Int.J. Behav. Med. DOI 10.1007/s12529-015-9493-z

Depression, Anxiety, and Pharmacotherapy Around the Time of Pregnancy in Hawaii Emily K. Roberson 1,2 & Eric L. Hurwitz 2 & Dongmei Li 3 & Robert V. Cooney 2 & Alan R. Katz 2 & Abby C. Collier 4

# International Society of Behavioral Medicine 2015

Abstract Background Depression and anxiety are common conditions among pregnant and postpartum women, but population-based information is lacking on treatments and help-seeking behaviors. Purpose This study described the prevalence of depression, anxiety, pharmaceutical treatment, and help-seeking behaviors among a multiethnic population of women with recent live births in Hawaii. Method Hawaii Pregnancy Risk Assessment Monitoring System data from 4735 respondents were weighted to be representative of all pregnancies resulting in live births in Hawaii in 2009–2011 and were used to estimate the prevalence of several indicators related to anxiety and depression before, during, and after pregnancy among women with recent live births. Results Of Hawaii women with live births in 2009–2011, 7.3 % reported visiting a healthcare worker to be checked or treated for depression or anxiety in the year before their most recent pregnancy, 4.9 % reported having depression in the 3 months before pregnancy, 5.9 % reported having anxiety in the same period, 9.1 % screened positive for postpartum depression, and 6.9 % reported asking a doctor, nurse, or other healthcare worker for help for anxiety postpartum. The prevalence of antianxiety and antidepressant prescription drug use was 2.3 % in the month before pregnancy and 1.4 % during pregnancy. Hawaii had lower * Emily K. Roberson [email protected] 1

Hawaii State Department of Health, 3652 Kilauea Avenue, Honolulu, HI 96816, USA

2

Office of Public Health Studies, University of Hawaii at Mānoa, 1960 East–West Road, Honolulu, HI 96822, USA

3

Clinical and Translational Science Institute, University of Rochester Medical Center, 601 Elmwood Ave, CU420708, Rochester, NY 14642, USA

4

The University of British Columbia, Vancouver Campus, 6609-2405 Wesbrook Mall, Vancouver, BC, Canada V6T 1Z3

prevalence of pre-pregnancy depression, anxiety, and depression/ anxiety health visits than other US states. Pre-pregnancy depression and anxiety and postpartum anxiety help-seeking behaviors differed significantly by race/ethnicity. Conclusion Depression and anxiety are common among pregnant and postpartum women in Hawaii. More research could better inform heath care professionals and patients of the treatment options available and their potential risks and benefits. Keywords Depression . Anxiety . Pregnancy . Psychiatric medication

Introduction Depression and anxiety are common among pregnant and postpartum women, as well as among women of reproductive age in general [1–5]. Anxiety, depression, and other psychiatric disorders occurring around the time of pregnancy have been associated with poor birth outcomes, decreased maternal health, and continued ill effects throughout infancy and childhood [2, 6–8]. Treatments for depression and anxiety include counseling or therapy, behavioral interventions, and prescription medications [3, 9]. However, pregnant and postpartum women require special considerations [9–11]. There is much that is not known about the safety of specific psychiatric medications, particularly in pregnancy. Pregnant women are frequently excluded from clinical trials for ethical and methodological reasons, so much of the research regarding medication exposures during pregnancy relies on information extrapolated from animal studies or on case reports and registries measuring adverse outcomes occurring in populations after the fact [12]. Recent United States (US) studies show that only 4 % of the most commonly reported medications used during the first trimester of pregnancy had a Bgood to excellent^ quality and quantity of safety data available to determine teratogenic potential; the vast majority had insufficient data to determine risks [13].

Int.J. Behav. Med.

Healthcare providers treating women with psychiatric conditions must be concerned with the potential dangers of continuing treatment that has unknown safety throughout pregnancy, and this must be balanced with the dangers of discontinuing treatment [10]. As has been shown with medications treating other chronic diseases during pregnancy, some providers choose to administer medications at lower levels in an attempt to reduce perceived risks to the fetus [12, 14]. If dosages fall below therapeutic thresholds, however, the pregnancy could be complicated by the underlying chronic condition [12, 14]. This is problematic with chronic psychiatric conditions as maternal depression and anxiety have both been independently associated with harmful maternal behaviors during pregnancy as well as poor birth outcomes [10, 15–17]. Patients are also often fearful of potentially harming their fetuses with prescription drugs during pregnancy and may become noncompliant with necessary treatment as a result [18]. Both of these scenarios are of special concern with regards to psychiatric medications as reducing or discontinuing medication can cause a relapse of serious psychiatric symptoms, including self-harm behaviors [12, 19, 20]. Anxiety and depression before, during, and after pregnancy, along with related help-seeking behaviors and treatment strategies, are not well described for the state of Hawaii. A small study conducted at a community medical center in the state among pregnant Asian, Native Hawaiian, and White women found that approximately 5 % screened positive for probable depression and 13 % screened positive for probable anxiety, with no statistically significant differences by race [21]. Pre-pregnancy and postpartum depression and anxiety prevalence, treatment, or help-seeking behaviors were not examined. A previous analysis by Hayes et al. of Hawaii Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2004 to 2007 indicated that symptomology consistent with postpartum depression (PPD) was relatively common, with approximately 14.5 % of women reporting PPD symptoms and 30.1 % reporting possible PPD symptoms, which differed significantly by race and ethnicity [22]. However, subsequently, the Centers for Disease Control and Prevention (CDC) in collaboration with the University of Iowa conducted an in-depth evaluation of the two PRAMS PPD symptomology questions used and recommended the addition of a third PPD symptomology question along with the utilization of a standardized cutoff point indicating PPD for analysis of future years of PRAMS survey data [23]. The Hayes et al. study also did not address pre-pregnancy anxiety or depression, psychiatric medication use, or postpartum help-seeking behavior. A more recent study using 2008 data from the Hawaii Behavioral Risk Factor Surveillance System found that Pacific Islander adults had higher rates of severe depression when compared with Asian adults in Hawaii [24], but this study did not discuss pregnant women specifically nor did it examine anxiety, help-seeking behavior, or psychiatric medication use.

Hawaii has a unique population in terms of race and ethnicity. There is no racial majority, and when compared to the other states in the US, Hawaii has the highest percentage of Asian residents, the highest percentage of multiracial residents, and the lowest percentage of White residents [25]. Approximately 38.6 % of the population of Hawaii identifies as Asian alone (with Filipino and Japanese being the most common groups at 14.5 % and 13.6 %, respectively), 24.7 % as White alone, 10.0 % as Native Hawaiian or other Pacific Islander alone, and 23 % as mixed race [25]. The picture becomes more complicated when taking into account the relative distribution of different race groups among mixed-race individuals, with 57.4 % of Hawaii residents being wholly or partly of Asian descent (meaning Asian race alone or in combination with another race), 41.5 % wholly or partly of European descent, 26.2 % wholly or partly of Native Hawaiian or other Pacific Islander descent, 2.9 % wholly or partly of African descent, 2.5 % wholly or partly of American Indian or Alaska Native descent, and 2.5 % wholly or partly some other race [25]. An estimated 42 % of all marriages in Hawaii in 2008–2010 were between individuals of different races [26], and the majority of infants born in the state are of mixed race [27]. In addition, the number of mixed-race individuals in Hawaii is far exceeded by the number of individuals identifying as mixed ethnicity [28]. The multiracial and multiethnic nature of the population of Hawaii means that the generalizability of research findings from studies conducted outside the state is unclear with regards to many different topics [29, 30]. Despite the fact that Asians and Pacific Islanders comprise the two fastest-growing race groups in the USA [31, 32], a 2003 study found that health research focusing on these populations is severely insufficient, with less than 0.2 % of all federally funded health-related grants even mentioning Asian or Pacific Islander Americans as groups being studied [33]. A MEDLINE search found that only 0.01 % of the published research available addressed Asian or Pacific Islander American health [33]. In addition, Asians and Pacific Islanders are often aggregated into a combined BAsian Pacific Islander^ grouping, which renders invisible important information on health disparities between different Asian and Pacific Islander subgroups [33–38]. Prevalence of depression and anxiety around the time of pregnancy, as well as throughout the lifespan, along with associated treatments and health-seeking behaviors had been shown to vary significantly between countries and sub-country regions [39–43] as well as between racial and ethnic groups within the same countries or regions [44–49]. This study included data on racial and ethnic groups not commonly reported in the scientific literature [28, 29, 33, 38, 50–52] as it sought to describe the prevalence of depression and anxiety, along with pharmaceutical treatment and help-seeking behaviors, among a multiracial and multiethnic population of women who recently delivered a live infant in Hawaii.

Int.J. Behav. Med.

Methods Data Source A secondary data analysis was performed of Hawaii PRAMS data from 2009 to 2011. PRAMS is a survey of women with recent live births designed to collect information on behaviors, attitudes, and experiences before, during, and immediately after pregnancy. PRAMS operates according to a standardized data collection protocol involving a mailed self-administered survey with follow-up by telephone for non-responders. Individuals are selected for participation as part of a stratified sample drawn from certificates of live births in Hawaii. Respondents complete the survey 3–8 months postpartum, with most responding 3– 4 months postpartum. In addition to information collected from

survey questions, the Hawaii PRAMS dataset includes selected linked birth certificate variables. Data are weighted annually according to CDC protocol to be representative of all pregnancies resulting in live births in Hawaii in a given year. PRAMS programs must achieve a minimum weighted response rate of 65 % for survey results to be considered generalizable to all live births in the participation area in a given year. Annual weighted response rates for Hawaii PRAMS in the years 2009–2011 ranged from 71 to 73 %. More comprehensive information on PRAMS methodology can be found at http://www.cdc.gov/ prams/Methodology.htm. Measures The following questions were used for this analysis:

At any time during the 12 months before you got pregnant with your new baby, did you do any of the following things? For each item, circle Y (Yes) if you did it or circle N (No) if you did not. f.

I visited a health care worker to be checked or treated for depression or anxiety

During the 3 months before you got pregnant with your new baby, did you have any of the following health problems? For each item, circle Y (Yes) if you had the problem or circle N (No) if you did not. g.

Depression

h.

Anxiety

During any of your prenatal care visits, did a doctor, nurse, or other health care worker talk with you about any of the things listed below? Please count only discussions, not reading materials or videos. For each item, circle Y (Yes) if someone talked with you about it or circle N (No) if no one talked with you about it. k.

What to do if I feel depressed during my pregnancy or after my baby is born

Below is a list of feelings and experiences that women sometimes have after childbirth. Read each item and determine how well it describes your feelings and experiences. Then, write on the line the number of the choice that best describes how often you have felt or experienced things this way since your new baby was born. Use the scale when answering: 1 Never

2 Rarely

3 Sometimes

4 Often

a.

I felt down, depressed, or sad

b.

I felt hopeless

c.

I felt slowed down

5 Always

Int.J. Behav. Med.

Since your baby was born, have you asked for help for anxiety from a doctor, nurse, or other health care worker? No Yes

Did you use any of these drugs in the month before you got pregnant? For each item, circle Y (Yes) if you used it or circle N (No) if you did not. a.

Prescription drugs

If yes, what kinds? Please tell us: _________________________

Did you use any of these drugs when you were pregnant? For each item, circle Y (Yes) if you used it or circle N (No) if you did not. a.

Prescription drugs

If yes, what kinds? Please tell us: __________________________

Written responses to the prescription drug questions were manually reviewed to correct for misspellings, multiple drugs listed, and other factors. When initial determination was difficult, clinicians and other resources were consulted to determine which drug was being referenced. Responses were coded into category groups using SAS 9.2 (SAS Institute Inc., Cary, NC) Bstring^ and Bupcase^ commands. Medications with possible indications in multiple groups were cross-checked with maternal and/or birth certificate report of diagnoses to determine the most likely group for categorization. For example, drugs such as lorazepam that could be prescribed for psychiatric or non-psychiatric conditions were cross-checked with maternal report of medical conditions to determine the most likely categorization and then were individually coded by a unique ID number. Entries of more than 30 characters were listed in a separate comment file, which was also manually reviewed, with responses coded into groupings by a unique ID number. The following prescription drugs (alone or in combination) were reported as used either before or during pregnancy in our dataset and were included in this analysis: alprazolam, amitriptyline, aripiprazole, bupropion, buspirone, citalopram, clonazepam, diazepam, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, lamotrigine, lorazepam, nortriptyline, paroxetine, quetiapine, sertraline, trazodone, and venlafaxine. Entries that did not specifically list drug names but instead included a reference to non-specific antidepressant or anxiety medication were also included.

Maternal age, race/ethnicity, education level, marital status, and parity were determined based on linked birth certificate variables included in the Hawaii PRAMS dataset. The maternal race/ethnicity variables were sorted into single race/ethnic groups based on a standard algorithm used by the Hawaii State Department of Health Office of Health Status and Monitoring [50]. According to this algorithm, if multiple ethnicities are reported on the birth certificate form, the following rules apply: (1) if Hawaiian is one of the ethnicities listed, the individual is classified as part-Hawaiian (simply referred to as Hawaiian for this analysis), (2) if any non-White ethnicity is listed with White, the individual is classified as of the nonWhite ethnicity, (3) if more than one non-White ethnicity is listed, the individual is classified as the first non-White ethnicity listed, and (4) if more than one White ethnicity is listed, the individual is classified as the first white ethnicity listed [50]. Federal Poverty Level (FPL) was based on a maternal report in the Hawaii PRAMS survey of annual household income and number of dependents in the year before delivery and was calculated according to year-specific Hawaii-specific threshold guidelines. PPD was assessed using the Hawaii PRAMS question asking about feelings and experiences that women sometimes have after childbirth, along with three subparts using a Likert scale. Based on question analysis and testing conducted by the CDC in coordination with the University of Iowa, CDC recommends using a cutoff of greater

Int.J. Behav. Med.

than or equal to 10 as an indication of PPD symptoms [53]. The cutoff point is calculated by adding parts A, B, and C of the depression question together (depressed, hopeless, and slowed down). This provides a sensitivity of 57 % and a specificity of 87 % [53]. Weighted frequency distributions and summary statistics were used to describe population characteristics using SAS-callable SUDAAN 10.0 (RTI International, Research Triangle Park, NC, USA) to account for complex sampling, and weighted chi-square tests were used to examine the association between pharmaceutical treatment and depression and anxiety. All significance levels were set at 5 %. Secondary analysis of this dataset is covered under pre-existing approvals granted by the Hawaii State Department of Health Institutional Review Board and the Institutional Review Board of the Human Research Protection Office of the CDC.

Results Data for 4735 respondents were used in this study, weighted to represent a total population of approximately 55,691 individuals with live births in Hawaii in 2009–2011. Maternal demographic characteristics and selected maternal mental health indicators before and after pregnancy are shown in Table 1. Overall, 4.9 % reported having depression in the 3 months before pregnancy, 5.9 % reported having anxiety in the same time period, 9.1 % screened positive for postpartum depression, and 6.9 % reported asking a doctor, nurse, or other healthcare worker for help for anxiety since their new baby was born (Table 1). There was significant overlap between pre-pregnancy depression and anxiety, with 7.6 % of women reporting suffering from anxiety, depression, or both in the 3 months before pregnancy (Table 2). Prevalence of pre-pregnancy depression was highest among women of other or unknown race/ethnicity (12.9 %), followed by White women (6.8 %) and women with annual household income at or below 100 % FPL (6.3 %). Differences in pre-pregnancy depression prevalence by race/ethnicity and FPL were statistically significant at the p

Depression, Anxiety, and Pharmacotherapy Around the Time of Pregnancy in Hawaii.

Depression and anxiety are common conditions among pregnant and postpartum women, but population-based information is lacking on treatments and help-s...
344KB Sizes 2 Downloads 6 Views