Postpartum Depression: Continuing the Downward Trajectory

Data from the Centers for Disease Control and Prevention (CDC) show that in 13 states the self-reported prevalence of postpartum depression symptoms (PDS) decreased from 14.8% in 2004 to 9.8% in 2012.¹

From 2004 to 2012, statistically significant decreases in PDS were identified in 8 of the 13 states (Alaska, Colorado, Georgia, Hawaii, Minnesota, Nebraska, Utah, and Washington). No statistically significant changes in the rate of PDS were found in the remaining 5 states (Maine, Maryland, Oregon, Rhode Island, or Vermont). Overall prevalence of PDS in 27 states was 11.5% in 2012.

Despite these declines, postpartum depression remains common, and decreasing PDS is a Healthy People 2020 objective. “Ongoing surveillance and activities to promote universal screening followed by appropriate referral and treatment are needed to reduce PDS among US women,” wrote Jean Y. Ko, PhD, from the division of reproductive health at the National Center for Chronic Disease Prevention and Health Promotion and colleagues.

While specific causes for postpartum depression remain unknown, risk factors include depression during pregnancy, low social support, stressful life events during pregnancy, preterm birth, and traumatic birth experience.

Factors that may help explain the reduction in self-reported PDS from 2004 to 2012 include:

• A reduction in birth rates in teens (age 15 to 19) from 41.5 per 1000 women in 2007 to 24.2 per 1000 women in 2014
• A reduction in preterm birth rates from 10.4% in 2007 to 9.5% in 2014²
• A reduction in the number of women experiencing stressful life events during the year before birth by 0.54% per year from 2000 to 2010³
• An increase in the number of antidepressant prescriptions provided to pregnant women from 0.7% in 2002 to 2006 to 2.1% in 2007 to 2010⁴

The researchers noted that although postpartum depression is treatable with pharmacologic therapy and behavioral health interventions, it is often underdiagnosed and untreated: “Nearly 60% of women with depressive symptoms do not receive a clinical diagnosis, and 50% of women with a diagnosis do not receive any treatment,” they noted.⁵

“Despite the observed decline, PDS remain[s] common, affecting 11.5% of new mothers in 2012, with prevalence varying by reporting state and subgroups of women,” the researchers wrote. “These findings underscore the need for universal screening and appropriate treatment for pregnant and postpartum women, as recommended by the American College of Obstetricians and Gynecologists (ACOG),⁶ the American Academy of Pediatrics (AAP),⁷ and the US Preventive Services Task Force.”

ACOG recommends that providers use a validated screening tool to assess depressive symptoms at least once during pregnancy or postpartum.⁶ AAP also recognizes that depression screening is part of family-centered well-child care, given that pediatricians have early access to both the mother and child.⁷

Both ACOG and AAP recommend collaboration between obstetric and pediatric providers for symptomatic women who are identified during newborn care.^6,7

“Recent efforts to address maternal depression include extending postpartum Medicaid coverage for women, integration of behavioral health services within primary care, and provider reimbursement for postpartum depression screening at well-baby visits,” the researchers noted.

Summary & Clinical Applicability

Despite an observed decline in the prevalence of PDS, approximately 1 in 9 women in the United States experience PDS, with higher prevalence rates in certain states and subgroups of women.

To reduce PDS in the United States, ongoing surveillance and promotion of appropriate screening, referral, and treatment are needed. More research is also necessary to understand the etiology of postpartum depression.

Limitations

• PDS is self-reported and might not represent a clinical diagnosis of depression.
• The Pregnancy Risk Assessment Monitoring System (PRAMS) PDS 2-item screener is based on the Patient Health Questionnaire-2. These questions with similar categorization schemes have a sensitivity of 58% and a specificity of 85%, compared with clinical assessments of major depressive episodes; the results in this report might therefore underestimate the true prevalence of postpartum depression.
• Data might not be generalizable to states not included in this analysis or to pregnancies that did not result in a live birth.
• Mental health treatment over time could not be assessed in this report because PRAMS has limited data on mental health treatment, including antidepressant use.

References

1. Ko JY, Rockhill KM, Tong VT, Morrow B, Farr SL. Trends in postpartum depressive symptoms – 27 States, 2004, 2008, and 2012. MMWR Morb Mortal Wkly Rep. 2017;66(6):153-158. doi:10.15585/mmwr.mm6606a1 
2. Ferré C, Callaghan W, Olson C, Sharma A, Barfield W. Effects of maternal age and age-specific preterm birth rates on overall preterm birth rates—United States, 2007 and 2014. MMWR Morb Mortal Wkly Rep. 2016;65:1181-1184. 
3. Burns ER, Farr SL, Howards PP. Stressful life events experienced by women in the year before their infants’ births—United States, 2000–2010. MMWR Morb Mortal Wkly Rep. 2015;64:247-251.
4. Meunier MR, Bennett IM, Coco AS. Use of antidepressant medication in the United States during pregnancy, 2002–2010. Psychiatr Serv. 2013;64:1157-1160.
5. Ko JY, Farr SL, Dietz PM, Robbins CL. Depression and treatment among U.S. pregnant and nonpregnant women of reproductive age, 2005–2009. J Womens Health (Larchmt). 2012;21:830-836.
6. Committee on Obstetric Practice. The American College of Obstetricians and Gynecologists Committee opinion no. 630. Screening for perinatal depression. Obstet Gynecol. 2015;125:1268-1271.
7. Earls MF; Committee on Psychosocial Aspects of Child and Family Health American Academy of Pediatrics. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics. 2010;126:1032-1039.