SAN DIEGO – Rare is the pregnant patient whose obstetrician fails to ask whether she cleans her cat's litter, yet few are asked about conditions that pose far greater risks to them and their babies than toxoplasmosis: depression and partner abuse.
The risk of peripartum depression is 1 in 10, with consequences for mother and fetus that can be profound.
Domestic violence kills more pregnant women than any single medical complication of pregnancy.
Yet both conditions are underdiagnosed and undertreated, according to speakers at the annual meeting of the American College of Obstetricians and Gynecologists.
“As ob.gyns., we need to look at the bigger picture and understand that good prenatal and postpartum care involve a focus not just on our patients' physical health but also on their emotional and psychological health,” said Dr. Stanley Zinberg, deputy executive vice president of ACOG and vice president for practice activities.
Dr. Sharon T. Phelan, professor of obstetrics and gynecology at the University of New Mexico, Albuquerque, said she believes priorities may need to be restructured.
“It's interesting that we have laws in effect that we have to offer all women screening for certain birth defects that have a rate far lower than 10%. Yet 10% is the rate of peripartum depression,” she said.
For Dr. Paul Gluck, the need to screen for depression in perinatal visits became clear when he conducted a pilot survey of 50 obstetricians in the Miami area where he practices and found that just 2 of the respondents asked any questions about patients' mental well-being.
The potential impact of such screening struck home when he gave a longtime patient a depression screening tool as part of a research project and learned she was severely depressed.
“I'd been seeing her for years. It never dawned on me she was depressed,” he said during an ACOG press briefing.
Six weeks after he prescribed the patient an antidepressant, he received “the most beautiful letter” that he said changed his practice.
“I didn't realize how depressed I really was,” the patient wrote. “I didn't realize how much life I was missing. … The sun shines brighter.”
“I did as much good for this woman as for the woman I take to surgery to perform a hysterectomy,” Dr. Gluck said. “This is something we can be diagnosing and treating within the scope of an ob.gyn. practice.”
Dr. Zinberg said maternal depression seems to get little attention, “except when tragedies occur such as Andrea Yates [the Texas mother with postpartum depression who drowned her children] or when celebrities are involved.”
Postpartum psychosis, suicide, and homocide are only the most visible consequences of maternal depression, emphasized Dr. Phelan.
Depressed women self-medicate with cigarettes, alcohol, and other drugs. Their depression often prevents them from seeking prenatal care or following advice for a healthy pregnancy. They are more prone than are other women to preterm labor, delivery of small-for-gestational-age infants, and even fetal death. As mothers, they may be inattentive and have trouble bonding with their infants, while struggling to find energy and focus to care for their older children.
Screening tools are often helpful in spotting these patients, since many symptoms of depression overlap with normal occurrences in pregnancy and new parenthood, including fatigue, sleep problems, changes in appetite, and mood swings.
Dr. Gluck said that he has implemented a multipronged approach to screening.
His general intake questionnaire now includes two mental health questions: “Do you feel down or depressed?” and “Do you not enjoy doing things you used to enjoy?”
He has trained his nurses to weave several questions about psychological well-being into the conversation while patients are being weighed and having their blood pressure taken. For example, they will say, “How are things going in your life? Are you feeling down at all?”
If either the intake form or the nurse indicates there might be reason to suspect a patient has depression, he uses a validated, 20-question screening tool. Patients found to have suicidal ideation are handled as “a medical emergency as much as a ruptured appendix.” He refers to a trusted network of mental health professionals.
He refers other patients for psychotherapy and/or prescribes antidepressants himself, although he is fully supportive of colleagues who refer all patients with depression to mental health professionals. Not all ob.gyns. feel comfortable managing psychotropic medications, but all should make the effort to find out if their patients are depressed, he said.
“I think it's very important that we're the ones doing the screening. We're the ones who have contact with women throughout their pregnancies and … throughout their whole lifetimes,” he said.