Detection, prevention and treatment of depression.
Depression in women is more prevalent than in men, and there are specific times in a patient’s life that make them more vulnerable: during adolescence, pregnancy, postpartum and menopausal transition. Screening for depression during these sensitive times in our patients’ lives is the key to the prevention of morbidity and mortality associated with depression. OB/GYNs as well as other primary care providers are well placed to screen and monitor patients for depression and initiate treatment for mild depression.
Adolescence is a transitional period with a high risk for behavioral and emotional disorders, and we as healthcare providers need to be aware of the risks to this group. Females are at a two to threefold higher risk for depression than males in the adolescent period and are at a fourfold higher risk of severe major depressive disorders. Thirty percent of adolescents with major depressive disorders report suicidal thoughts, and up to 10.8% report a suicide attempt. It is recommended that if you see adolescent girls, they be screened for depression during this transition. It is also recommended, for those with depression, that they also be screened for sexually transmitted diseases, substance abuse and eating disorders.
The reproductive-age patient is the most common age group cared for by OB/GYN, but other primary care providers also care for this population as well. Perinatal depression rates vary from 7% to 20% and, if untreated, leads to health implications for the patient, child and the entire family. This is a period of time when major and minor depressive episodes can occur during pregnancy and for the 12 months after delivery.
Screening is recommended in this population, especially during pregnancy and the postpartum period, as 11% with depression will present without symptoms. The Edinburgh Postnatal Depression Scale (EPDS) and the nine-item Patient Health Questionnaire are recommended. It would be optimal to identify and prevent/treat depression prior to pregnancy in this patient population for optimal outcomes, which makes screening crucial in the reproductive age group.
Patients with premenstrual dysphoric disorder (PMDD) are at higher risk for postpartum depression and for depression during the menopausal transition. PMDD occurs in 3-8% of all women. There is evidence-based recommendations that use of a serotonin reuptake inhibitor (SSRI) is helpful when used at the luteal phase or symptom-onset instead of continuous therapy. Usually used at lower doses than therapeutic levels, it will alleviate the symptoms of PMDD, thus not sustaining them on continuous SSRI therapy.
The transition years of menopause is another high-risk time for depression in women. Mood disorders are very common in the pre-menopausal period but are actually higher in the late menopausal transition, which is 2 years prior to the final menstrual period. Women with a history of depression are more likely to have recurrent depression during this time.
Atypical symptoms are often confused with the transition symptoms such as sleep disturbance, changes in appetit, and weight gain. We as providers should not automatically assume these changes are related to the transition and should be screening this population for depression as well.
Estrogen therapy may help with other transitional symptoms but is not a treatment for postmenopausal major depressive disorders. It is recommended that all women presenting for menopausal care be universally screened.
It is important to note that all patients who screen positive for depression do not have major depressive disorder. Mild depression can lead to impairment, but the treatment options differ. In all cases, it is appropriate to establish suicidal ideation and establish a treatment plan for these patients. It is strongly recommended that a screening program for depression is established in each practice, but that it not be without an appropriate team-based plan for those who have severe depressive disorder and need to be escalated to mental health for management.
There are several care models available that can assist in setting up this type of collaborative practice. These can be found in reference # 2, Table 1. Most programs include: on-site screening, patient engagement, education, treatment and tracking, having behavioral and medical therapies available and psychiatric consultation. Regardless, systems should be in place to ensure follow-up for diagnosis and treatment, including a referral plan for those with severe symptoms.
With the shortages in mental health services available to our patients, it becomes even more important for OB/GYN as well as other primary care specialties to address the issues of depression, anxiety and mood disorders in our patients. There are resources available at www.acog.org/More-Info/PerinatalDepression. This is not a comprehensive list and is meant for reference to more information.
1.ACOG Committee Opinion: Number 757 Screening for Perinatal Depression
2.The Obstetrician-Gynecologist’s role in Detecting, Preventing, and treating Depression: Amritha Bhat, MD Susan D. Reed, MD, MPH, and Jurgen Unutzer, MD, MPH; Obstetrics and Gynecology, Vol. 129, No. 1, January 2017 157-163
3.Can we identify mothers at risk for postpartum depression in the immediate postpartum period using the Edinburgh Postnatal Depression Scale? Journal of Affective Disorders: Vol. 78, Issue 2 February 2004, Pages 163-169
4.Optimizing Postpartum Care: ACOG Committee Opinion Number 736, May 2018
Dr. Sandra Reed is chair of The American College of Obstetricians and Gynecologists District IV. A Fellow of the College and a faculty member in Emory University’s Department of Gynecology and Obstetrics, Dr. Reed has devoted her professional career to women’s health. She graduated from the Medical College of Georgia and conducted her residency at the Medical College in Augusta. She is currently a Georgia delegate to the American Medical Association House of Delegates. She has also served multiple terms on the Technical College System of Georgia Board and the state’s Board of Education.