Data BriefMaternal and Child Health

PREGNANCY-RELATED DEPRESSION AND ANXIETY IN COLORADO

AUGUST 2017

Why pregnancy-related depression and anxiety are problemsPregnancy-related depression and anxiety are mood disorders that occur during pregnancy or up to one year after giving birth or experiencing pregnancy loss. Postpartum depressive symptoms appear similar but are distinct from the “baby blues” which is more common, milder, and lasts only a few weeks.1,2 Pregnancy-related depression and anxiety are the most common complications of pregnancy. However, they are the most underdiagnosed obstetric complications in America with more than 75 percent of new mothers remaining untreated.3,4,5,6

If untreated, depression and anxiety can have long-lasting impacts on the health and well-being of mothers and children. Depression and anxiety are associated with problematic safety practices in mothers and negative mother-child interactions.7 Children born to mothers with pregnancy-related depression and anxiety have an increased risk of health concerns and long-term emotional, behavioral, and cognitive problems.1,7 Untreated depression and anxiety can have lasting impacts. However, with the help of supportive environments, the effects of pregnancy-related depression and anxiety can be reduced.

Nearly 1 in 10 (9.6 percent) women who had a recent live birth between 2012 and 2014 in Colorado reported experience of postpartum depressive symptoms since their new baby was born (Figure 1).8 This estimate likely underreports the number of women suffering from postpartum depression in Colorado, falling short of national estimates of roughly 1 in 7.9

Figure 1. Percent of Colorado women who self-reported experience of postpartum depressive symptoms, 2004-2008 and 2012-2014.8

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2004 2005 2006 2007 2008 2012 2013 2014

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Survey methodologychange 2009-2011

Pregnancy-related depression and anxiety are the most common complications of pregnancy, but not all women are getting the help they need.

Life stress that can increase a woman’s risk for experiencing pregnancy-related depression and anxiety is not always obvious. Although any woman can experience postpartum depressive symptoms, they are more prevalent among women who experience interpersonal violence and those who experience food insecurity.

Social and economic health disparities Figure 2. Percent of Colorado women who self-reported experience of postpartum depressive symptoms, by maternal age, 2012-2014.8

Among women giving birth between 2012 and 2014, 19.2 percent (95% CI: 11.3-27.1) of those ages 15-19 reported experience of postpartum depressive symptoms, significantly higher than the 7.7 percent (95% CI: 6.3-9.2) of women ages 25-34 (Figure 2).8

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Figure 3. Percent of Colorado women who self-reported experience of postpartum depressive symptoms, by race/ethnicity, 2012-2014.8

In 2012-2014, report of postpartum depressive symptoms was highest among Black, non-Hispanic women; however, no statistically significant differences were found by race/ethnicity (Figure 3).8

Figure 4. Percent of Colorado women who self-reported experience of postpartum depressive symptoms, by prenatal care insurance type, 2012-2014.8

In 2012-2014, 14.0 percent (95% CI: 11.6-16.3) of women enrolled in Medicaid, Child Health Plan Plus (CHP+), or Colorado Indigent Care Program (CICP) during prenatal care reported experiencing postpartum depressive symptoms, significantly higher than the 6.6 percent (95% CI: 5.2-8.0) of privately insured women (Figure 4).8

All women, irrespective of age, race, and income, are at risk of pregnancy-related depression and anxiety; however, younger and low-income Colorado women report even higher rates of postpartum depressive symptoms than their older, higher-income counterparts.

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Among Colorado women in 2012-2014...

...also experienced postpartum depressive symptoms.8

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Risk factors for pregnancy-related depression and its impact on womenSimilar to general depression, pregnancy-related depression and anxiety are caused by a combination of biological, psychosocial, and environmental factors. Strong predictors of postpartum depressive symptoms include a personal or family history of mood or anxiety disorders, sensitivity to hormonal changes, life stress, and poor social support.2 Pregnancy and birth complications and infant health issues are also associated with depression and anxiety.1

Life stress before and during pregnancy, such as losing a job, arguing with a husband or partner more than usual, homelessness, or having a close family member hospitalized, appears to have a cumulative effect on a woman’s increased risk for pregnancy-related depression and anxiety. In 2012-2014, the prevalence of postpartum depressive symptoms was significantly higher among women who experienced six or more stressors* in the year before birth (23.7 percent, 95% CI: 16.6-30.9) compared to those who experienced no stressors (5.0 percent, 95% CI: 3.2-6.7) and 1-2 stressors (7.5 percent, 95% CI: 5.9-9.1) (Figure 5).8

Stressors that can increase a woman’s risk for developing depression and anxiety are not always visible or obvious. Among women who experienced intimate partner violence during the 12 months before delivery and among those who experienced food insecurity during the 12 months before delivery, 34.3 percent and 28.8 percent also experienced postpartum depressive symptoms, respectively.8

Women with untreated depression and anxiety during pregnancy not only have an increased risk for social isolation and future mood disorders, but are also more likely to retain excess gestational weight than women without untreated pregnancy-related depression and anxiety.10,11 Women with postpartum depressive symptoms are also less likely to attend well-child visits, complete immunizations, and place children in recommended sleeping positions.1

Figure 5. Percent of Colorado women who self-reported experience of postpartum depressive symptoms, by number of stressors* experienced during the 12 months before birth, 2012-2014.8

*Stressors include homelessness; problems paying rent, mortgage, or other bills; moving to a new address; loss of job; loss of job by husband or partner; cut in work hours or pay for self, husband, or partner; self, husband, or partner went to jail; extended time apart from husband or partner due to military deployment or work-related travel; arguing with husband or partner more than usual; husband or partner said pregnancy was unwanted; separation or divorce; someone close had problem with drinking or drugs; sickness and hospitalization of close family member; and death of someone close.

You can’t tell by looking. Life stressors, important risk factors of pregnancy-related depression and anxiety, are oftentimes not apparent. Healthcare providers are often unaware of life stressors women may be experiencing, underscoring the need to screen all women for pregnancy-related depression and anxiety.

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34.3% 28.8% 18.5% 15.6%

of women who experienced interpersonal violence during the 12 months

before delivery

of women who experienced food insecurity during the 12

months before delivery

of women who had trouble paying rent, mortgage, or bills during the 12 months

before delivery

of women who were very close to someone who had problems with drinking or drugs during the 12 months before delivery

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Getting women the help they needAdditionally, untreated depression and anxiety are major contributors to maternal mortality. Approximately one-third (30 percent; n=63) of pregnancy-associated deaths occurring in Colorado between 2004 and 2013 were attributed to self-harm through accidental overdose or suicide, reiterating the need to address a woman’s mental health during the pregnancy and postpartum time periods.12,13 Regular screening and education can increase awareness and identification of pregnancy-related depression and anxiety and increase the number of women receiving treatment. However, not all women are screened or know what to do if they experience symptoms of depression or anxiety. Likewise, their family members and/or friends may not recognize symptoms or know how to help connect them with available resources to address their depression or anxiety.

Many women do not seek care or report their symptoms of depression and anxiety. In one study fewer than 20 percent of women diagnosed with postpartum depression reported their symptoms to a health care provider.9 Stigma surrounding mental health as well as financial and logistical challenges create barriers to women seeking and receiving treatment.14 In 2015, 13.3 percent of Colorado women of reproductive age reported that during the past 12 months they did not get needed counseling health services, with 60.2 percent of these women reporting they were concerned about the cost of treatment and 35.4 percent concerned about what would happen if someone found out they had a problem.15

The American Congress of Obstetricians and Gynecologists recommends that all women receive at least one screening for depression and anxiety symptoms during the perinatal period, and the American Academy of Pediatrics also recommends additional screening during the 1-, 2-, 4-, and 6-month well-child visits.9,3 In 2016, healthcare providers submitted claims for Medicaid reimbursement for a depression screen for 21.6 percent of all pregnant beneficiaries, up from 16.1 percent in 2015.16 Though screening is not yet universal in Colorado, 77.6 percent (95% CI: 74.8-80.4) of women reported that a health care provider talked to them about what to do if they felt depressed during pregnancy or after delivery in 2014, up from 72.6 percent (95% CI: 69.8-75.4) in 2009 (Figure 6).8 By 2020, Colorado aims to increase to 85.8 percent the number of women who report a health care provider discussed depression during prenatal care. Preventing and treating pregnancy-related depression and anxiety can help Colorado women and families lead happier, healthier lives.

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2009 2010 2011 2012 2013 2014

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Figure 6. Percent of Colorado women who reported a health care provider talked with them about what to do if they felt depressed during pregnancy or after delivery, 2009-2014.8

The Colorado Department of Public Health and Environment acknowledges that social, economic and environmental inequities result in adverse health outcomes and have a greater impact than individual choices. Reducing health disparities through systems change can help improve opportunities for all Coloradans and have an important impact on population health measures.

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Maternal and Child Health Program, Prevention Services DivisionTelephone: 303-692-2503

www.mchcolorado.org

This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number H18MC00006, State Systems Development Iniative (SSDI) for $95,374. This information or content and conclusions are those of the author and

should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

References

1. O’Hara, M. W., & McCabe, J. E. (2013). Postpartum depression: current status and future directions. Annual Review of Clinical Psychology, 9, 379-407.

2. O’Hara, M. W., & Wisner, K. L. (2014). Perinatal mental illness: definition, description and aetiology. Best Practices & Research Clinical Obstetrics and Gynaecology, 28, 3-12.

3. Earls, M.F. (2010). Clinical Report- Incorporating recognition and Management of Perinatal and Postpartum Depression into Pediatric Practice. Pediatrics, 126(4), 1032-1039.

4. Carter, F.A., Carter, J.D., Luty, S.E., Wilson, D.A., Frampton, C.M.A., & Joyce, P.R. (2005). Screening and treatment for depression during pregnancy: a cautionary note. Australian and New Zealand Journal of Psychiatry, 39(4), 255-261.

5. Marcus, S.M., Flynn, H.A., Blow, F.C., & Barry, K.L. (2003). Depressive Symptoms among Pregnant Women Screened in Obstetrics Settings. Journal of Women’s Health. 12(4), 373-380.

6. Smith, M.V., Shao, L., Howell, H., Wang, H., Poschman, K., & Yonkers, K.A. (2009). Success of mental health referral among pregnant and postpartum women with psychiatric distress. General Hospital Psychiatry, 31(2), 155-162.

7. Glover, V. (2014). Maternal depression, anxiety and stress during pregnancy and child outcome; what needs to be done. Best Practices & Research Clinical Obstetrics and Gynaecology, 28, 25-35.

8. Colorado Pregnancy Risk Assessment Monitoring System (PRAMS), Colorado Department of Public Health and Environment, 2004-2014.

9. American College of Obstetricians and Gynecologists (2015). Screening for perinatal depression. Committee Opinion No. 630. Obstetrics & Gynecology, 125, 1268-1271.

10. Letourneau, N. L., Dennis, C., Benzies, K., Duffett-Leger, L., Stewart, M., Tryphonopoulos, P. D., Este, D., & Watson, W. (2012). Postpartum depression is a family affair: addressing the impact on mothers, fathers, and children. Issues in Mental Health Nursing, 33(7), 445-457.

11. Meltzer-Brody, S., & Stuebe, A. (2015). The long-term psychiatric and medical prognosis of perinatal mental illness. Best Practices & Research Clinical Obstetrics and Gynaecology, 28, 49-60.

12. Maternal Mortality Prevention Program, Colorado Department of Public Health and Environment, 2004-2013.

13. Metz, T.D., Rovner, P., Hoffman, M.C., Allshouse, A.A., Beckwith, K.M., & Binswanger, I.A. (2016). Maternal Deaths from Suicide and Overdose in Colorado, 2004-2012. Obstetrics & Gynecology, 128(6), 1233-1240.

14. Byatt, N., Moore Simas, T. A., Lundquist, R. S., Johnson, J. V., & Ziedonis, D. M. (2012). Strategies for improving perinatal depression treatment in North American outpatient obstetric settings. Journal of Psychosomatic Obstetrics & Gynecology, 33(4), 143-161.

15. Colorado Health Access Survey, Colorado Health Institute, 2015.

16. Health First Colorado, Colorado Department of Health Care Policy and Financing, 2010-2016.