Preventing Perinatal Depression
Counseling at-risk women can prevent pregnancy-related depression. Rebecca Starck, MD, explains the new recommendation from the US Preventive Task Force.
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Last week, the US Preventive Services Task Force (USPSTF) published new recommendations based on its evaluation of interventions to prevent perinatal depression. Defined as a depressive episode that occurs during pregnancy or in the 12 months following delivery, perinatal depression is a pervasive disorder that can have long-lasting effects on the health and well-being of mothers and infants.
After evaluating a variety of interventions, including cognitive behavioral therapy, exercise, education and pharmacological approaches, the USPSTF found adequate evidence to support only counseling as a preventive measure that provides moderate benefit and little harm for women at increased risk.
One of the things I like about the USPSTF recommendation is that it is unrelated to presenting symptoms. If your patient has one or more of the risk factors, she gets referred. Clinical risk factors, according to the USPSTF report, include a personal or family history of depression, history of physical or sexual abuse, having an unplanned pregnancy, current stressful life events, diabetes or complications with the pregnancy. Other, more social factors include low income, partner violence, a lack of social support or being young or a single parent.
We know that 10-15% of women will experience significant post-partum depression, which can have adverse effects on the mother and infant. Symptoms can include lethargy, hopelessness, feeling disconnected from infant and social supports, fluctuations in weight, difficulty sleeping and suicidal ideation. Evidence suggests women with perinatal depression have higher levels of negative maternal behaviors and significantly lower levels of positive maternal behaviors, which can impact bonding. Women with perinatal depression may interact less positively with their infants; they may praise or play less frequently. Perinatal depression is also associated with breastfeeding difficulties, headaches and other health stressors, as well as an inability to focus or pay attention upon return to work.
As providers, we are constantly seeking ways to reduce the burden of disease – to improve quality of life for our patients and their families. While other mental health interventions may complement counseling, the USPSTF did not find enough evidence of their efficacy to recommend them as effective preventive measures. Only counseling interventions, such as cognitive behavioral therapy and interpersonal therapy, met the organization’s evidence threshold.
Recommendations at this level from the USPSTF have significant societal impact. Insurers must cover such evidence-based services, with no cost-sharing. This is great news for women and their children, and really, our society as a whole.
The challenge, however, is that we will still see barriers to patients’ ability to effectively seek mental health services in a timely manner. Caregiving demands may make it difficult to keep an appointment. It might take a while to establish rapport with a counselor. Some people will seek help from several counselors before they find the right one. Finally, we may not have enough mental health providers to keep up with a surge in demand.
There is stigma associated with depression and counseling. Whether the stigma is a result of societal pressures or self-perceived failure, it can feel embarrassing to seek help. Hopefully this new practice will go a long way toward destigmatizing perinatal depression, but change at this level will not happen overnight.
As healthcare providers, we must counsel and educate our patients (and their family members) about perinatal depression and its associated risk factors. Overall, the important thing for me is that, as a society, we recognize the stressors that can impact mood disorders, and that we work toward changing what we can change in those environments.
It seems that mental health has become more recognized as an overall health and wellness priority. I encourage all patients to address any mental health and psychosocial stressors that they may experience at any stage of their lives. Whether they are adolescents, prenatal, post-partum or menopausal, counseling can help.
Dr. Starck is President of Cleveland Clinic Avon Hospital and practices obstetrics and gynecology at Avon Pointe Family Health Center.