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Sunday, March 28, 2010

Screening for depression before, during, after pregnancy can help

Amber cried a lot after the birth of her first child, a son.

“Small things upset me – not to the angry point, but to the confused point,” said the 26-year-old part-time preschool teacher from northern Ohio.

This is just how confused: She showed up at her obstetrician’s office for her eight-week post-delivery checkup at the wrong time on the wrong day.

“That was very odd for me,” Amber said.

“The final straw that told me I needed help was when I was driving home from that and thought what would happen if I put my car into a tree,” she added. “When I went back the next day” for the real appointment, “I told him, ‘There’s something wrong.’ ”

She voiced her concerns and filled out a form, and the doctor told her she needed more help than he could provide. He suggested she contact Dr. Katherine Wisner at the University of Pittsburgh about getting into one of the studies of postpartum depression at Magee-Womens’ Hospital.

She qualified for a National Institute of Mental Health-funded study of a form of the hormone estrogen called estradiol to treat postpartum depression through skin patches.

Postpartum depression, which the American College of Obstetricians and Gynecologists says affects an estimated 5 percent to 25 percent of women, is half of the so-called “hot-button issue” for that group right now. Gerald Joseph, president of the physicians group, made screening women for depression both during and after pregnancy the theme of his 2009-10 initiative.

Screening for both also was the topic of an opinion piece in the February issue of the group’s journal, Obstetrics & Gynecology.

In a statement about its editorial, the OB/GYN group said depression can lead to pre-eclampsia, preterm delivery and low birth weight. It also can affect an infant’s cognitive, neurologic and motor-skill development and the mental health and behavior of older children, the statement said.

There are signs for doctors to look for before an infant is born. According to the U.S. Department of Health and Human Services, pregnant women with depression tend to eat poorly, not gain enough weight, have trouble sleeping, miss prenatal visits, have difficulty following medical instructions and use harmful substances such as tobacco, alcohol or illegal drugs.

Although it did acknowledge there is insufficient evidence to support a “firm recommendation” for screening in pregnant and postpartum women, the physicians’ group said it “should be strongly considered.”

And so it has been for quite a while at Magee.

“A federal grant allows me to offer screening (for depression) to every woman who delivers at Magee,” Wisner said.

There also is a treatment study for patients who, like Amber, didn’t give birth at Magee.

“We have been screening at Magee almost four years now,” said Wisner, an investigator at Magee Womens Research Institute and a multidisciplinary professor at the University of Pittsburgh. “What we found is roughly 14 percent are positive for (postpartum) depression, so that’s our rate in Pittsburgh – actually, 14.1 percent.

“Of women that were in that 14.1 percent, when we talked to them and asked when did (the depression) begin, it began post-birth in a third of them, during pregnancy in a third and before pregnancy in the other third.”

The results were even more startling in a collaborative screening program Magee has with DuBois Regional Medical Center, about 100 miles northeast of Pittsburgh.

“Their postpartum depression rate is 20 percent now,” she said.

The DuBois center screens for depression during pregnancy, as well, and those numbers are even more troublesome than those of depressed women postpartum: 29 percent during the first prenatal visit.

“Again, the rural area has a higher rate of positive screens,” Wisner said. “Some population groups are going to have a higher rate, so it’s a big problem.”

For example, according to the University of Pittsburgh Office of Child Development, the rate of depression is higher among low-income families and more prevalent among parents who didn’t earn a high school diploma.

Depression can interfere with a woman’s ability to care for her child. Interaction between mother and child can enhance a child’s development if it’s stimulating, responsive and nurturing.

“There is no question that if the mother is dealing with depression that you are going to have greater neonatal adaptation for the baby,” said Dr. Ronald Thomas, director of the Division of Maternal-Fetal Medicine for the West Penn Allegheny Health System. “There, we’re talking about what people typically refer to as bonding.”

A doctor’s ability to detect depression has limitations, according to neonatologist Nilima T. Karamchandani, chief of the Division of Neonatology and medical director of the Infant Apnea Center, both at the Western Pennsylvania Hospital.

Mother-infant bonding can be hard to measure, she said: “It is subjective, to a certain point.”

What causes it? Hormonal changes can be a culprit, but other factors also can be to blame: family pressures, the stresses of trying to be the perfect mother, genetics and history of depression.

“It’s never quite that simple in that it may not simply be a change in hormones,” Thomas said. “It may be a change in her relationship with her husband, the stress of having a preterm baby or simply how having a baby changes your life.”

And, like mothers who are candidates for gestational hypertension or diabetes, he added, “Pregnancy may bring out a diagnosis of depression in a patient who has that baseline risk anyway.”

That doesn’t seem to be the case for Amber, who was feeling fine a couple months after her participation in the Magee study.

“The treatment was taking one pill a day and wearing four small patches,” she said. “I didn’t know which it was – patches of estradiol or the pill – “or if either one was active; both could have been placebos. But I knew it would not harm the baby.”

Her course of participation ended after about 15 weeks, when the researchers told her what was in her patches and pills.

“Within the first week or two of taking the medications, I did start feeling better,” she said.

But because the study will be enrolling for three more years, Amber isn’t allowed to tell anyone what her study drug was.

Pohla Smith can be reached at psmith@post-gazette.com. Distributed by Scripps Howard News Service.