SUMMARY
We examined mental health care use in relation to depressive symptoms (PHQ-9 ≥10) among a nationally representative sample of pregnant women using data from the National Health and Nutrition Examination Survey 2005–2012. Logistic regression models estimated crude and adjusted odds ratios for mental health care use in past year in relation to depressive symptoms. While 8.2% (95% CI: 4.6–11.8) of pregnant women were depressed, only 12% (95% CI: 1.8–22.1) of these women reported mental health care use in past year.
Keywords: pregnancy, depression, mental health care, treatment, access
Introduction
Major depressive disorder is the leading cause of disability among women of reproductive age (World Health Organization 2008) and a major public health concern. One in 8 women experience perinatal depression (Gavin et al. 2005) which is associated with negative birth (Grote et al. 2010), infant (Britton et al. 2001), and child outcomes (Deave et al. 2008).
Perinatal depression is also under-diagnosed and under-treated (Byatt et al. 2012). Despite legislation and numerous recommendations to screen for perinatal depression, screening remains controversial because screening alone does not translate into improved outcomes (Thombs et al. 2014). While much of the legislation and recommendations have focused on detection and treatment of postpartum depression, more than 50% of women with postpartum depression enter pregnancy depressed or have an onset during pregnancy (Wisner et al. 2013). Thus, it is critical to detect and treat depression during pregnancy. There is a dearth of studies examining mental health care use among pregnant women as it relates to symptoms of depression. Thus, the purpose of this study is to examine mental health care use in relation to depressive symptoms among pregnant women.
METHODS
We analyzed data from the National Health and Nutrition Examination Survey (NHANES) 2005–2012, a nationally representative survey of the civilian non-institutionalized population in the US. NHANES first asked about mental health care use in 2005–2006. NHANES includes a household interview and a physical examination in a mobile examination center (MEC) that includes laboratory tests, physiological measurements, and additional interviews (Curtin et al. 2012). Additional information about NHANES can be found at www.cdc.gov/nhanes. All participants provided written informed consent. The University of Massachusetts Medical School Institutional Review Board determined that this study did not require their oversight because analyses included only publically-available de-identified data. Women were included in the analytic sample if they were aged 20–44 years, pregnant as determined by a positive urine or serum hCG test, and had information available about depressive symptoms and mental health care use.
During the home interview, women were asked, “During the past 12 months, have you seen or talked to a mental health professional such as a psychologist, psychiatrist, psychiatric nurse, or clinical social worker about your health?” Respondents that answered “yes” to this question were defined as having used mental health care and those that answered “no” were defined as not having used having mental health care. Participants who refused to answer or who answered “don’t know” were excluded from the analysis.
At the Mobile Examination Center, depressive symptoms were assessed using the Patient Health Questionnaire (PHQ-9), a nine-item self-report questionnaire that has been widely validated for use in primary care settings (Kroenke et al. 2001). Interviewers asked participants the nine items about the frequency of symptoms of depression over the past 2 weeks. Response categories of "not at all," "several days," "more than half the days" and "nearly every day" were scored from 0 to 3. We summed these nine items for a total PHQ-9 score. The total PHQ-9 scores were categorized into not depressed (score of < 10) or depressed (score ≥10). In general adult populations, PHQ-9 scores of 10 or above are indicative of depression with a sensitivity of 74%–88% and specificity of 88%–91% (Kroenke et al. 2001). In pregnant populations, its sensitivity and specificity (Kroenke et al. 2001) are comparable to those of the Edinburgh Postnatal Depression Scale (EPDS), a broadly accepted and commonly used depression screening tool in pregnant populations (Flynn et al. 2011).
We examined several potential confounders. Demographic characteristics were self-reported and included age, race/ethnicity (categorized as non-Hispanic White, non-Hispanic Black, Mexican American/other Hispanic, and other race/multi-racial), education, marital status, and household poverty status. Education was categorized as less than high school, high school graduate/GED or equivalent, some college or associates degree, and college graduate or above. Marital status was categorized as married, living with partner, or widowed/divorced/separated/never married. Poverty status was measured by the poverty income ratio (PIR) expressed as a percentage of the federal poverty threshold (0%–199%, 200–399%, ≥400%, or not provided). Women reported their current month of pregnancy. Gravidity was categorized as 1, 2, 3, or ≥4 pregnancies. Health insurance status was categorized as currently uninsured, current coverage but time without coverage in the past 12 months, and continuous insurance coverage for the past 12 months. Participants reported whether they had consumed alcohol within the past 12 months and whether they had ever used marijuana or hashish, methamphetamines (including crank, crystal, ice, or speed), heroin, or cocaine (including crack cocaine or free base).
All analyses were weighted to represent pregnant women nationally. Characteristics of depressed and non-depressed women were compared by using t-tests for continuous variables, and chi-square tests for categorical variables. Logistic regression models estimated crude and adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) for access to mental health care in the past year in relation to depression. We included covariates in the adjusted model that were associated both with depression and mental health care access with p<0.20. All analyses were conducted using SAS (Version 9.3, SAS Institute Inc, Cary, NC).
RESULTS
Of the 502 pregnant women aged 20–44 years in NHANES 2005–2012, we excluded women missing PHQ-9 data (n=39), resulting in an analytic sample of 463 pregnant women which represents 2,581,833 women nationally. One in twelve pregnant women (8.2%; 95% CI: 4.6–11.8%) reported symptoms of depression. Characteristics of women in relation to depressive symptoms are presented in Table 1.
Table I.
Characteristics of pregnant women in relation to depressive symptoms: NHANES 2005–2012, mean (SE) or % (95%CI)
| Depressed | Non-depressed | |
|---|---|---|
| Sample N | 45 | 418 |
| Weighted N | 211,584 | 2,370,249 |
| Age (years) | 27.7 (1.1) | 28.8 (0.4) |
| Race/ethnicity | ||
| Non-Hispanic White | 26.3 (5.0, 47.5) | 55.4 (47.2, 63.7) |
| Non-Hispanic Black | 23.6 (7.7, 39.4) | 13.1 (8.6, 17.6) |
| Mexican American/ other Hispanic | 41.1 (21.9, 60.2) | 21.3 (16.0, 26.5) |
| Other race/ multi-racial | 9.1 (0.0, 22.1) | 10.2 (5.5, 14.9) |
| Poverty-to-income ratio (PIR) | ||
| 0–199% | 65.6 (48.6, 82.5) | 30.7 (25.1, 36.3) |
| 200–399% | 20.5 (4.0, 37.0) | 25.3 (18.7, 32.0) |
| 400+ % | 3.0 (0.0, 6.7) | 39.0 (31.1, 46.8) |
| Missing | 11.0 (0.3, 21.6) | 5.0 (2.4, 7.6) |
| Education | ||
| Less than high school | 47.7 (26.1, 69.3) | 16.1 (12.2, 20.0) |
| High school graduate/GED or equivalent | 17.0 (1.4, 32.6) | 16.1 (11.5, 20.8) |
| Some college or AA degree | 25.3 (10.8, 39.8) | 32.8 (27.3, 38.3) |
| College graduate or above | 10.0 (0.0, 23.6) | 35.0 (28.1, 41.9) |
| Marital Status | ||
| Married | 41.9 (23.0, 60.8) | 71.3 (65.2, 77.5) |
| Living with partner | 29.6 (11.6, 47.7) | 10.5 (6.6, 14.3) |
| Widowed, divorced, separated, never married | 28.4 (12.8, 44.0) | 18.2 (12.7, 23.7) |
| Mean month of pregnancy | 5.0 (0.4) | 5.5 (0.2) |
| Gravidity | ||
| One pregnancy | 13.7 (0.0, 28.2) | 22.4 (15.2, 29.6) |
| Two pregnancies | 18.9 (5.4, 32.5) | 27.9 (21.7, 34.0) |
| Three pregnancies | 12.9 (1.6, 24.2) | 25.5 (20.3, 30.8) |
| Four or more pregnancies | 54.4 (35.6, 73.2) | 24.2 (17.7, 30.8) |
| Health insurance status | ||
| Currently uninsured | 29.3 (8.9, 49.7) | 14.2 (10.2, 18.3) |
| Current coverage but time without coverage in past 12 months | 25.7 (10.2, 41.3) | 17.3 (12.5, 22.1) |
| Continuous insurance coverage for past 12 months | 44.9 (26.0, 63.9) | 68.4 (61.6, 75.2) |
| Alcohol use in past 12 months | 59.7 (44.5, 74.9) | 56.7 (49.7, 63.7) |
| Ever used marijuana | 60.5 (44.5, 76.5) | 45.4 (37.0, 53.9) |
| Ever used methamphetamines | 2.6 (1.1, 4.2) | 0.8 (0, 2.4) |
| Ever used heroin | 0.7 (0, 1.9) | 0.6 (0, 2.0) |
| Ever used cocaine | 9.9 (5.0, 14.8) | 6.2 (0, 13.6) |
OR= odds ratio; CI=confidence interval;
Adjusted for poverty-to-income ratio (PIR) and race/ethnicity
Twelve percent of women with depressive symptoms and 4% of non-depressed women reported mental health care use in the past year (Table 2). After adjusting for PIR and race/ethnicity, women with symptoms of depression had 3.5 times increased odds of mental health care use in the past 12 months (95% CI=1.1–11.0; Table 2).
Table II.
Mental health care use in past 12 months in relation to depressive symptoms among pregnant women: NHANES 2005–2012
| Mental health care use, % (95% CI) |
Crude OR (95% CI) |
Adjusted* OR (95% CI) |
|
|---|---|---|---|
| Depression | |||
| Non-depressed | 4.1 (1.3, 6.9) | (Reference) | (Reference) |
| Depressed | 12.0 (1.8, 22.1) | 3.2 (0.9, 10.9) | 3.5 (1,1, 11.0) |
| Race/ethnicity | |||
| Non-Hispanic white | 5.0 (0.7, 9.3) | (Reference) | |
| Non-Hispanic black | 4.6 (0.0, 10.6) | 0.8 (0.1, 4.5) | |
| Mexican American/other Hispanic | 5.9 (2.2, 9.7) | 0.9 (0.3, 3.2) | |
| Multiracial/other race/ethnicity | 0.6 (0.0, 2.0) | 0.1 (0.01, 0.8) | |
| Poverty-to-income ratio (PIR) | |||
| 0–199% | 4.5 (1,3, 7.7) | (Reference) | |
| 200–399% | 3.0 (0.0, 6.5) | 0.7 (0.2, 3.6) | |
| 400% or greater | 5.0 (0.0, 10.8) | 1.4 (0.4, 5.8) | |
| Missing PIR | 12.0 (0.0, 25.3) | 3.6 (0.9, 15.2) | |
OR= odds ratio; CI=confidence interval;
Adjusted for poverty-to-income ratio (PIR) and race/ethnicity
DISCUSSION
To our knowledge, this is the first study to describe mental health care use among a nationally representative sample of U.S. pregnant women in relation to depressive symptoms. Consistent with the range estimated in prior studies (Gavin et al. 2005), 8.2% of pregnant women reported symptoms suggestive of depression. While we found that while pregnant women with depressive symptoms were three times more likely to have accessed mental health care in the past year than non-depressed pregnant women, only 12% of pregnant women with depressive symptoms reported having accessed mental health care. Our study builds on prior research (Byatt et al. 2012) and suggests that mental health care use is low among a nationally representative sample of pregnant women.
Women with depressive symptoms were less likely to be married and more likely to be poor, less educated, and lack consistent insurance coverage. This is consistent with prior research suggesting that less educated socioeconomically diverse women are at increased risk of perinatal depression (Segre et al. 2007). Interventions aimed to engage pregnant women in and increase mental health care use may need to target vulnerable populations of women who may have limited financial resources, lack social supports, and/or are uninsured.
Strengths of the current study include generalizability to pregnant women across the United States. Screening for depression was conducted using a well-validated screening tool, the PHQ-9 (Kroenke et al. 2001) (Flynn et al. 2011). However, due to the constraints of the available data we also were not able to assess other potentially important covariates such as past psychiatric history. Respondents were also not asked when or why mental health care was used, and whether that use was because of depression related to pregnancy. NHANES did not inquire about whether women received depression treatment from a non-mental health provider, thus it is possible that a subset of women categorized as not receiving mental health care, may have received depression treatment from a non-mental health specialist. For example, women may have received treatment with an antidepressant from an obstetric or primary care provider. Another limitation is the timing of the depressive symptoms in relation to treatment. The PHQ-9 captures symptoms during the past 2 weeks yet mental health care use included use during the past 12 months, a wider range of time than depressive symptoms, and including time before pregnancy. Women were on average, in their fifth month of pregnancy, and it is possible that additional women may have had symptoms of depression during pregnancy either before or after assessment of depressive symptoms.
In summary, only one in eight pregnant women with depressive symptoms reported mental health care use in the past year. In order to promote maternal and child health, it is essential that pregnant women are able to engage in and access effective, evidence-based treatments for depression. This mission may be realized by developing and evaluating multi-disciplinary interventions or models of perinatal depression care that can be broadly disseminated in low-resource, real-world settings.
Acknowledgments
The first author has received grant funding/support for this project from the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant KL2TR000160. Additional support provided by NIH grants UL1TR000161 (Xiao), KL2TR000160 (Waring), and U01HL105268 (Waring). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Footnotes
Disclosures
The first author has received salary and funding support from Massachusetts Department of Mental Health via the Massachusetts Child Psychiatry Access Project for Moms (MCPAP for Moms). The first author is also the statewide Medical Director of MCPAP for Moms.
Previous presentation
None
Contributor Information
Nancy Byatt, Medical Director, Massachusetts Child Psychiatry Access Project for Moms (MCPAP for Moms), Assistant Professor of Psychiatry and Obstetrics & Gynecology, UMass Memorial Medical Center/UMass Medical School, 55 Lake Ave North, Worcester, MA 01655, ph:(508) 334-7839, fax: (508) 856-6426, nancy.byatt@umassmemorial.org
Rui S. Xiao, Clinical and Population Health Research Program, Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
Kate H. Dinh, Department of Surgery, University of Massachusetts Medical School, Worcester, MA
Molly E. Waring, Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Departments of Quantitative Health Sciences and Obstetrics & Gynecology, University of Massachusetts Medical School, Worcester, MA
References
- Britton HL, Gronwaldt V, Britton JR. Maternal postpartum behaviors and mother-infant relationship during the first year of life. J Pediatr. 2001;138(6):905–909. doi: 10.1067/mpd.2001.113358. doi:S0022-3476(01)91723-8. [DOI] [PubMed] [Google Scholar]
- Byatt N, Simas TA, Lundquist RS, Johnson JV, Ziedonis DM. Strategies for improving perinatal depression treatment in North American outpatient obstetric settings. J Psychosom Obstet Gynaecol. 2012;33(4):143–161. doi: 10.3109/0167482X.2012.728649. [DOI] [PubMed] [Google Scholar]
- Curtin LR, Mohadjer LK, Dohrmann SM, Montaquila JM, Kruszan-Moran D, Mirel LB, Carroll MD, Hirsch R, Schober S, Johnson CL. The National Health and Nutrition Examination Survey: Sample Design, 1999–2006. Vital Health Stat. 2012;2(155):1–39. [PubMed] [Google Scholar]
- Deave T, Heron J, Evans J, Emond A. The impact of maternal depression in pregnancy on early child development. BJOG. 2008;115(8):1043–1051. doi: 10.1111/j.1471-0528.2008.01752.x. [DOI] [PubMed] [Google Scholar]
- Flynn HA, Sexton M, Ratliff S, Porter K, Zivin K. Comparative performance of the Edinburgh Postnatal Depression Scale and the Patient Health Questionnaire-9 in pregnant and postpartum women seeking psychiatric services. Psychiatry Res. 2011;187(1–2):130–134. doi: 10.1016/j.psychres.2010.10.022. [DOI] [PubMed] [Google Scholar]
- Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol. 2005;106(5 Pt 1):1071–1083. doi: 10.1097/01.AOG.0000183597.31630.db. [DOI] [PubMed] [Google Scholar]
- Grote NK, Bridge JA, Gavin AR, Melville JL, Iyengar S, Katon WJ. A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Arch Gen Psychiatry. 2010;67(10):1012–1024. doi: 10.1001/archgenpsychiatry.2010.111. 10.1001/archgenpsychiatry.2010.111. [DOI] [PMC free article] [PubMed] [Google Scholar]
- World Health Organization. The Global Burden of Disease: 2004 update. Department of Health Statistics and Informatics, Information Evidence and Research Cluster of WHO; [Accessed 4 March 4 2014]. http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf. [Google Scholar]
- Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–613. doi: 10.1046/j.1525-1497.2001.016009606.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Segre LS, O'Hara MW, Arndt S, Stuart S. The prevalence of postpartum depression: the relative significance of three social status indices. Soc Psychiatry Psychiatr Epidemiol. 2007;42(4):316–321. doi: 10.1007/s00127-007-0168-1. [DOI] [PubMed] [Google Scholar]
- Thombs BD, Arthurs E, Coronado-Montoya S, Roseman M, Delisle VC, Leavens A, Levis B, Azoulay L, Smith C, Ciofani L, Coyne JC, Feeley N, Gilbody S, Schinazi J, Stewart DE, Zelkowitz P. Depression screening and patient outcomes in pregnancy or postpartum: a systematic review. J Psychosom Res. 2014;76(6):433–446. doi: 10.1016/j.jpsychores.2014.01.006. [DOI] [PubMed] [Google Scholar]
- Wisner KL, Sit DK, McShea MC, Rizzo DM, Zoretich RA, Hughes CL, Eng HF, Luther JF, Wisniewski SR, Costantino ML, Confer AL, Moses-Kolko EL, Famy CS, Hanusa BH. Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry. 2013;70(5):490–498. doi: 10.1001/jamapsychiatry.2013.87. [DOI] [PMC free article] [PubMed] [Google Scholar]