gyns. Reported rates of perinatal depression vary from 7% to 20%,19 and untreated perinatal depression is a major public health problem with implications not just for the mother, but for the child and the family as well.20 Screening for depression in this age group is especially important because only approximately 11% of those with clinically significant depression present with a chief complaint of depressive symptoms.21 Several depression screening tools have been validated for use in this population including the Edinburgh Postnatal Depression Scale and the nine-item Patient Health Questionnaire.22 Obstetricians should screen at least once during the perinatal period,1,2 perhaps arranging for closer monitoring or repeat screening in women with recognized risk factors for depression such as a past or family history of depression (Fig. 1).
Prevention of depression is best begun before pregnancy. At prenatal visits, attention should be paid not just to nutrition and traditional prenatal care, but also to the expectant mothers' emotional well-being, self-efficacy, and readiness to parent. There is preliminary evidence that parenting support and anticipatory parenting guidance can prevent postpartum depression.23 Obstetricians can play a key role in recognizing women with need for additional parenting support and refer to appropriate resources such as home visiting programs or maternity support services, available in most states.
PREMENSTRUAL DYSPHORIC DISORDER MAY BE A RISK FACTOR FOR A MAJOR DEPRESSIVE EPISODE AT OTHER VULNERABLE PERIODS
Premenstrual dysphoric disorder is a common mood disorder, observed in menstruating women, with prevalence rates of 3–8%.24 The diagnosis is made based on at least 4 of 11 physical (eg, bloating, weight gain, joint pain) and one of four behavioral (mood swings, irritability, depression, anxiety) symptoms during the luteal phase.25 Premenstrual dysphoric disorder onset is in the early 20s and many of these women may never see a psychiatrist. Evidence-based treatment for premenstrual dysphoric disorder includes luteal phase or symptom-onset treatment with selective serotonin reuptake inhibitors24 rather than the continuous selective serotonin reuptake inhibitor therapy recommended for depression. There is preliminary evidence that women with premenstrual dysphoric disorder may be at elevated risk for postpartum depression and depression in the menopause transition.26 Monitoring mood more frequently in vulnerable periods is recommended.
THE LATE MENOPAUSE TRANSITION IS A TIME OF INCREASED RISK FOR A MAJOR DEPRESSIVE EPISODE
Mood disorders are more common in the late menopausal transition as compared with premenopausal and late postmenopausal states.27 The late transition occurs on average 2 years before the final menstrual period and is defined by an episode of 60 or more days of amenorrhea. Not only are the rates of new-onset depressive symptoms higher in the late transition, but women with pre-existing major depressive disorder are at a higher risk of recurrence during this time.26 Risk factors and comorbidities for depression in the late transition are summarized in Figure 1. Perimenopausal women often present with atypical depressive symptoms such as increased sleep disturbances or increased weight gain and appetite28 and ob-gyns should account for this in their differential diagnosis.
Estrogen has been suggested as a treatment for major depressive disorder in perimenopausal women; however, the evidence for this is controversial.29 Estradiol (oral or transdermal) may have antidepressant efficacy for women in the late transition who are experiencing other menopausal symptoms, but is not effective in postmenopausal major depressive disorder treatment. There is insufficient evidence to inform the choice between estradiol monotherapy and estradiol plus an antidepressant. Similarly, the ideal duration of estradiol treatment is unclear.29 For women already on antidepressants, it is important to be aware that menopausal status, oral contraceptives, and postmenopausal hormone therapy can all have an effect on antidepressant response. Rather than targeted screening, we recommend universal screening of all women presenting at midlife requesting menopausal care.
OBSTETRICIAN–GYNECOLOGISTS CAN MAKE THE DIAGNOSIS OF DEPRESSION AND INITIATE TREATMENT
All patients who screen positive for depression do not have major depressive disorder (Box 1; Fig. 2). Although subsyndromal depression can cause considerable impairment, treatment approaches differ and hence it is important to make this distinction. In all cases, attention must be paid to the suicidal ideation item in the screening questionnaire with clinic-specific procedures in place to follow up if endorsed. Adopting an integrated care model into your clinic as described subsequently is evidence-based and can ensure high-quality depression treatment while reducing physician burden.
Box 1.Diagnosis of Depression
Diagnostic and Statistical Manual of Mental Disorders, 5th Edition Diagnostic Criteria for Major Depressive Disorder25 Cited Here...
- A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either 1) depressed mood or 2) loss of interest or pleasure.
- Note: Do not include symptoms that are clearly attributable to another medical condition.
- 1) Depressed mood most of the day, nearly every day, as indicated by either subjective report (eg, feels sad, empty, hopeless) or observation made by others (eg, appears tearful). (Note: In children and adolescents, can be irritable mood.)
- 2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
- 3) Significant weight loss when not dieting or weight gain (eg, a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
- 4) Insomnia or hypersomnia nearly every day.
- 5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
- 6) Fatigue or loss of energy nearly every day.
- 7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
- 8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
- 9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
- B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- C. The episode is not attributable to the physiological effects of a substance or to another medical condition.
- D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
- E. There has never been a manic episode or a hypomanic episode.
- Note: Criteria A–C represent a major depressive episode.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (Copyright © 2013). American Psychiatric Association. All rights reserved.
DEPRESSION TREATMENT PROGRAMS INTEGRATED INTO BUSY OBSTETRICS AND GYNECOLOGY PRACTICES ARE THE WAVE OF THE FUTURE—EASY TO IMPLEMENT, EXTREMELY EFFECTIVE, AND WELL ACCEPTED
We strongly recommend that obstetricians and gynecologists consider implementation of a depression care model and do not attempt to screen and treat in a vacuum. Commonly implemented programs are summarized in Table 1, but this is not an exhaustive list. Key features of the programs include: on-site screening, patient engagement, education, treatment, and tracking, having both behavioral and medical therapies available, and psychiatric consultation. As obstetrics and gynecology practices become more patient-centered and team-based, these models become increasingly relevant. Paying attention to women's mental health and emotional well-being has far reaching benefits, reducing both physical and social disabilities30 with the potential to improve outcomes for children31 and families.32 The extra few minutes spent on screening, counseling, and coordination of care have tremendous downstream effects. Thus, ob-gyns have a key role to play to positively influence women and their families and to make important public health contributions.
1. Siu AL; US Preventive Services Task Force (USPSTF), Bibbins-Domingo K, Grossman DC, Baumann LC, Davidson KW, et al.. Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA 2016;315:380–7.
2. Screening for perinatal depression. Committee Opinion No. 630. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:1268–71.
3. Melville JL, Reed SD, Russo J, Croicu CA, Ludman E, LaRocco-Cockburn A, et al.. Improving care for depression in obstetrics and gynecology: a randomized controlled trial. Obstet Gynecol 2014;123:1237–46.
4. Sepulcri Rde P, do Amaral VF. Depressive symptoms, anxiety, and quality of life in women with pelvic endometriosis. Eur J Obstet Gynecol Reprod Biol 2009;142:53–6.
5. Annagür BB, Kerimoglu ÖS, Tazegül A, Gündüz Ş, Gençoglu BB. Psychiatric comorbidity in women with polycystic ovary syndrome. J Obstet Gynaecol Res 2015;41:1229–33.
6. Bhat A, Byatt N. Infertility and perinatal loss: when the bough breaks. Curr Psychiatry Rep 2016;18:31.
7. Khastgir G, Studd J. Hysterectomy, ovarian failure, and depression. Menopause 1998;5:113–22.
8. National Prevention Council. National prevention strategy. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General; 2011.
9. Fine A, Kotelchuck M. Rethinking MCH: the life course model as an organizing framework. Washington, DC: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau; 2010.
10. Makuc DM, Freid VM, Kleinman JC. National trends in the use of preventive health care by women. Am J Public Health 1989;79:21–6.
11. Horton JA, Creuss DF, Pearse WH. Primary and preventive care services provided by obstetrician-gynecologists. Obstet Gynecol 1993;82:723–6.
12. Byatt N, Biebel K, Lundquist RS, Moore Simas TA, Debordes-Jackson G, Allison J, et al.. Patient, provider, and system-level barriers and facilitators to addressing perinatal depression. J Reprod Infant Psychol 2012;30:436–49.
13. Grote NK, Katon WJ, Russo JE, Lohr MJ, Curran M, Galvin E, et al.. Collaborative care for perinatal depression in socioeconomically disadvantaged women: a randomized controlled trial. Depress Anxiety 2015;32:821–34.
14. Byatt N, Biebel K, Moore Simas TA, Sarvet B, Ravech M, Allison J, et al.. Improving perinatal depression care: the Massachusetts Child Psychiatry Access Project for Moms. Gen Hosp Psychiatry 2016;40:12–7.
15. Avenevoli S, Swendsen J, He JP, Burstein M, Merikangas KR. Major depression in the national comorbidity survey—adolescent supplement: prevalence, correlates, and treatment. J Am Acad Child Adolesc Psychiatry 2015;54:37–44.e2.
16. Fergusson DM, Woodward LJ. Mental health, educational, and social role outcomes of adolescents with depression. Arch Gen Psychiatry 2002;59:225–31.
17. Curtin SC, Warner M, Hedegaard H. Increase in Suicide in the United States, 1999–2014. NCHS Data Brief 2016:1–8.
18. Barnet B, Liu J, Devoe M. Double jeopardy: depressive symptoms and rapid subsequent pregnancy in adolescent mothers. Arch Pediatr Adolesc Med 2008;162:246–52.
19. 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.
20. Goodman SH, Rouse MH, Connell AM, Broth MR, Hall CM, Heyward D. Maternal depression and child psychopathology: a meta-analytic review. Clin Child Fam Psychol Rev 2011;14:1–27.
21. Cerimele JM, Vanderlip ER, Croicu CA, Melville JL, Russo J, Reed SD, et al.. Presenting symptoms of women with depression in an obstetrics and gynecology setting. Obstet Gynecol 2013;122:313–8.
22. Zhong QY, Gelaye B, Rondon MB, Sánchez SE, Simon GE, Henderson DC, et al.. Using the Patient Health Questionnaire (PHQ-9) and the Edinburgh Postnatal Depression Scale (EPDS) to assess suicidal ideation among pregnant women in Lima, Peru. Arch Womens Ment Health 2015;18:783–92.
23. Werner EA, Gustafsson HC, Lee S, Feng T, Jiang N, Desai P, et al.. PREPP: postpartum depression prevention through the mother–infant dyad. Arch Womens Ment Health 2016;19:229–42.
24. Hantsoo L, Epperson CN. Premenstrual dysphoric disorder: epidemiology and treatment. Curr Psychiatry Rep 2015;17:87.
25. American Psychiatric Association. DSM 5. Arlington (VA): American Psychiatric Association; 2013.
26. Soares CN, Zitek B. Reproductive hormone sensitivity and risk for depression across the female life cycle: a continuum of vulnerability? J Psychiatry Neurosci 2008;33:331–43.
27. Freeman EW. Associations of depression with the transition to menopause. Menopause 2010;17:823–7.
28. Burt VK, Stein K. Epidemiology of depression throughout the female life cycle. J Clin Psychiatry 2001;63(suppl):9–15.
29. Rubinow DR, Johnson SL, Schmidt PJ, Girdler S, Gaynes B. Efficacy of estradiol in perimenopausal depression: so much promise and so few answers. Depress Anxiety 2015;32:539–49.
30. Bruce ML, Seeman TE, Merrill SS, Blazer DG. The impact of depressive symptomatology on physical disability: MacArthur Studies of Successful Aging. Am J Public Health 1994;84:1796–9.
31. Gunlicks ML, Weissman MM. Change in child psychopathology with improvement in parental depression: a systematic review. J Am Acad Child Adolesc Psychiatry 2008;47:379–89.
32. Burke L. The impact of maternal depression on familial relationships. Int Rev Psychiatry 2003;15:243–55.
33. Huang H, Chan YF, Katon W, Tabb K, Sieu N, Bauer AM, et al.. Variations in depression care and outcomes among high-risk mothers from different racial/ethnic groups. Fam Pract 2012;29:394–400.
34. Scholle SH, Haskett RF, Hanusa BH, Pincus HA, Kupfer DJ. Addressing depression in obstetrics/gynecology practice. Gen Hosp Psychiatry 2003;25:83–90.
35. Flynn HA, O'Mahen HA, Massey L, Marcus S. The impact of a brief obstetrics clinic-based intervention on treatment use for perinatal depression. J Womens Health 2006;15:1195–204.