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. Author manuscript; available in PMC: 2017 Jan 1.
Published in final edited form as: Behav Modif. 2015 Dec 7;40(1-2):325–340. doi: 10.1177/0145445515615353

Depression and a Rural Environment are Associated with Poor Oral Health among Pregnant Women in Northern Appalachia

Daniel W McNeil, Sarah E Hayes, Cameron L Randall, Deborah E Polk, Kathy Neiswanger, John R Shaffer, Robert J Weyant, Betsy Foxman, Elizabeth Kao, Richard J Crout, Stella Chapman, Linda J Brown, Jennifer L Maurer, Mary L Marazita
PMCID: PMC4893820  NIHMSID: NIHMS758511  PMID: 26643277

Abstract

Objectives

Both oral health problems and depression among pregnant women contribute to maternal-infant health outcomes. Little is known, however, about the potential effects of clinically-significant depression on the oral health status of pregnant women. The purpose of the present study was to determine the influence of clinically-significant depression and rural- or urban-dwelling status on oral health outcomes among pregnant women.

Materials and Methods

Pregnant women (N=685) in rural (i.e., West Virginia) and urban (i.e., Pittsburgh, Pennsylvania) areas of northern Appalachia were assessed by calibrated examiners regarding gingivitis, oral hygiene, and DMFT, completed the Center for Epidemiological Studies–Depression scale (CESD), and provided demographics. Participants were categorized based on clinically significant depressive symptoms (CESD>=16) and rural/urban domicile.

Results

Women with depression and those living in rural areas had worse oral health on all three indices than their non-depressed and urban counterparts.

Conclusions

Depression, particularly among women in rural areas, impacts certain oral health indices, and represents a modifiable target for intervention. Moreover, treatments designed specifically for rural populations may be of particular utility. Women who are pregnant or planning to become pregnant may benefit from regular depression screenings from their dental and medical healthcare providers.

Keywords: Oral health, pregnancy, depression, Appalachia, rural, health disparities

Oral health among pregnant women is a crucial issue in terms of its impact on both maternal and fetal overall health, and its specific implications for gestation (Silk, Douglass, Douglass, & Silk, 2008; Xiong, Buekens, Fraser, Beck, & Offenbacher, 2006). Described as a “mirror of overall health” (McNeil, Crout, & Marazita, 2012), oral health status often reflects systemic health problems, such as cardiovascular and respiratory diseases (Needleman & Hirsch, 2007; Seymour, Preshaw, & Steele, 2002).

During pregnancy, oral health reflects not only the mother’s overall and gestational health, but also the future health of the child. Women experience a variety of physiological and behavioral changes during pregnancy that impact oral health, such as higher oral cavity acidity due to increased vomiting and acid reflux, decreased attention to oral hygiene, hormonal changes, and cravings for foods with high sugar content (Scheutz, Baelum, Matee, & Mwangosi, 2002; Silk et al., 2008). Combined, these factors increase pregnant women’s experience of problems such as periodontitis, gingivitis, caries, oral lesions, and teeth movement (Silk et al., 2008). In the long-term, children of women with tooth decay during pregnancy experience increased rates of caries (Boggess & Edelstein, 2006). Children of women with caries during pregnancy also are susceptible to other poor health outcomes, such as respiratory infection (Boggess, Society for Maternal-Fetal Publications Committee, 2008).

Pregnant women with periodontitis at the time of delivery are more likely to experience preeclampsia (Boggess et al., 2003). Additionally, there is evidence to suggest an association between maternal periodontitis and poor infant outcomes, such as preterm labor and low-birth weight infants (Lopez, Smith, & Gutierrez, 2002; Moliterno, Monteiro, Da Silva Figueredo, & Fischer, 2005). It should be noted, however, that the mechanism by which this association occurs is controversial in the literature (Clothier, Stringer, & Jeffcoat, 2007; Silk et al., 2008), and it is possible that periodontitis represents a “surrogate” for another maternal variable (Boggess & Edelstein, 2006). Regardless, maternal oral health during pregnancy appears to predict a range of child health outcomes, and so the oral health of pregnant women – and those factors that affect their oral health – warrants study.

Both pre- and post-natal depression is associated with negative maternal and fetal outcomes (Dayan et al., 2006). West Virginia has one of the highest rates of depression of any state in the USA (Centers for Disease Control and Prevention, 2010), and depression is prevalent elsewhere in Appalachia, including Appalachian counties of Pennsylvania (Davis, Bangs, Wallace, & Crawley, 2007). It is estimated that 20% of women experience significant depression during pregnancy, but that the majority of these cases are left untreated (Marcus, Flynn, Blow, & Barry, 2003).

Clinically significant depression during pregnancy has been associated with obstetrical complications (e.g., spontaneous abortion, early labor, increased bleeding; Bonari et al., 2004) both nationwide and in Appalachia specifically (Jesse, Seaver, & Wallace, 2003). Depression during pregnancy also is related to negative infant outcomes such as increased likelihood of lower Apgar scores, admission to neonatal intensive care units, and elevated cortisol levels at birth (Bonari et al., 2004; Zax, Sameroff, & Babigian, 1977).

In the general adult population in the USA, the prevalence rate of depression is significantly higher among rural-dwelling adults as compared to those living in urban settings (Probst et al., 2006). More specific to the present study is that in both Canada and Australia, women living in rural areas are more likely to experience postpartum depression in comparison to their urban-dwelling peers (Griepsma et al., 1993; Vigod et al., 2013). It is unknown, however, how rural-urban status may differentially affect depression during pregnancy, or how dwelling status may interact with depression to affect oral health outcomes.

Rural-urban differences in oral health

Greater prevalence of oral disease and edentulism (i.e., toothlessness) has been documented in rural populations relative to urban ones (Eberhardt et al., 2001; Meit et al., 2014). Differences in oral health status between rural and urban populations have been observed across the lifespan. Though rural and urban children/adolescents do not have significantly different caries experience, rural children/adolescents, compared to their urban counterparts, report more unmet dental need (Vargas, Ronzio, & Hayes, 2003). For adults, prevalence of unmet dental need, caries experience, and edentulism is significantly greater for those living in rural versus urban areas (Vargas, Dye, & Hayes, 2002). Likewise, rural older adults are more likely than their urban counterparts to be edentulous and to report poor oral health status (Vargas, Yellowitz, & Hayes, 2003). Indeed, similar trends are observed internationally (e.g., rural Australians have poorer oral health than those living in major cities, antenatal women living in rural Sri Lanka have greater prevalence of decayed and filled teeth than their urban counterparts; Crocombe, Stewart, Brennan, Slade, & Spencer, 2013; Karunachandra, Perera, & Fernando, 2012). Rural-urban differences in oral health status likely are the product, in part, of differences in dental treatment utilization patterns (e.g., frequency, symptomatic versus preventive; Vargas, Dye, & Hayes, 2003) and other oral health behaviors. Additionally, differences in socioeconomic status, culturally-based oral health values, dental insurance coverage, and availability of dental services likely also play important roles (Skillman, Doescher, Mouradian, & Brunson, 2010).

Oral health in Appalachia

There is an array of health issues, including oral health concerns, in Appalachia (Ludke & Obermiller, 2012). Many parts of Appalachia are rural, so a substantial proportion of residents of the region are affected by factors that contribute to poor oral health in rural areas (McNeil et al., 2012). Specifically, caries experience and prevalence of decayed, missing, and filled teeth is higher in Appalachia relative to other regions of the USA (Krause, May, Lane, Cossman, & Konrad, 2012; McNeil et al., 2012; Polk et al., 2008). Additionally, utilization of dental treatment, including preventive and restorative care, and the desire for orthodontic care, is poor in Appalachia (Martin et al., 2008). Rates of tooth loss are higher in Appalachia than in the USA as a whole, and are persistent across time (Gorusch, Sanders, & Wu, 2014; Hendryx, Ducatman, Zullig, Ahern, & Crout, 2012). Prevalence of edentulism in Appalachia is disproportionate when compared to other regions of the United States of America (Slade, Akinkugbe, & Sanders, 2014), and rates of edentualism are particularly high in West Virginia (National Oral Health Surveillance System, 2010), the only state in the USA entirely encompassed within Appalachia.

Objectives and hypotheses

This study was designed to assess the impact of clinically-significant levels of depression on oral health in pregnant women in Appalachia, exploring the influence of rural-urban status and other psychosocial factors. It was predicted that high levels of depression, and having a rural domicile, would be associated with poorer oral health status. Additionally, rural-dwelling women were expected to have higher levels of depression than their urban counterparts, and to be more likely to meet a cut-off for a clinically-significant level of depression. Differences in education and income were expected across rural-urban and depression status factors. Rural-urban and depression status were expected to interact, with depressed rural women being most at risk for poor oral health and negative demographic indices.

Methods

Design

The women in this study were participants in the Center for Oral Health Research in Appalachia (COHRA) study of pregnant women recruited in northern Appalachia (COHRA2 cohort), specifically from across the state of West Virginia and from the urban Pittsburgh, Pennsylvania area. Pregnant women were recruited and initially assessed during their second trimester. This study is part of a larger, longitudinal project on pregnant women and their offspring, including genetic, microbiological, community-level, environmental, and psychosocial variables; additional details about the protocol are available from Neiswanger et al. [submitted]. This research was approved by the Institutional Review Boards of West Virginia University and the University of Pittsburgh.

Participants

The total sample consisted of 685 women, ranging in age from 18 through 42 (M age = 28.4, SD = 5.4), who were recruited from November 2011 through February of 2015. Given the design requirements of the study related to genetic factors, all women were Caucasian, and not of Hispanic descent. Eligibility criteria included being at least 18 years old, being fluent in English, having a singleton pregnancy, and not having a serious medical condition (e.g., tuberculosis, being immunocompromised).

Instruments

Oral health indices

The presence or absence of generalized gingivitis was assessed by the oral examiner. Additionally, an Oral Rating Index (ORI) was assigned by the oral examiner as a visual measure of oral hygiene and overall gingival health (ORI; Camgoz, Gurgan, Kajiwara, & Kawamura, 2008; Kawamura, Fukuda, Inoue, Sasahara, & Iwamoto, 2000). For ease of exposition, ORI scores, originally ranging from −2 to +2, were converted to a 1 to 5 scale, with more positive scores indicating better gingival health. A caries assessment was conducted to yield an index of decayed, missing, and filled teeth (DMFT), including white spots. Examiners were trained and calibrated on all indices; reliability data can be found in Neiswanger et al. (2015).

Center for Epidemiologic Studies Depression Scale (CESD; Radloff, 1977)

The CESD was completed at the time of enrollment. With a 0–3 response format, and a range of 0 – 60, higher scores are indicative of more depression. A standardized cut-off score (i.e., >= 16; Radloff, 1977) was used, such that women scoring at or above that level were considered as clinically depressed, while the remainder of the women were regarded as not depressed.

Demographic information

Age, ethnicity and race, location of domicile, educational level, and annual household income were recorded.

Procedure

After telephone screening, women were assessed in-person by calibrated oral examiners (i.e., licensed dentists or dental hygienists) to evaluate oral health status via methods described above and to collect biological samples (e.g., unstimulated saliva for bacterial and human DNA, gingival samples for bacterial DNA and RNA, supra-gingival plaque samples for biochemical analysis of bacteria) to address study questions beyond the scope of those described here. Information about training of examiners and inter-reliability can be found in Neiswanger et al. (2015). Thereafter, participants were contacted by telephone for a structured interview by trained staff.

Women were provided information about any possible clinically-significant oral health findings at their in-person appointment. Additionally, participants whose CESD scores met or exceeded the criterion for a clinically-significant level of depression were contacted, provided information about the level of depression that was suggested by the CESD as well as about mental health care options in their community, and encouraged to make an appointment for further evaluation and possible treatment. Help in securing follow-up mental health care related to their possible depression also was offered.

Design and Statistical Analyses

Participants were sorted into depressed (i.e., CESD >= 16) and non-depressed (i.e., CESD < 16) groups, and were classified based on their domicile (i.e., in West Virginia, or in the Pittsburgh, PA area).1 Participants from West Virginia were considered rural and those from the Pittsburgh, PA area were regarded as urban. A 2 (depressed − non-depressed) × 2 (rural or urban) factorial design was the basis for the univariate analyses of variance (ANOVAs) that were conducted on educational level, household income, and the three oral health indices. Missing data was excluded pairwise, and are reflected in the degrees of freedom for the various statistical tests.

Results

Across the entire sample, CESD scores ranged from 0 through 52 (M = 9.9, SD = 9.0). There were 336 (49.1%) women who were rural-dwelling and 349 (50.9%) who were urban-dwelling. In terms of depression, the rural women had significantly higher CESD scores (M = 11.5, SD = 9.6) and the urban women had lower scores (M = 8.3, SD = 8.1), t(683) = 4,81, p < .0005. Further, 133 (19.4%) women met the criterion for a clinically-significant level of depression (i.e., CESD > = 16) and 552 (80.6%) did not. Of the 336 rural-dwelling women, 80 (23.8%) met criterion for a clinically-significant level of depression, while 53 (15.2%) of the 349 urban-dwelling women met that criterion. There were 17 women (12.8%) in the depressed group, and 27 women (4.9%) in the non-depressed group who reported taking antidepressant medication, which was a significant difference between groups, χ2 (1, N = 685) = 11.10, p < 0.001.

Table 1 presents means and results from statistical tests. The ANOVAs revealed main effects for both education and income, such that both income and education were higher among women living in urban areas. The interaction effects for both education and income were significant, indicating that income and education among non-depressed women were greater among women in urban areas than in rural areas, but education and income did not differ by dwelling status among women with clinically-significant levels of depression.

Table 1.

Demographics, generalized gingivitis, ORI, and DMFT means, (standard deviations,) and ANOVA results by main effects (depression status and urban-rural distinction) and their interaction.

Depressed Non-Depressed
Variable Rural Urban Rural Urban ANOVA Depression Status Urban-Rural Interaction
Demographics
Education 4.1
(1.5)		 4.5
(1.6)		 4.5
(1.6)		 5.6
(1.6)		 F (3,685)
P
η2P 		20.63
.0005
.03		 24.72
.0005
.04		 5.36
.021
.01
Annual Household Income 31,869
(32,962)		 32,037
(29,747)		 50,144
(48,331)		 86,630
(87,477)		 F(3,548)
P
η2P 		23.29
.0005
.04		 6.21
.013
.01		 6.10
.014
.01
Oral Health Indices
Generalized Gingivitis 0.41
(.50)		 0.23
(42)		 0.30
(46)		 0.13
(.34)		 F (3,680)
p
η2P 		6.67
.01
.01		 18.54
.0005
.03		 .075
.78
.00
 ORI 3.1
(1.2)		 2.8
(1.2)		 2.7
(1.3)		 2.3
(1.2)		 F (3,680)
P
η2P 		14.49
.0005
.02		 9.19
.003
.01		 .21
.65
.00
 DMFT 15.85
(7.2)		 11.0
(8.0)		 12.9
(7.2)		 8.4
(6.9)		 F (3,680)
P
η2P 		15.46
.0005
.02		 45.21
.0005
.06		 0.21
.82
.00
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Note. Education: 1 =8th grade or less, 2 = 9th–12th grade, but no diploma, 3 = High school graduate or GED, 4 =Some college, but no degree, 5 = Associate degree, 6 = Bachelor’s degree, 7 = Master’s degree, 8 = Doctoral degree; ORI: Oral Rating Index; DMFT: Decayed, Missing, Filled Teeth.

ANOVA analyses further revealed a main effect for depression status for all three oral health indices, and a main effect for rural-urban status for all of them as well, but no interaction effects. Findings were that depressed women, and those living in rural areas, had significantly poorer oral health. On average, depressed women had significantly more decayed, missing, or restored teeth (DMFT = 13.9) than their non-depressed counterparts (DMFT = 10.5), t(653) = −4.55, p < .001. Also on average, rural women (DMFT = 13.6) also had significantly more negatively affected teeth compared to their urban peers (DMFT = 8.8), t(653) = 8.63, p < .001.

Discussion

Depression was found to be an important factor relating to oral health in pregnant women in northern Appalachia. Consistent with prior literature including general population and other groups, these findings are unique in emphasizing the importance of depression to oral health during the perinatal period. This factor provides a target for possible intervention that may impact oral health, psychological health, and overall health. Detection of clinically-significant depression is of critical importance during pregnancy and post-partum due to its potential impact on self-care, readiness to care for an infant, potential for relation to self-harm, and life functioning. Various evidence-based psychotherapeutic and pharmacotherapeutic approaches are available for depression that could improve mood and overall quality of life in pregnant women.

These results additionally point out that women residing in rural areas of northern Appalachia, specifically in West Virginia, have a greater burden of oral health problems than their urban counterparts. Prior literature has found similar oral health vulnerabilities in other rural samples, possibly related to socioeconomic factors and access to dental care, as well as oral health and other cultural values.

There was no evidence in this study that depression and rural-urban status interacted in affecting oral health in this group of Appalachian women. Nevertheless, depressed, rural women did have lower levels of education and household income than other groups in this sample. While the sample size overall was large, the relatively smaller numbers of depressed women in both the rural and urban subsamples (i.e., 19.4% of the total sample may have made it difficult to detect interactions of depression and rural-urban status relating to oral health.

In this sample, urban-dwelling status was associated with higher income and education levels among women who did not meet criterion for clinically-significant depression. Among women who had clinically-significant depression, income and education did not vary by dwelling status. There is evidence in the literature to suggest income- and education- based inequalities in the prevalence of depression in the general population (Dohrenwend et al., 1992; Kessler, Foster, Saunders, & Stang, 1995; Lorant et al., 2003). These results are not surprising, given that rural populations tend to have lower incomes and lower levels of education than their urban counterparts (Housing Assistance Council, 2010).

Limitations

Overall, the effect sizes are low, so depression and rural-urban status explain only some of the variance observed in oral health status in this northern Appalachia sample of pregnant women. The West Virginia sample was not exclusively rural, depending on one’s definition of rurality, in that participants came from across the state, which includes cities and urbanized areas. Nevertheless, the relation of residency in West Virginia to poorer oral health indicators is significant, and may relate to social and economic conditions. For design reasons, this sample included only Caucasian women, so the results may not be generalizable to other ethnic and racial groups. This demonstration of the importance of depression to oral health during pregnancy, however, provides a basis for study and possible intervention in other ethnic and racial groups. In addition, there are numerous factors which impact oral health that were not included in the present study, such as access to dental care services, dental insurance, and oral health values (Allison, Locker, Jokovic, & Slade, 1999; Bloom, Simile, Adams, & Cohen, 2012).

Future Research

Opportunities for future research in the domain of maternal depression and oral health are plentiful. In general, future research in this area would benefit from including a wide variety of behavioral, socio-economic, and environmental variables, in order to more accurately model the factors contributing to both depression and oral health among prenatal and peripartum women. Policy-level interventions, particularly in rural areas, (e.g., incentivize healthcare providers for screening for depression among pregnant women) are another direction for future investigations. Future research may also benefit from incorporating experimental methods to test the effects of treatment for depression during pregnancy on postpartum oral health outcomes. Both cognitive-behavior therapy and interpersonal therapy have been shown to be effective treatments for depression among pregnant women (Yonkers et al., 2009). Employing a more longitudinal approach, such as including infant child oral health outcomes in the study, may help to uncover the potentially complex associations between maternal oral health, depression, and child oral, mental, and systemic health.

Clinical Implications

The association between depression and poor oral health implies a need for screening and attention to depression among pregnant and perinatal women in both dental and primary care settings. Mental health care providers, too, should be aware of the oral health consequences of depression during pregnancy to encourage appropriate self-care and professional dental assessment and treatment. In order to provide better access to oral health care to rural populations, practitioners may consider incorporating internet-based, mobile, or community-based services (Skillman et al., 2010).

Conclusions

Pregnant women who are clinically depressed or those from rural areas of northern Appalachia, have a greater burden of oral disease, specifically caries. Both clinically significant levels of depression and dwelling in a rural environment (i.e., West Virginia) are associated with more generalized gingivitis and poorer overall gingival health, as well as with lower education and household income. Depression provides a modifiable target for interventions with pregnant women in northern Appalachia who are vulnerable to disparities that burden them with greater oral disease and socioeconomic disadvantage.

Acknowledgments

The authors thank the participants in this study, as well as the partner facilities in West Virginia and Pennsylvania that provided support for this project. Appreciation also is extended to the COHRA2 External Advisors and Design Group: Debra L. Bogan (U Pitt), Ilana R.A. Chertok (WVU), Eleanor Feingold (U Pitt), Teresa Marshall (U Iowa), Jeffrey C. Murray (U Iowa), Alexandre R. Vieira (U Pitt), John J. Warren (U Iowa), and Steven K. Wendell (U Pitt). The research teams in West Virginia (Michael Law, Emily Kerwin, Tiffany Ngan, Tiffany Summerlin) and Pittsburgh (Andrea R. Warzynski, Helen M. Hawkey, Elizabeth G. Onik, Louise A. Platt, Zelda T. Dahl, Anna Kamelin, Jessica A. Ferraro, Karen Debes, Megan S. Branning, Vonya M. King, Wendy M. Carricato, Dan Knight) are acknowledged with thanks. Also, UCSUR (Stephen J. Strotmeyer Jr., Robert M. Keene, Linda Connelly) and the Magee CTRC (Kathy Laychek, Mary McQueen, Cindy Schatzman) made important contributions to this overall project.

This research was supported by the National Institute for Dental and Craniofacial Research/National Institutes of Health (R01 DE014899).

Biographies

Daniel W. McNeil, PhD, is a Professor of Psychology at West Virginia University, Distinguished Eberly Family Professor of Public Service, and Clinical Professor of Dental Practice & Rural Health. Dr. McNeil researches health psychology, including behavioral dentistry. He has been funded by the National Institutes of Health for 10+ years.

Sarah E. Hayes, MS, MPH is a doctoral student in clinical psychology at West Virginia University. Her research interests focus on health psychology, maternal depression and anxiety, and behavioral dentistry

Cameron L. Randall, MS, is a doctoral candidate in clinical psychology at West Virginia University, where his training is supported by a predoctoral fellowship from the National Institutes of Health. He studies pain perception, the etiology and treatment of healthcare-related fears, medical and dental treatment-seeking behavior, and the dissemination of behavioral sciences research to healthcare professionals.

Deborah E. Polk, PhD, is an assistant professor at the University of Pittsburgh. Dr. Polk studies the relationship between social determinants of oral health and oral health behaviors, indicators of oral health, such as dental caries and periodontal disease, and disparities in oral health.

Kathy Neiswanger, PhD, is a research associate professor at the University of Pittsburgh, and the project manager of the COHRA2 research study. Her research interests focus on the genetics of dental and oral health problems, including early childhood cavities in Northern Appalachia, and orofacial clefting.

John R. Shaffer, PhD, is an Assistant Professor of Human Genetics at the University of Pittsburgh. His primary research interest is the application of statistical and bioinformatics approaches to understand the genetic contributors to common complex human diseases.

Robert J. Weyant, PhD, DrPH, is professor and chair of the Department of Dental Public Health at the University of Pittsburgh. He is a social epidemiologist with research interests in social determinants of dental disease with particular emphasis on the development of oral health disparities in rural and low income children.

Betsy Foxman, PhD, is the Hunein F. and Hilda Maassab Endowed Professor of Epidemiology at the University of Michigan’s School of Public Health. Her research focuses on understanding the transmission of infectious agents, particularly those that can be both commensals and pathogens.

Elizabeth Kao, DMD, is a Professor of Restorative Dentistry at the West Virginia University School of Dentistry. Dr. Kao is a Fellow of the Academy of General Dentistry, and is a staff dentist for the West Virginia arm of the Center for Oral Health Research in Appalachia.

Richard J. Crout, DMD, PhD, was Associate Dean for Research and Professor of Periodontics at the West Virginia University School of Dentistry and Professor of Biochemistry at the West Virginia University School of Medicine. Dr. Crout’s research includes oral health disparities, dental pharmacology and clinical periodontics. He is currently professor emeritus.

Stella Chapman, BS, MPH, is the COHRA2 Program Manager at WVU. She has been employed with the School of Dentistry since 2005. She earned her Bachelor’s of Science in biology from West Virginia Wesleyan College in Buckhannon, WV, and her Master’s of Public Health degree from West Virginia University.

Linda J. Brown, RDH, is an oral evaluator for the COHRA2 project at WVU. She graduated from WVIT in 1997 with her degree in Dental Hygiene. She worked in private practices for 8 years before becoming part of West Virginia University School of Dentistry’s research team in December of 2004.

Jennifer L. Maurer, MLIS, is a Database Manager at the University of Pittsburgh’s Center for Craniofacial and Dental Genetics and has worked on the Center for Oral Health Research in Appalachia study since 2011.

Mary L. Marazita, PhD is a Professor of Oral Biology, Human Genetics, and Clinical and Translational Science at the University of Pittsburgh, and is the Director of the Center for Craniofacial and Dental Genetics. Dr. Marazita studies the human genetics of complex traits including oral disease.

Footnotes

1

Additional analyses were conducted including non-depressed women taking antidepressants in the depressed group, in comparison to the other non-depressed women. There were 14 rural women and 13 urban women, for a total of 27 participants, who reported taking antidepressants but were not classified by the CESD as significantly depressed. Analyses were conducted with and without these women in the depressed group. The pattern of results was the same for both analyses, so only the analyses based on classification of women based on the CESD was used.

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