The Obstetrician-Gynecologist's Role in Detecting, Preventing, and Treating Depression

Mood disorders are more common in the late menopausal transition as compared with premenopausal and late postmenopausal states.( 27 ) The late transition occurs on average 2 years before the final menstrual period, and is defined by an episode of 60 or more days of amenorrhea. Not only are the rates of new onset depressive symptoms higher in the late transition, but women with preexisting major depressive disorder are at a higher risk of recurrence during this time.( 26 ) Risk factors and comorbidities for depression in the late transition are summarized in Figure 1 . Perimenopausal women often present with atypical depressive symptoms such as increased sleep disturbances or increased weight gain and appetite( 28 ) and obstetrician–gynecologists should account for this in their differential diagnosis. Estrogen has been suggested as a treatment for MDD in perimenopausal women, however the evidence for this is controversial.( 29 ) Estradiol (oral or transdermal) may have antidepressant efficacy for women in the late transition who are experiencing other menopausal symptoms, but is not effective in postmenopausal MDD treatment. There is insufficient evidence to inform the choice between estradiol monotherapy and estradiol plus an antidepressant. Similarly the ideal duration of estradiol treatment is unclear.( 29 ) For women already on antidepressants, it is important to be aware that menopausal status, oral contraceptives and postmenopausal hormone therapy can all have an effect on antidepressant response. Rather than targeted screening, we recommend universal screening of all women presenting at midlife requesting menopausal care.

Reproductive age women who are at a high risk for depression constitute the most common age group cared for by obstetrician–gynecologists. Reported rates of perinatal depression vary from 7 to 20%, ( 19 ) and untreated perinatal depression is a major public health problem, with implications not just for the mother but for the child and the family as well.( 20 ) Screening for depression in this age group is especially important as only about 11% of those with clinically significant depression present with a chief complaint of depressive symptoms.( 21 ) Several depression screening tools have been validated for use in this population including the Edinburgh Postnatal Depression Scale (EPDS) and the PHQ-9.( 22 ) Obstetricians should screen at least once during the perinatal period ( 1 , 2 ), perhaps arranging for closer monitoring or repeat screening in women with recognized risk factors for depression such as past or family history of depression ( Figure 1 ). Prevention of depression is best begun before pregnancy. At prenatal visits, attention should be paid not just to nutrition and traditional prenatal care but also to the expectant mothers’ emotional wellbeing, self-efficacy and readiness to parent. There is preliminary evidence that parenting support and anticipatory parenting guidance can prevent postpartum depression.( 23 ) Obstetricians can play a key role in recognizing women with need for additional parenting support and refer to appropriate resources such as home visiting programs or maternity support services, available in most states.

The United States Preventive Services Task Force (USPSTF) recently recommended depression screening for all adults with specific mention of pregnant and postpartum women.( 1 ) This is of direct relevance to obstetrician gynecologists and comes close on the heels of the American College of Obstetricians and Gynecologists’ (ACOG)’s committee opinion recommending screening for depression and anxiety symptoms at least once during the perinatal period.( 2 ) These recommendations are fitting as women are twice as likely to have a lifetime diagnosis of major depression as men.( 3 ) Obstetrician–gynecologists are well-placed to detect depression early and to treat before symptoms become chronic with a devastating effect on families and societies. Not only do many women consider their obstetrician–gynecologist as their primary care provider, but almost 50% of obstetrician–gynecologists also consider themselves as primary care providers.( 3 ) In addition, several gynecologic conditions encountered by obstetrician–gynecologists e.g. endometriosis,( 4 ) polycystic ovarian syndrome,( 5 ) infertility, recurrent pregnancy loss,( 6 ) and premature ovarian insufficiency,( 7 ) are associated with depressive symptoms - either as risk factors or comorbidities ( Figure 1 ).

Prevention goes hand-in-hand with early detection, as early detection and treatment can help prevent the morbidity associated with the primary disorder and comorbid conditions. Underscoring the importance of prevention, the Affordable Care Act instituted the national prevention strategy (NPS). One of 6 NPS priority areas is “mental and emotional wellbeing”. NPS emphasizes integration of early detection of mental health problems into primary care settings.( 8 ) Preventive measures have the highest yield when delivered at routine intervals, e.g. at the annual gynecologic examination and at “critical periods” or “windows of vulnerability”- specific periods along the life course when adverse events or exposures have the greatest negative impact.( 9 ) In women, specific reproductive stages (e.g. adolescence, pregnancy, postpartum, menopause transition) are particularly vulnerable periods when reproductive hormone levels and psychosocial circumstances are in flux. These windows of vulnerability, when appropriately identified, provide opportunities for prevention. Several effective screening and preventive interventions for other conditions commonly treated in obstetric gynecology settings already exist: cervical and breast cancer, hypertension, sexually transmitted infections; and family planning.( 10 , 11 ) However, interventions to promote mental and emotional wellbeing are not yet systematically offered. Although obstetrician–gynecologists are aware of the importance of depression screening,( 3 ) they may be reticent to make depression screening routine, perhaps due to lack of resources and limited clinical time allotment. Additional concerns that may arise relate to the question of necessary follow up and treatment availability for women who screen positive for depression.( 12 ) New treatment models for depression, based in primary care( 13 ) and obstetrics and gynecology( 3 , 14 ) clinics are relatively easy to implement, effective, and well-accepted by busy practices. We argue that, given the high prevalence and burden of depression in women, the influence that an obstetrician–gynecologist might have by identifying and treating depression early, is substantial. This should be our new patient care paradigm. We describe the importance of depression screening and early treatment and summarize models of care that can achieve these goals in an obstetric and gynecology practice setting. Commonly used screening tools such as the 9-item Patient Health Questionnaire (PHQ-9) are integrated into many electronic health records and are easy for patients to complete in the office. Anxiety is frequently comorbid with depression, particularly in adolescence, but details are beyond the scope of this commentary. We organize our recommendations by focusing on vulnerable periods - adolescence, pregnancy, postpartum, and the menopause transition and conclude with recommendations regarding initiation of treatment. Details of our recommendations and all primary references to those recommendations can be found at www.dawncare.org .

We strongly recommend that obstetricians and gynecologists consider implementation of a depression care model and do not attempt to screen and treat in a vacuum. Commonly implemented programs are summarized in Table 1 , but this is not an exhaustive list. Key features of the programs include: on site screening, patient engagement, education, treatment, and tracking, having both behavioral and medical therapies available and psychiatric consultation. As obstetrician -gynecologist practices become more patient centered and team based these models become increasingly relevant. Paying attention to women’s mental health and emotional wellbeing has far reaching benefits, reducing both physical and social disabilities.( 30 ) with the potential to improve outcomes for children( 31 ) and families.( 32 ) The extra few minutes spent on screening, counseling and coordination of care have tremendous downstream effects. Thus, obstetrician–gynecologists have a key role to play to positively influence women and their families and to make important public health contributions.

The increased risk for depression in females begins at puberty. Female adolescents are at a 2- to 3-fold higher risk of major depressive disorder (MDD) than males, and a nearly 4-fold higher risk of severe MDD.( 15 ) Adolescents with depressive symptoms are at a higher risk of educational underachievement, unemployment, early parenthood and anxiety disorders, nicotine dependence, alcohol abuse and suicidality.( 16 ) Thirty percent of adolescents with MDD report suicidality in the past year and 10.8% report a suicide attempt. Centers for Disease Control and Prevention data from 1999 to 2014, demonstrated suicide rates increased in both men and women of all age groups. In females, the largest increase was in adolescent girls, almost tripling in fifteen years.( 17 ) We recommend that obstetrician–gynecologists screen all adolescent patients for depression and anxiety. Further care coordination may be required with the pediatric provider or specialists. Knowledge of the commonly comorbid conditions in depressed adolescents ( Figure 1 ) can guide further preventive measures. For example, assuring adequate family planning services for teens can prevent subsequent pregnancies, more common in adolescents with depression (49% of depressed adolescent mothers experienced a subsequent pregnancy within 2 years).( 18 ) Similarly, adolescents with depression should be screened for sexually transmitted infections, substance abuse, and eating disorders.

PMDD is a common mood disorder, observed in menstruating women, with prevalence rates of 3 – 8%.( 24 ) The diagnosis is made based on at least 4 of 11 physical (e.g. bloating, weight gain, joint pain), and 1 of 4 behavioral (e.g. mood swings, irritability, depression, anxiety) symptoms during the luteal phase.( 25 ) PMDD onset is in the early 20s and many of these women may never see a psychiatrist. Evidence based treatments for PMDD include luteal phase or symptom onset treatment with SSRIs,( 24 ) rather than the continuous SSRI therapy recommended for depression. There is preliminary evidence that women with PMDD may be at elevated risk for postpartum depression and depression in the menopause transition.( 26 ) Monitoring mood more frequently in vulnerable periods is recommended.

All patients who screen positive for depression do not have major depressive disorder ( Box 1 , Figure 2 ). Although subsyndromal depression can cause considerable impairment, treatment approaches differ and hence it is important to make this distinction. In all cases, attention must be paid to the suicidal ideation item in the screening questionnaire, with clinic specific procedures in place to follow up if endorsed. Adopting an integrated care model into your clinic as described below, is evidence based and can ensure high quality depression treatment while reducing physician burden.