Matern Child Health J DOI 10.1007/s10995-014-1511-2
Prevalence of Serious Psychological Distress and Mental Health Treatment in a National Sample of Pregnant and Postpartum Women Cristie Glasheen • Lisa Colpe • Valerie Hoffman Lauren Klein Warren
•
Ó Springer Science+Business Media New York (outside the USA) 2014
Abstract This study examines the prevalence and correlates of past month serious psychological distress (SPD) and past year mental health treatment (MHT) across pregnancy and the postpartum. Data are from the 2008 to 2012 National Surveys on Drug Use and Health. Prevalence estimates of SPD as well as MHT among women with SPD were generated for each trimester and across the postpartum period. Correlates of SPD and MHT were examined among pregnant and postpartum women. The prevalence of past month SPD was 6.4 % in first trimester women and 3.9 % in third trimester women. In postpartum women, SPD prevalence ranged from 4.6 % (0–2 months) to 6.9 % (3–5 months). Correlates of SPD among pregnant and postpartum women included being younger; non-Hispanic black; unmarried; making under $20,000 annually; having past month cigarette use; or having a past year alcohol or illicit drug use disorder. Only 38.5 % of pregnant and 49.5 % of postpartum women with past month SPD reported past year MHT. Those who received MHT were more likely to be white; widowed, divorced, or separated; have insurance; and have a history of depression or anxiety than their counterparts with no MHT. Pregnant women with SPD were less likely to report past C. Glasheen V. Hoffman L. K. Warren RTI International, 3040 Cornwallis Rd., Research Triangle Park, NC 27709, USA e-mail: [email protected] V. Hoffman e-mail: [email protected] L. K. Warren e-mail: [email protected] L. Colpe (&) National Institute of Mental Health, 6001 Executive Boulevard, Bethesda, MD 20892-9663, USA e-mail: [email protected]; [email protected]
year MHT than postpartum women, even after adjusting for potential confounders. Over half of pregnant and postpartum women with past month SPD are not receiving MHT. Increased contact with health care professionals during this time may be an opportunity for screening, identification, and referral to MHT. Keywords Pregnancy Postpartum Psychological distress Mental health treatment Mental health service use
Introduction Maternal distress during pregnancy and the postpartum period may adversely affect fetal and early childhood development [1–5] and have a negative impact on maternal quality of life [6, 7]. Moreover, the severity of distress may affect these outcomes [8, 9]. Despite this, few studies have estimated the prevalence of serious psychological distress (SPD) among pregnant or postpartum women from general populations, and methodological issues with those studies limit their generalizability [10, 11]. Previous studies have shown fluctuation in psychological distress across pregnancy and the postpartum period. Kearns et al. [11] examined patterns of psychological distress from pregnancy into the postpartum period in a small group of New Zealand women recruited from antenatal classes. Using the Edinburgh Postnatal Depression Scale, the study found a decrease in psychological distress from the third trimester through 10 weeks postpartum. In a small study of women with low-risk pregnancies, DiPietro et al. [10] followed women from the second half of pregnancy through 2 years postpartum and also found that mean levels of psychological distress decreased from
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pregnancy to 2 years postpartum but only among multiparous women. Psychological distress was lower and more stable among primiparous women when compared with distress levels of multiparous women. However, none of these studies examined the prenatal and postpartum periods with nationally representative samples. Researchers have examined factors associated with psychological distress during pregnancy and the postpartum and found that pregnant and postpartum women are at higher risk for distress if they are older [11, 12], are single [13], have less education [12, 14–17], have low social support [11, 14], are unemployed [12, 14, 18], or have financial instability [12]. In addition, tobacco [19, 20], alcohol use [20, 21], and prior psychological problems [16, 22] have been linked to distress among pregnant and postpartum women. One under researched area is mental health treatment (MHT) among pregnant and postpartum women. Pregnancy and the postpartum are times of increased contact with medical professionals and present opportunities for women experiencing psychological distress to be identified and advised of treatment options. One report using data from a nationally representative study of US adults found that pregnant women with psychiatric disorders were less likely to seek MHT than nonpregnant women with psychiatric disorders [23]. The current study uses US population-based data to examine (a) the prevalence of SPD by pregnancy trimester and postpartum period; (b) the demographic, health, and behavioral correlates of SPD in pregnant and postpartum women; and (c) the proportion and correlates of pregnant and postpartum women with SPD who received MHT. Better identification of the prevalence and correlates of SPD among pregnant and postpartum women may help target screening and treatment for women at high risk for SPD.
Methods Sample Data are from the 2008 to 2012 National Surveys on Drug Use and Health (NSDUHs), a nationally representative cross-sectional survey of the civilian, noninstitutionalized US population aged 12 and older conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA). This stratified household-based survey covers residents of households, civilians living on military bases, and persons in noninstitutional group quarters. Excluded from the survey are persons with no fixed household address (e.g., homeless and/or transient persons not in shelters), activeduty military personnel, and residents of institutional group quarters, such as correctional facilities and mental
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institutions. Data are collected in person using computerassisted interviewing (CAI) methods to provide a private and confidential setting for the interview [24]. The primary analytic sample consisted of women aged 18–44 who were currently pregnant (n * 4,600), postpartum (n * 8,000), and not pregnant or postpartum (n * 80,400). Women who were missing trimester data (n \ 30) were excluded. Measures Pregnancy/Postpartum Status Pregnancy status was self-reported. Postpartum status was identified through questions asking respondents about the age and number of biological children living in the household. Women were classified as postpartum if they had a biological child of 12 months or younger living in the household. Women who were both pregnant and postpartum were classified as pregnant. Outcomes There were two outcomes of interest: SPD and MHT. Past month (30 days) psychological distress was measured using the Kessler 6-item (K6) distress scale, a self-report screener that evaluates nonspecific psychological distress and has been clinically validated to maximize the scale’s discernment of serious mental illness [25, 26]. A cut point of 13 or higher is an indicator of SPD [27, 28]. Past year MHT was defined as having received inpatient or outpatient treatment, or prescription medication for ‘‘problems with emotions, nerves, or mental health’’ in the 12 months before the survey, not including treatment for alcohol or drug use. Covariates Covariates were drawn from the relevant literature and include demographics, family environment, physical and mental health status, and tobacco, alcohol, and drug use. Demographics included age, race/ethnicity, marital status, education, employment, income, and poverty status [using the US Census Bureau’s Federal Poverty Level calculation (FPL)]. Family environmentrelated covariates included having had a rapid repeat birth (defined in Healthy People 2010 as having two biological children within 24 months of age of each other living in the household [29]) and the number of biological children in the household. Physical and mental health-related covariates included health insurance status, overall health status, number of significant health problems in the past year, and lifetime history of depression or anxiety (respondent reported being diagnosed with depression or anxiety by a doctor). Substance use included past month cigarette use, past year alcohol use disorder, and past year illicit drug use and illicit drug use disorder.
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Analyses SPD Analyses Prevalence estimates of SPD were generated for all pregnant women and for each trimester and for all postpartum women and then grouped into four categories of postpartum months (0–2, 3–5, 6–8, and 9–12 months postpartum). Prevalence estimates were also estimated for nonpregnant/nonpostpartum women. Differences in demographic characteristics between women with and without SPD were evaluated among pregnant and postpartum women. Statistical testing was conducted using Shah’s Wald F tests (transformed from the standard Wald Chi square) for overall significance to control for multiple comparisons and t tests for post hoc comparisons of proportions. T tests are used because the t-distribution more accurately describes the test statistic under finite sample sizes when the variances of the test statistic are estimated. For more details, see the 2012 National Survey on Drug Use and Health: Statistical Inference Report [30]. Multivariable logistic regression analyses were used to evaluate the adjusted association of pregnancy status with SPD.
MHT Analyses Prevalence estimates of MHT were generated for pregnant and postpartum women with SPD, overall and by trimester/ postpartum category and among nonpregnant/nonpostpartum women. Differences in demographic characteristics between women with SPD who did and did not receive MHT were evaluated similar to the methods used for SPD. For these analyses, pregnant and postpartum women with SPD were combined to increase the sample size. Multivariable logistic regression analyses were used to evaluate the adjusted association of pregnancy status with MHT. All analyses were conducted using SUDAANÒ [31] to account for NSDUH’s complex survey design. All statistical tests were two-tailed, with an alpha of 0.05; 95 % confidence intervals (CIs) are also shown. The study was approved by the RTI International Institutional Review Board.
Results SPD Prevalence of SPD Past month SPD prevalence was similar in pregnant (4.8 %) and postpartum women (5.4 %); these rates were lower than the prevalence of SPD among nonpregnant/
nonpostpartum women (7.4 %; p \ 0.001 and p \ 0.001, respectively; Fig. 1). Across trimesters, SPD prevalence was 6.4 % in first trimester women, significantly higher than the 4.3 % among second trimester women (p = 0.036), and the 3.9 % among third trimester women (p = 0.016). In postpartum women, SPD prevalence was 4.6 % at 0–2 months postpartum and then hovered between 5.1 % (9–12 months postpartum) and 6.9 % (3–5 months postpartum). The prevalence of SPD in the first trimester did not differ significantly from the prevalence in each of the postpartum windows (p [ 0.05). Examining only women who had been pregnant at least once, the prevalence of SPD increased linearly from 4.8 % among pregnant women to 5.4 % among postpartum women to 6.3 % among women who had at least one biological child but were not currently pregnant or postpartum (t test for linear trend = 3.32, p \ 0.001). The prevalence of SPD was significantly lower among pregnant women aged 35–44 (0.8 %) than among postpartum (3.2 %) and nonpregnant/nonpostpartum women (5.9 %, Table 1). A similar pattern of differences (SPD being lower among pregnant than among postpartum and nonpregnant/nonpostpartum women) was seen among married women, women with an annual income between $50,000 and $74,999, women with a family income 200 % or more above FPL, women who had had a prior rapid repeat birth, and women with no serious health problems. The prevalence of SPD across race/ethnicity, education, employment, insurance status, health status, history of depression or anxiety, past month cigarette use, and past year alcohol or illicit drug use, did not differ by pregnancy status. Correlates of SPD Among Pregnant and Postpartum Women Correlates of past month SPD were largely similar among pregnant and postpartum women (Table 2). SPD was associated with being in the youngest age group (18–25), being unmarried, having less education, being unemployed, making \$20,000 annually, living below FPL, being in good or fair/poor health, having a significant health problem, having a lifetime history of depression or anxiety, smoking cigarettes in the past month, having an alcohol use disorder in the past year, using illicit drugs in the past year and having a past year illicit drug use disorder. Race/ethnicity was also associated with SPD. However, this association was not the same in pregnant and postpartum women. An estimated 20.9 % of pregnant women with SPD were black, compared with 13.1 % of pregnant women without SPD. Among postpartum women, there was no association between being black and having past month SPD, but fewer postpartum women with SPD were
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Fig. 1 Prevalence (and 95 % CI) of SPD among females aged 18–44 by pregnancy or postpartum status: annual averages, National Surveys on Drug Use and Health, 2008–2012. Source 2008–2010 (revised 3/12) and 2011–2012 SAMHSA NSDUHs
Hispanic (14.5 %) than women without SPD (21.7 %). Number of biological children in the household, and health insurance status were not associated with SPD. Adjusted Odds of SPD by Pregnancy Status Evaluating the adjusted odds of past month SPD among women aged 18–44 indicated that nonpregnant/nonpostpartum women had 50 % greater odds of SPD than pregnant women [odds ratio (OR) 1.51, p \ 0.001; Table 3]. The odds of SPD was also higher among postpartum women than pregnant women; however, this difference only approached significance (OR 1.27, p = 0.051). MHT Prevalence and Pattern of MHT Only 38.5 % of pregnant women, 49.5 % of postpartum women, and 51.5 % of nonpostpartum/nonpregnant women with past month SPD reported receiving MHT in the past year (Fig. 2). The prevalence of MHT among pregnant women ranged from 35.5 % among second trimester women to 43.8 % among third trimester women. The prevalence of MHT in the postpartum period ranged between 44.8 % (3–5 months) to 53.6 % (9–12 months). The prevalence of
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past year MHT was lower among pregnant women than among postpartum women (p = 0.036) and nonpregnant/ nonpostpartum controls (p = 0.002). The prevalence of MHT was lower among never married pregnant or postpartum women (36.6 %; Table 1) than among their nonpregnant/nonpostpartum counterparts (46.1 %). Similarly, the prevalence of MHT was lower among pregnant and postpartum women with an employment status of ‘‘other’’ (45.5 %) than among their nonpregnant/nonpostpartum counterparts (60.7 %). A similar pattern of SPD prevalence (lower in pregnant/postpartum women than their nonpregnant/nonpostpartum counterparts) was seen among women making \$20,000 annually, women with a family income below the federal poverty threshold, women with one or two biological children living in the household, women with insurance, those with a health problem, and women who did not smoke cigarettes in the past month. The prevalence of MHT across pregnancy/postpartum status did not differ by age, race/ethnicity, education, rapid repeat birth, health status, and history of depression or anxiety. Correlates of MHT Receipt Among Pregnant and Postpartum Women Pregnant and postpartum women with past month SPD who received MHT in the past year were more likely to be
Matern Child Health J Table 1 Weighted prevalence of past month SPD and past year use of MHT by pregnancy/postpartum status and selected characteristics, among women aged 18–44, percentage and standard error (SE) Covariates
SPD
MHT among women with SPD
Nonpregnant and nonpostpartum (*80,400)1
Pregnant (*4,600)
Postpartum (*8,000)
Nonpregnant and nonpostpartum (*6,700)1
Pregnant or postpartum (*900)
18–25
9.4 (0.18)
8.2 (0.63)
8.0 (0.49)
39.4 (0.94)
40.6 (2.51)
26–34
7.2 (0.28)
3.2 (0.63)
4.5 (0.62)
56.3 (1.99)
50.5 (5.65)
61.3 (2.10)
* (*)
Age group
35–44
a,b
5.9
(0.25)
0.8
b,c
(0.48)
a,c
3.2
(0.87)
Race/ethnicity White
7.8 (0.17)
4.6 (0.51)
5.9 (0.52)
60.9 (1.11)
55.4 (3.79)
Black
8.0 (0.38)
7.5 (1.37)
6.7 (0.90)
37.1 (2.77)
34.7 (5.59)
Other
5.6 (0.43)
2.9 (0.93)
4.7 (1.50)
33.2 (3.40)
* (*)
Hispanic
6.1 (0.33)
4.5 (0.87)
3.7 (0.64)
33.1 (2.73)
* (*)
Married
4.9a,b (0.20)
2.4b,c (0.43)
3.6a,c (0.43)
55.6 (2.14)
52.3 (5.02)
Widowed, divorced, or separated
10.3 (0.47)
9.9 (2.17)
15.0 (3.05)
61.6 (2.44)
* (*)
Never married
9.0 (0.20)
8.4 (0.83)
7.0 (0.57)
46.1d (1.18)
36.6 (3.15)
Marital status
Education Less than high school
12.1 (0.52)
9.1 (1.31)
6.5 (0.79)
43.5 (2.32)
41.1 (4.49)
High school
9.3 (0.29)
7.0 (0.96)
8.4 (0.94)
47.9 (1.59)
41.9 (4.49)
Some college
7.5 (0.26)
4.4 (0.78)
5.3 (0.70)
55.6 (1.66)
49.1 (4.97)
College graduate
3.6 (0.19)
1.1 (0.34)
2.2 (0.52)
61.8 (2.61)
* (*)
Employment status Employed full time
5.2 (0.17)
3.4 (0.47)
4.7 (0.61)
50.5 (1.74)
46.6 (5.39)
Employed part time
7.1 (0.27)
3.7 (0.73)
4.2 (0.65)
44.6 (1.98)
39.7 (5.26)
Unemployed
13.0 (0.59)
10.6 (2.22)
11.2 (1.93)
42.9 (2.42)
* (*)
Other (including not in labor force)
10.8 (0.39)
5.8 (0.82)
5.8 (0.60)
60.7d (1.72)
45.5 (4.20)
\$20,000
11.8 (0.36)
9.3 (1.07)
8.7 (0.89)
51.4d (1.53)
42.0 (3.87)
$20,000–$49,999
7.9 (0.25)
5.7 (0.78)
6.0 (0.66)
48.8 (1.63)
43.6 (4.34)
$50,000–$74,999
5.6a (0.32)
2.6b,c (0.68)
5.2a (1.07)
58.9 (2.81)
* (*)
C$75,000
4.3 (0.21)
1.6 (0.55)
2.2 (0.48)
51.6 (2.48)
* (*)
Below FPL
12.0 (0.39)
9.2 (1.20)
8.5 (0.84)
49.2d (1.62)
39.0 (3.87)
100–199 % FPL
8.7 (0.31)
6.1 (0.92)
4.9 (0.59)
50.3 (1.88)
50.7 (4.80)
C200 % FPL
5.3a,b (0.16)
2.5b,c (0.39)
3.9a,c (0.55)
54.0 (1.56)
51.8 (5.69)
Income
Federal poverty level (FPL)
Rapid repeat birth Current
N/A
5.9 (1.13)
6.1 (0.80)
N/A
44.4 (5.43)
Past
5.9a (0.34)
2.0b,c (0.71)
6.4a (1.34)
52.4 (2.90)
* (*)
Neither
7.7 (0.16)
4.9 (0.47)
5.1 (0.44)
51.3 (1.04)
47.8 (3.50)
0
8.6a (0.20)
5.1c (0.55)
N/A
48.4 (1.19)
N/A
1
7.2 (0.33)
4.5 (0.65)
6.0 (0.57)
56.4d (2.32)
45.9 (4.28)
2
5.4 (0.27)
4.5 (1.16)
4.9 (0.67)
55.9d (2.87)
42.7 (5.94)
C3
6.5 (0.43)
5.2 (1.81)
5.2 (0.74)
52.5 (3.46)
* (*)
6.8 (0.16)
4.5 (0.40)
5.3 (0.42)
56.5d (1.15)
49.4 (3.11)
Number of biological children in the household
Health insurance Has insurance
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Matern Child Health J Table 1 continued Covariates
Does not have insurance
SPD
MHT among women with SPD
Nonpregnant and nonpostpartum (*80,400)1
Pregnant (*4,600)
Postpartum (*8,000)
Nonpregnant and nonpostpartum (*6,700)1
Pregnant or postpartum (*900)
9.3 (0.33)
7.6 (1.88)
6.0 (0.89)
37.4 (1.70)
* (*)
Health status Excellent
3.1 (0.17)
1.8 (0.34)
2.4 (0.44)
38.9 (2.96)
* (*)
Very good
5.6 (0.19)
3.5 (0.50)
4.5 (0.57)
48.1 (1.72)
50.7 (4.95)
Good
9.8 (0.31)
8.8 (1.17)
7.7 (0.90)
49.7 (1.68)
44.5 (4.60)
Fair/poor
22.1 (0.81)
19.9 (4.14)
19.6 (2.81)
63.6 (1.90)
* (*)
None
6.2a,b (0.16)
3.5b,c (0.38)
4.7a,c (0.40)
46.4 (1.29)
44.4 (3.65)
One
9.3 (0.35)
9.5 (1.35)
6.6 (0.82)
53.6d (1.88)
43.3 (4.83)
Two or more History of depression
16.3 (0.86)
* (*)
17.5 (3.98)
73.8 (2.43)
* (*)
Yes
22.5 (0.55)
16.3 (1.84)
18.6 (1.77)
74.9 (1.15)
73.6 (3.57)
No
4.1 (0.12)
3.1 (0.36)
3.3 (0.31)
23.6 (1.22)
21.6 (3.32)
Yes
22.9 (0.61)
15.8 (2.21)
17.7 (2.30)
79.2 (1.21)
77.7 (4.02)
No
5.0 (0.13)
3.7 (0.39)
4.2 (0.34)
32.8 (1.22)
32.6 (3.13)
Health problems
History of anxiety
Past month cigarette use Yes
13.1 (0.36)
11.8 (1.45)
10.9 (1.04)
55.9 (1.36)
55.6 (4.04)
No
5.1 (0.14)
3.5 (0.39)
3.8 (0.37)
47.1d (1.42)
38.4 (3.69)
18.1 (0.68) 6.4 (0.14)
19.3 (3.05) 4.0 (0.39)
25.4 (4.98) 5.0 (0.37)
53.1 (2.10) 51.1d (1.12)
* (*) 44.0 (3.06)
No illicit drug use
5.5 (0.15)
3.4 (0.39)
4.4 (0.38)
50.1d (1.33)
42.8 (3.39)
Illicit drug use, no SUD
11.1 (0.38)
8.3 (1.34)
10.6 (1.65)
50.9 (1.84)
* (*)
Illicit drug SUD
32.2 (1.28)
31.2 (4.65)
31.0 (4.61)
58.4 (2.30)
* (*)
Past year alcohol use disorder Yes No Past year illicit drug use
Source: 2008–2010 (revised 3/12) and 2011–2012 SAMHSA National Surveys on Drug Use and Health (NSDUHs) N/A not applicable, SUD substance use disorder, * low precision, no estimate reported 1
SAMHSA does not permit the reporting of exact sample sizes from the restricted data file to protect against the accidental identification of respondents. Totals may not equal pregnant and postpartum women separately due to rounding
a
Difference between estimate and pregnant SPD estimate, p \ 0.05
b
Difference between estimate and postpartum SPD estimate, p \ 0.05
c
Difference between estimate and Nonpregnant and Nonpostpartum SPD estimate, p \ 0.05
d
Difference between estimate and pregnant/postpartum MHT/counseling estimate, p \ 0.05
white; have health insurance; have a history of depression or anxiety; and have used cigarettes in the past month (Table 2). Not receiving MHT was associated with being black or of an ‘‘other’’ race/ethnicity, and having never been married. Age, education, employment, income, poverty, rapid repeat birth, the number of biological children in the household, health status and significant health problems, past year illicit drug use, and past year alcohol or illicit drug use disorder were not associated with past year MHT among pregnant and postpartum women with SPD.
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Adjusted Odds of MHT Receipt Postpartum women with past month SPD had significantly greater odds of having MHT in the past year than pregnant women (OR 1.77, p = 0.045), after controlling for age, race/ethnicity, marital status, education, employment status, poverty status, history of rapid repeat birth, number of biological children in the household, health insurance, physical health status, number of physical health problems, history of depression or anxiety, past month cigarette use,
Matern Child Health J Table 2 Correlates of past month SPD and past year use of MHT among pregnant and postpartum women, aged 18–44, percentage and standard error (SE) Characteristic
Pregnant women
Postpartum women
Pregnant or postpartum women with SPD
SPD % (SE)
No SPD % (SE)
SPD % (SE)
No SPD % (SE)
MHT % (SE)
No MHT % (SE)
18–25
65.3 (4.71)**
36.9 (1.08)
48.4 (3.53)**
31.8 (0.71)
47.4 (4.04)
59.1 (4.00)
26–34
32.5 (4.74)**
49.6 (1.26)
41.2 (3.87)*
50.1 (0.94)
42.2 (4.58)
35.2 (3.82)
35–44
2.3 (1.29)**
13.6 (1.00)
10.4 (2.63)**
18.1 (0.91)
10.3 (3.34)
5.7 (1.95)
Age group
Race/ethnicity White
56.7 (4.24)
59.8 (1.32)
61.4 (3.48)
56.4 (1.03)
72.2 (3.60)**
49.4 (3.87)
Black
20.9 (3.44)*
13.1 (0.75)
17.0 (2.21)
13.6 (0.63)
13.8 (2.68)*
22.1 (2.83)
Other
4.6 (1.45)*
7.9 (0.90)
7.2 (2.19)
8.3 (0.61)
2.6 (0.73)*
9.6 (2.76)
Hispanic
17.7 (3.14)
19.2 (1.05)
14.5 (2.31)**
21.7 (0.92)
11.5 (2.61)
19.0 (2.75)
Marital status Married
30.3 (4.30)**
62.8 (1.19)
42.2 (3.57)**
63.9 (0.94)
43.8 (4.38)
33.9 (3.70)
Widowed, divorced, or separated
13.2 (2.72)*
6.1 (0.61)
17.8 (3.32)**
5.7 (0.53)
20.2 (4.14)
13.0 (2.71)
Never married
56.5 (4.21)**
31.1 (1.09)
40.1 (3.30)**
30.3 (0.88)
36.1 (3.81)**
53.0 (3.73)
Less than high school
31.2 (3.83)**
15.7 (0.87)
20.0 (2.35)
16.4 (0.75)
21.1 (2.90)
25.7 (2.86)
High school
37.8 (4.14)**
25.2 (1.11)
42.5 (3.52)**
26.5 (0.77)
37.3 (4.20)
43.9 (3.35)
Some college
24.2 (3.67)
Education
26.4 (1.12)
25.2 (2.97)
25.6 (0.85)
26.7 (3.39)
23.5 (2.91)
6.9 (2.14)**
32.6 (1.29)
12.3 (2.65)**
31.5 (0.94)
15.0 (3.59)
6.9 (1.81)
Employed full time
29.3 (3.61)**
42.0 (1.24)
32.5 (3.42)
37.9 (0.93)
31.9 (4.33)
31.1 (3.20)
Employed part time
13.3 (2.51)
17.4 (0.94)
13.7 (1.97)*
17.9 (0.70)
11.8 (2.10)
15.2 (2.16)
College graduate Employment status
Unemployed
15.6 (3.13)**
12.0 (2.09)**
5.5 (0.36)
15.0 (3.17)
11.6 (1.72)
Other (including not in labor force)
41.8 (4.21)
34.0 (1.19)
6.7 (0.47)
41.8 (3.33)
38.8 (0.89)
41.4 (3.96)
42.1 (3.49)
\$20,000 $20,000–$49,999
44.2 (4.10)** 37.2 (4.13)
21.8 (0.97) 31.3 (1.15)
37.5 (3.46)** 35.6 (3.20)
22.6 (0.76) 32.2 (0.89)
36.2 (4.08) 34.2 (3.73)
42.5 (3.38) 37.7 (3.31)
$50,000–$74,999
8.8 (2.24)**
16.6 (0.92)
15.9 (3.01)
16.7 (0.74)
18.0 (4.06)
9.9 (1.88)
C$75,000
9.7 (3.09)**
30.2 (1.30)
11.0 (2.27)**
28.6 (0.94)
11.5 (3.13)
9.9 (2.10)
Below FPL
43.6 (4.18)**
21.8 (1.02)
43.7 (3.65)**
27.0 (0.86)
37.0 (4.15)
49.2 (3.59)
100–199 % FPL
27.3 (3.64)
21.2 (1.02)
21.6 (2.53)
23.8 (0.76)
25.9 (3.42)
21.4 (2.62)
C200 % FPL
29.0 (3.74)**
57.0 (1.28)
34.6 (3.64)**
49.2 (1.00)
37.1 (4.37)
29.3 (3.53)
23.6 (3.98)
19.0 (0.98)
22.0 (2.68)
19.4 (0.76)
21.8 (3.15)
23.2 (3.11)
9.8 (0.80)
12.5 (2.42)
10.4 (0.64)
7.9 (2.17)
11.4 (2.62)
72.5 (4.05)
71.2 (1.15)
65.6 (3.17)
70.1 (0.91)
70.4 (3.61)
65.5 (3.49)
0
43.9 (4.03)
41.4 (1.19)
N/A
N/A
12.3 (2.23)
15.5 (2.06)
1
30.2 (3.70)
32.3 (1.18)
43.1 (3.40)
38.6 (0.95)
38.8 (4.04)
38.9 (3.40)
2
15.7 (3.64)
16.9 (0.94)
30.7 (3.38)
33.9 (0.92)
24.1 (3.79)
27.5 (3.56)
C3 Health insurance
10.3 (3.36)
9.5 (0.84)
26.2 (3.22)
27.5 (0.90)
24.7 (3.97)
18.1 (3.16)
Insured
86.2 (3.10)
91.6 (0.78)
80.2 (2.68)
82.3 (0.77)
88.3 (3.08) *
76.9 (3.05)
Uninsured
13.8 (3.10)
8.4 (0.78)
19.8 (2.68)
17.7 (0.77)
11.7 (3.08)
23.1 (3.05)
Income
Federal poverty level (FPL)
Rapid repeat birth Current Past Neither
3.9 (1.37)**
Number of biological children in the household
Health status
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Matern Child Health J Table 2 continued Characteristic
Pregnant women
Postpartum women
Pregnant or postpartum women with SPD
SPD % (SE)
SPD % (SE)
MHT % (SE)
No SPD % (SE)
No SPD % (SE)
No MHT % (SE)
Excellent
13.2 (2.35)**
35.8 (1.25)
13.9 (2.43)**
32.5 (0.92)
10.4 (2.11)
16.6 (2.76)
Very good
27.6 (3.41)**
38.6 (1.18)
33.5 (3.40)*
40.5 (0.91)
34.9 (4.29)
28.9 (2.83)
Good
42.1 (4.18)**
22.1 (0.95)
32.3 (3.25)**
22.2 (0.79)
34.2 (3.85)
36.3 (3.56)
Fair/poor
17.2 (3.44)**
3.5 (0.43)
20.3 (2.84)**
4.8 (0.42)
20.6 (3.42)
18.2 (2.89)
56.8 (4.37)** 36.6 (4.23)**
79.4 (0.96) 17.8 (0.91)
66.9 (3.08)** 22.6 (2.60)
78.7 (0.75) 18.5 (0.73)
61.5 (4.16) 25.4 (3.56)
65.7 (3.26) 28.4 (3.06)
6.6 (2.61)
2.8 (0.34)
10.4 (2.53)**
2.8 (0.28)
13.1 (3.38)
5.9 (1.91)
Yes
44.3 (4.14)**
11.5 (0.75)
48.2 (3.39)**
12.2 (0.62)
75.1 (3.66)**
23.0 (2.96)
No
55.7 (4.14)
88.5 (0.75)
51.8 (3.39)
87.8 (0.62)
24.9 (3.66)
77.0 (2.96)
30.1 (3.42)**
8.0 (0.51)
50.4 (4.42)**
12.3 (2.12)
Health problems 0 1 C2 History of depression
History of anxiety Yes
29.3 (3.80)**
7.9 (0.62)
No
70.7 (3.80)
92.1 (0.62)
69.9 (3.42)
92.0 (0.51)
49.6 (4.42)
87.7 (2.12)
Yes
39.4 (4.13)**
14.9 (0.82)
46.3 (3.51)**
21.7 (0.75)
53.3 (4.32)**
36.2 (3.29)
No
60.6 (4.13)
85.1 (0.82)
53.7 (3.51)
78.3 (0.75)
46.7 (4.32)
63.8 (3.29)
Past month cigarette use
Past year alcohol use disorder Yes
21.8 (3.32)**
10.3 (2.25)**
1.7 (0.21)
17.6 (3.42)
10.9 (1.87)
No
78.2 (3.32)
95.4 (0.47)
4.6 (0.47)
89.7 (2.25)
98.3 (0.21)
82.4 (3.42)
89.1 (1.87)
Past year illicit drug use No illicit drug use
59.9 (4.08)**
86.6 (0.78)
72.2 (3.09)**
89.4 (0.55)
63.5 (4.08)
72.2 (2.87)
Illicit drug use, no SUD
19.8 (3.01)**
11.1 (0.73)
19.8 (2.90)**
9.6 (0.53)
21.2 (3.88)
18.7 (2.41)
Illicit drug SUD
20.3 (3.32)**
2.3 (0.27)
8.1 (1.39)**
1.0 (0.14)
15.3 (2.48)
9.1 (1.71)
Yes
38.5 (4.04)**
10.4 (0.72)
49.5 (3.53)**
11.7 (0.60)
100
N/A
No
61.5 (4.04)
89.6 (0.72)
50.5 (3.53)
88.3 (0.60)
N/A
100
Past year MHT
Source: 2008–2010 (revised 3/12) and 2011–2012 SAMHSA National Surveys on Drug Use and Health (NSDUHs) N/A not applicable, SUD substance use disorder, – low precision, no estimate reported * Difference (t test of proportion) between SPD and no SPD or MHT and no MHT, p \ 0.05 ** Difference (t test of proportion) between SPD and no SPD or MHT and no MHT, p \ 0.01
and past year alcohol and illicit drug use. The odds of past year MHT was not significantly different among nonpregnant/nonpostpartum women and pregnant women.
Discussion In a nationally representative sample, the prevalence of past month SPD was 4.8 % among pregnant women and 5.4 % among postpartum women. These prevalence estimates appear lower than those reported by Ahluwalia, Mack, and Mokdad (12.3 %) [20], Skari et al. [13] (9 %),
123
and Saurel-Cubizolles et al. [32] (8.7 %). However, there are methodological differences that may account for differences in prevalence and patterns over time. Our study used the K6 instrument to detect SPD, whereas Skari et al. [13] and Saurel-Cubizolles et al. [32] examined clinically significant distress using the General Health Questionnaire, and Ahluwalia et al. [20] used a measure of stress and anxiety frequency from Health Related Quality of Life indicators used in the Behavioral Risk Factor Surveillance System. Thus, the prevalence estimates may reflect differences in both instrumentation and the cut point for distress. Furthermore, we report on the overall average prevalence during the first year postpartum, whereas Skari
Matern Child Health J Table 3 Adjusted odds of SPD among women aged 18–44 and adjusted odds of MHT among women aged 18–44 with SPD Covariate
Serious psychological distress B (SE)
Mental health treatment
OR (95 % CI)
p value
B (SE)
OR (95 % CI)
p value
Pregnancy status Pregnant
Reference
1.00
–
Reference
1.00
–
Postpartum
0.24 (0.12)
1.27 (1.00, 1.62)
0.051
0.57 (0.28)
1.77 (1.01, 3.09)
0.045
Not pregnant or postpartum
0.41 (0.10)
1.51 (1.24, 1.82)
\0.001
0.32 (0.27)
1.38 (0.81, 2.33)
0.237
Age group 18–25
Reference
1.00
–
Reference
1.00
–
26–34 35–44
-0.09 (0.06) -0.28 (0.07)
0.92 (0.82, 1.02) 0.76 (0.65, 0.88)
0.116 \0.001
0.33 (0.12) 0.64 (0.15)
1.40 (1.11, 1.76) 1.89 (1.42, 2.53)
0.005 \0.001
Race/ethnicity White
Reference
1.00
–
Reference
1.00
–
Black
-0.16 (0.06)
0.85 (0.76, 0.95)
0.005
-0.40 (0.13)
0.67 (0.52, 0.88)
0.003
Other
-0.18 (0.09)
0.83 (0.70, 0.99)
0.039
-0.94 (0.18)
0.39 (0.28, 0.55)
\0.001
Hispanic
-0.42 (0.07)
0.66 (0.58, 0.75)
\0.001
-0.66 (0.16)
0.52 (0.38, 0.71)
\0.001
Marital status Married
Reference
1.00
–
Reference
1.00
–
Widowed/divorced/separated
0.34 (0.07)
1.41 (1.23, 1.61)
\0.001
0.16 (0.16)
1.17 (0.86, 1.61)
0.316
Never married
0.09 (0.06)
1.09 (0.96, 1.23)
0.173
0.09 (0.13)
1.09 (0.84, 1.41)
0.499
-0.02 (0.06)
0.98 (0.87, 1.10)
0.718
-0.07 (0.14)
0.93 (0.71, 1.23)
0.625 –
Education Less than high school High school
Reference
1.00
–
Reference
1.00
Some college
-0.17 (0.05)
0.84 (0.76, 0.93)
0.001
0.21 (0.11)
1.24 (1.00, 1.53)
0.050
College graduate Employment status
-0.53 (0.07)
0.59 (0.51, 0.68)
\0.001
0.52 (0.15)
1.69 (1.27, 2.25)
\0.001
Employed full time
Reference
1.00
–
Reference
1.00
–
Employed part time
0.12 (0.06)
1.13 (1.01, 1.26)
0.026
-0.10 (0.12)
0.91 (0.71, 1.16)
0.437
Unemployed
0.48 (0.07)
1.61 (1.41, 1.84)
\0.001
0.09 (0.14)
1.10 (0.83, 1.46)
0.511
Other (including not in the labor force)
0.42 (0.06)
1.52 (1.36, 1.70)
\0.001
0.19 (0.12)
1.20 (0.95, 1.53)
0.125
0.32 (0.05)
1.37 (1.23, 1.53)
\0.001
0.14 (0.11)
1.15 (0.92, 1.44)
0.208
Federal poverty level (FPL) Below FPL 100–199 % FPL
0.17 (0.05)
1.19 (1.07, 1.32)
0.002
0.07 (0.11)
1.08 (0.86, 1.35)
0.529
C200 % FPL
Reference
1.00
–
Reference
1.00
–
Current
0.21 (0.14)
1.23 (0.93, 1.63)
0.152
0.04 (0.33)
1.05 (0.55, 1.99)
0.893
Past
-0.06 (0.10)
0.94 (0.78, 1.14)
0.539
-0.14 (0.20)
0.87 (0.58, 1.30)
0.497
Neither
Reference
1.00
–
Reference
1.00
–
0
0.25 (0.08)
1.29 (1.11, 1.50)
0.001
0.02 (0.18)
1.02 (0.71, 1.46)
0.910
1 2
0.11 (0.08) Reference
1.12 (0.97, 1.30) 1.00
0.134 –
0.12 (0.18) Reference
1.13 (0.80, 1.59) 1.00
0.503 –
C3
0.13 (0.09)
1.13 (0.95, 1.36)
0.171
0.01 (0.22)
1.01 (0.65, 1.57)
0.971
Rapid repeat birth
Number of biological children in the household
Health insurance Insured
Reference
1.00
–
Reference
1.00
–
Uninsured
-0.01 (0.05)
0.99 (0.90, 1.09)
0.774
-0.92 (0.10)
0.40 (0.33, 0.49)
\0.001
Reference
1.00
–
Reference
1.00
–
Health status Excellent Very good
0.44 (0.07)
1.55 (1.36, 1.76)
\0.001
-0.08 (0.15)
0.93 (0.70, 1.23)
0.604
Good
0.89 (0.07)
2.43 (2.13, 2.78)
\0.001
-0.12 (0.15)
0.89 (0.66, 1.19)
0.440
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Matern Child Health J Table 3 continued Covariate
Fair/poor
Serious psychological distress
Mental health treatment
B (SE)
OR (95 % CI)
p value
B (SE)
OR (95 % CI)
p value
1.66 (0.08)
5.24 (4.51, 6.08)
\0.001
0.18 (0.16)
1.20 (0.87, 1.65)
0.277
Health problems 0
Reference
1.00
–
Reference
1.00
–
1
0.24 (0.05)
1.27 (1.15, 1.41)
\0.001
0.18 (0.10)
1.20 (0.98, 1.47)
0.080
C2
0.60 (0.08)
1.82 (1.57, 2.11)
\0.001
0.43 (0.16)
1.54 (1.12, 2.11)
0.008
Yes
0.33 (0.05)
1.39 (1.26, 1.53)
\0.001
0.11 (0.10)
1.11 (0.91, 1.36)
0.306
No
Reference
1.00
–
Reference
1.00
–
Yes
0.71 (0.06)
2.04 (1.81, 2.30)
\0.001
0.11 (0.12)
1.11 (0.88, 1.41)
0.373
No
Reference
1.00
–
Reference
1.00
–
No illicit drug use
Reference
1.00
–
Reference
1.00
–
Illicit drug use, no SUD Illicit drug SUD
0.37 (0.05) 1.28 (0.07)
1.44 (1.30, 1.61) 3.58 (3.11, 4.13)
\0.001 \0.001
-0.12 (0.11) 0.25 (0.14)
0.89 (0.71, 1.10) 1.28 (0.98, 1.67)
0.273 0.069
Yes
N/A
N/A
N/A
1.70 (0.09)
5.50 (4.58, 6.60)
\0.001
No
N/A
N/A
N/A
Reference
1.00
–
Yes
N/A
N/A
N/A
1.30 (0.10)
3.66 (2.98, 4.49)
\0.001
No
N/A
N/A
N/A
Reference
1.00
–
Past month cigarette use
Past year alcohol use disorder
Past year illicit drug use
History of depression
History of anxiety
Source: 2008–2010 (revised 3/12) and 2011–2012 SAMHSA National Surveys on Drug Use and Health (NSDUHs) 95 % CI confidence interval, N/A variable not included in model, OR odds ratio, SUD substance use disorder
et al. [13] report prevalence estimates a few days after birth. Additionally, the study by Saurel-Cubizolles and et al. [32] was conducted in France; cultural variation potentially could affect the comparability of results. Our finding that the prevalence of past month distress was lower among pregnant and postpartum women than among nonpregnant/nonpostpartum women was consistent with other studies that have compared prevalence estimates in these groups. Ahluwalia et al. [20] found that frequent mental distress was more common among nonpregnant women than among pregnant women. Similarly, Wallace et al. [33] and Saurel-Cubizolles et al. [32] found that the lowest prevalence of psychological distress was among pregnant women, compared with postpartum and nonpregnant/nonpostpartum women. This study demonstrates a linear increase in past month SPD prevalence in pregnant, postpartum, and nonpregnant/ nonpostpartum women who had at least one biological child in the household. Previous within-person studies generally have found women to have stable or decreasing levels of psychological distress from pregnancy through postpartum [10, 11, 13, 14, 34]. However, comparisons
123
must be made with caution because studies examining symptom course in individuals often examine changes in overall mean levels of psychological distress [10, 11, 14] and not among individuals meeting a clinical cut point for SPD. It may be that the patterns are different for women reaching clinical thresholds than for women with lower distress scores. Both of these possibilities present an opportunity for future research. Correlates of past month SPD were similar in pregnant and postpartum women. Notably, more than 4 times as many pregnant and postpartum women with SPD reported past year alcohol or illicit drug use disorders than pregnant and postpartum women without SPD; more than twice as many women with SPD reported past month cigarette use than women without SPD. This suggests that physicians who identify pregnant or postpartum women with SPD may need to pay particular attention to smoking, alcohol, and drug use behaviors. Physicians identifying these behaviors in pregnant and postpartum women should also be aware of the increased odds of SPD in these women. Other correlates indicated that younger women, unmarried women, and women of lower socioeconomic status (less education,
Matern Child Health J
Fig. 2 Prevalence (and 95 % CI) of MHT among women with SPD, aged 18–44, by pregnancy or postpartum status: annual averages, National Surveys on Drug Use and Health, 2008–2012. Source 2008–2010 (revised 3/12) and 2011–2012 SAMHSA NSDUHs
lower income, unemployment, and poverty) had the highest prevalence of past month SPD. Perhaps the most important finding was that pregnant women with past month SPD were less likely than postpartum women to report MHT, even after we controlled for potential confounders. These findings were similar to those identified in the National Epidemiologic Survey on Alcohol and Related Conditions, which found that pregnant women with psychiatric disorders were less likely to seek MHT than were nonpregnant women with psychiatric disorders [23]. This may be a result of the lack of screening for mental health problems among obstetrical patients. For example, Birndorf et al. [35] reported that among patients in one obstetrical practice, only 30 % of women who screened positive for depression had discussed the symptoms with their ob-gyn, although 82 % said they would be willing to discuss the symptoms and all of them reported that they would seek MHT if their ob-gyn referred them. Other studies have reported similarly low rates of problem recognition and treatment receipt [36, 37]. Examination of the correlates of MHT among pregnant and postpartum women with past month SPD indicated that non-Hispanic black women and women of an ‘‘other’’ race, unmarried women, and uninsured women had particularly low rates of MHT although all women may benefit from screening. There are a few limitations to this study that should be acknowledged. First, NSDUH is a cross-sectional survey
and not appropriate for the individual course of psychological distress analyses. In NSDUH, individuals who may have had elevated psychological distress in their first trimester are not the same women with elevated distress in the postpartum period. Thus, it is not possible to compare the pattern of prevalence estimates directly to studies that provide longitudinal analyses of distress over time. Second, sample size limitations made comparisons of each trimester and postpartum period imprecise, as evidenced by large confidence intervals. Moreover, the small sample size necessitated combining pregnant and postpartum women with SPD to examine correlates of MHT. Although pregnant and postpartum women with SPD were similar in most characteristics, there were a few significant differences. Compared to pregnant women with SPD, postpartum women with SPD were older, more likely to be married, and less likely to have had a past year alcohol or drug use disorder (results not shown). Future research with a larger sample is needed to determine if there are unique correlates of MHT in pregnant or postpartum women with SPD. Third, misclassification is a concern. NSDUH collects data on past month psychological distress; therefore, women who have just entered a new period (e.g., 1 week into the first postpartum period) may be reporting distress from the prior period. This is more likely to affect estimates using the shorter time increments (trimester and
123
Matern Child Health J
postpartum months) than the combined pregnant and postpartum categories. In addition, measures of MHT reflect any treatment in the past year, so a woman who reported MHT may have received that treatment before, during, or after pregnancy. A similar misclassification can be seen with past year alcohol use disorders and illicit drug use. Pregnant women who report past year drug use may be reporting use prior to pregnancy, whereas postpartum women reporting use are almost assuredly reporting use during pregnancy or the postpartum period. Additional misclassification may have arisen if women who put newborns up for adoption were classified as being nonpregnant/nonpostpartum. However, results from the National Survey of Family Growth suggest that voluntary placement of infants is rare [38]. Women who experienced miscarriages, abortions, or infant deaths also may have been misclassified as being nonpregnant/nonpostpartum women. In these analyses, response bias may have arisen if women close to delivery were less likely to participate in NSDUH. Evaluation of the unweighted frequency of response for each month of pregnancy suggests that this may have occurred: 13.2 % of pregnant women reported being in their eighth month of pregnancy, whereas only 7.1 % of pregnant women were in their ninth month. If past month SPD or past year MHT in pregnant or postpartum women was associated with this potential nonresponse, the direction and magnitude of this bias would be unknown. Even if this potential response bias were not related to SPD or MHT, it would still result in decreased statistical power. Despite these limitations, the prevalence of past month SPD in pregnant and postpartum women is not negligible. An estimated 4.8 % of pregnant women and 5.4 % of postpartum women had SPD; this equates to an estimated 111,000 pregnant and 234,000 postpartum women annually. Moreover, of the women with SPD, more than half did not receive MHT in the past year. Pregnancy and the postpartum period are times of increased contact with medical professionals, providing opportunities for mental health screening and referral to treatment. Some practitioners have recommended [39, 40] and implemented [41, 42] screening and intervention programs; however, the results of this study suggest that there is room for improvement. Acknowledgments The authors would like to acknowledge Christine Ulbricht for her contributions in the early design phase of this project. The National Survey on Drug Use and Health (NSDUH) is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Behavioral Health Statistics and Quality (CBHSQ). This study was funded and approved under SAMHSA Contract No. 284-2010-0003C, Project No. 0212800.002, which was supported by funding from the National Institute of Mental Health (NIMH). The views expressed in this manuscript do not necessarily represent the views of the National Institutes of Health or the Federal Government.
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Prevalence of Serious Psychological Distress and Mental Health Treatment in a National Sample of Pregnant and Postpartum Women Cristie Glasheen • Lisa Colpe • Valerie Hoffman Lauren Klein Warren
•
Ó Springer Science+Business Media New York (outside the USA) 2014
Abstract This study examines the prevalence and correlates of past month serious psychological distress (SPD) and past year mental health treatment (MHT) across pregnancy and the postpartum. Data are from the 2008 to 2012 National Surveys on Drug Use and Health. Prevalence estimates of SPD as well as MHT among women with SPD were generated for each trimester and across the postpartum period. Correlates of SPD and MHT were examined among pregnant and postpartum women. The prevalence of past month SPD was 6.4 % in first trimester women and 3.9 % in third trimester women. In postpartum women, SPD prevalence ranged from 4.6 % (0–2 months) to 6.9 % (3–5 months). Correlates of SPD among pregnant and postpartum women included being younger; non-Hispanic black; unmarried; making under $20,000 annually; having past month cigarette use; or having a past year alcohol or illicit drug use disorder. Only 38.5 % of pregnant and 49.5 % of postpartum women with past month SPD reported past year MHT. Those who received MHT were more likely to be white; widowed, divorced, or separated; have insurance; and have a history of depression or anxiety than their counterparts with no MHT. Pregnant women with SPD were less likely to report past C. Glasheen V. Hoffman L. K. Warren RTI International, 3040 Cornwallis Rd., Research Triangle Park, NC 27709, USA e-mail: [email protected] V. Hoffman e-mail: [email protected] L. K. Warren e-mail: [email protected] L. Colpe (&) National Institute of Mental Health, 6001 Executive Boulevard, Bethesda, MD 20892-9663, USA e-mail: [email protected]; [email protected]
year MHT than postpartum women, even after adjusting for potential confounders. Over half of pregnant and postpartum women with past month SPD are not receiving MHT. Increased contact with health care professionals during this time may be an opportunity for screening, identification, and referral to MHT. Keywords Pregnancy Postpartum Psychological distress Mental health treatment Mental health service use
Introduction Maternal distress during pregnancy and the postpartum period may adversely affect fetal and early childhood development [1–5] and have a negative impact on maternal quality of life [6, 7]. Moreover, the severity of distress may affect these outcomes [8, 9]. Despite this, few studies have estimated the prevalence of serious psychological distress (SPD) among pregnant or postpartum women from general populations, and methodological issues with those studies limit their generalizability [10, 11]. Previous studies have shown fluctuation in psychological distress across pregnancy and the postpartum period. Kearns et al. [11] examined patterns of psychological distress from pregnancy into the postpartum period in a small group of New Zealand women recruited from antenatal classes. Using the Edinburgh Postnatal Depression Scale, the study found a decrease in psychological distress from the third trimester through 10 weeks postpartum. In a small study of women with low-risk pregnancies, DiPietro et al. [10] followed women from the second half of pregnancy through 2 years postpartum and also found that mean levels of psychological distress decreased from
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pregnancy to 2 years postpartum but only among multiparous women. Psychological distress was lower and more stable among primiparous women when compared with distress levels of multiparous women. However, none of these studies examined the prenatal and postpartum periods with nationally representative samples. Researchers have examined factors associated with psychological distress during pregnancy and the postpartum and found that pregnant and postpartum women are at higher risk for distress if they are older [11, 12], are single [13], have less education [12, 14–17], have low social support [11, 14], are unemployed [12, 14, 18], or have financial instability [12]. In addition, tobacco [19, 20], alcohol use [20, 21], and prior psychological problems [16, 22] have been linked to distress among pregnant and postpartum women. One under researched area is mental health treatment (MHT) among pregnant and postpartum women. Pregnancy and the postpartum are times of increased contact with medical professionals and present opportunities for women experiencing psychological distress to be identified and advised of treatment options. One report using data from a nationally representative study of US adults found that pregnant women with psychiatric disorders were less likely to seek MHT than nonpregnant women with psychiatric disorders [23]. The current study uses US population-based data to examine (a) the prevalence of SPD by pregnancy trimester and postpartum period; (b) the demographic, health, and behavioral correlates of SPD in pregnant and postpartum women; and (c) the proportion and correlates of pregnant and postpartum women with SPD who received MHT. Better identification of the prevalence and correlates of SPD among pregnant and postpartum women may help target screening and treatment for women at high risk for SPD.
Methods Sample Data are from the 2008 to 2012 National Surveys on Drug Use and Health (NSDUHs), a nationally representative cross-sectional survey of the civilian, noninstitutionalized US population aged 12 and older conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA). This stratified household-based survey covers residents of households, civilians living on military bases, and persons in noninstitutional group quarters. Excluded from the survey are persons with no fixed household address (e.g., homeless and/or transient persons not in shelters), activeduty military personnel, and residents of institutional group quarters, such as correctional facilities and mental
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institutions. Data are collected in person using computerassisted interviewing (CAI) methods to provide a private and confidential setting for the interview [24]. The primary analytic sample consisted of women aged 18–44 who were currently pregnant (n * 4,600), postpartum (n * 8,000), and not pregnant or postpartum (n * 80,400). Women who were missing trimester data (n \ 30) were excluded. Measures Pregnancy/Postpartum Status Pregnancy status was self-reported. Postpartum status was identified through questions asking respondents about the age and number of biological children living in the household. Women were classified as postpartum if they had a biological child of 12 months or younger living in the household. Women who were both pregnant and postpartum were classified as pregnant. Outcomes There were two outcomes of interest: SPD and MHT. Past month (30 days) psychological distress was measured using the Kessler 6-item (K6) distress scale, a self-report screener that evaluates nonspecific psychological distress and has been clinically validated to maximize the scale’s discernment of serious mental illness [25, 26]. A cut point of 13 or higher is an indicator of SPD [27, 28]. Past year MHT was defined as having received inpatient or outpatient treatment, or prescription medication for ‘‘problems with emotions, nerves, or mental health’’ in the 12 months before the survey, not including treatment for alcohol or drug use. Covariates Covariates were drawn from the relevant literature and include demographics, family environment, physical and mental health status, and tobacco, alcohol, and drug use. Demographics included age, race/ethnicity, marital status, education, employment, income, and poverty status [using the US Census Bureau’s Federal Poverty Level calculation (FPL)]. Family environmentrelated covariates included having had a rapid repeat birth (defined in Healthy People 2010 as having two biological children within 24 months of age of each other living in the household [29]) and the number of biological children in the household. Physical and mental health-related covariates included health insurance status, overall health status, number of significant health problems in the past year, and lifetime history of depression or anxiety (respondent reported being diagnosed with depression or anxiety by a doctor). Substance use included past month cigarette use, past year alcohol use disorder, and past year illicit drug use and illicit drug use disorder.
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Analyses SPD Analyses Prevalence estimates of SPD were generated for all pregnant women and for each trimester and for all postpartum women and then grouped into four categories of postpartum months (0–2, 3–5, 6–8, and 9–12 months postpartum). Prevalence estimates were also estimated for nonpregnant/nonpostpartum women. Differences in demographic characteristics between women with and without SPD were evaluated among pregnant and postpartum women. Statistical testing was conducted using Shah’s Wald F tests (transformed from the standard Wald Chi square) for overall significance to control for multiple comparisons and t tests for post hoc comparisons of proportions. T tests are used because the t-distribution more accurately describes the test statistic under finite sample sizes when the variances of the test statistic are estimated. For more details, see the 2012 National Survey on Drug Use and Health: Statistical Inference Report [30]. Multivariable logistic regression analyses were used to evaluate the adjusted association of pregnancy status with SPD.
MHT Analyses Prevalence estimates of MHT were generated for pregnant and postpartum women with SPD, overall and by trimester/ postpartum category and among nonpregnant/nonpostpartum women. Differences in demographic characteristics between women with SPD who did and did not receive MHT were evaluated similar to the methods used for SPD. For these analyses, pregnant and postpartum women with SPD were combined to increase the sample size. Multivariable logistic regression analyses were used to evaluate the adjusted association of pregnancy status with MHT. All analyses were conducted using SUDAANÒ [31] to account for NSDUH’s complex survey design. All statistical tests were two-tailed, with an alpha of 0.05; 95 % confidence intervals (CIs) are also shown. The study was approved by the RTI International Institutional Review Board.
Results SPD Prevalence of SPD Past month SPD prevalence was similar in pregnant (4.8 %) and postpartum women (5.4 %); these rates were lower than the prevalence of SPD among nonpregnant/
nonpostpartum women (7.4 %; p \ 0.001 and p \ 0.001, respectively; Fig. 1). Across trimesters, SPD prevalence was 6.4 % in first trimester women, significantly higher than the 4.3 % among second trimester women (p = 0.036), and the 3.9 % among third trimester women (p = 0.016). In postpartum women, SPD prevalence was 4.6 % at 0–2 months postpartum and then hovered between 5.1 % (9–12 months postpartum) and 6.9 % (3–5 months postpartum). The prevalence of SPD in the first trimester did not differ significantly from the prevalence in each of the postpartum windows (p [ 0.05). Examining only women who had been pregnant at least once, the prevalence of SPD increased linearly from 4.8 % among pregnant women to 5.4 % among postpartum women to 6.3 % among women who had at least one biological child but were not currently pregnant or postpartum (t test for linear trend = 3.32, p \ 0.001). The prevalence of SPD was significantly lower among pregnant women aged 35–44 (0.8 %) than among postpartum (3.2 %) and nonpregnant/nonpostpartum women (5.9 %, Table 1). A similar pattern of differences (SPD being lower among pregnant than among postpartum and nonpregnant/nonpostpartum women) was seen among married women, women with an annual income between $50,000 and $74,999, women with a family income 200 % or more above FPL, women who had had a prior rapid repeat birth, and women with no serious health problems. The prevalence of SPD across race/ethnicity, education, employment, insurance status, health status, history of depression or anxiety, past month cigarette use, and past year alcohol or illicit drug use, did not differ by pregnancy status. Correlates of SPD Among Pregnant and Postpartum Women Correlates of past month SPD were largely similar among pregnant and postpartum women (Table 2). SPD was associated with being in the youngest age group (18–25), being unmarried, having less education, being unemployed, making \$20,000 annually, living below FPL, being in good or fair/poor health, having a significant health problem, having a lifetime history of depression or anxiety, smoking cigarettes in the past month, having an alcohol use disorder in the past year, using illicit drugs in the past year and having a past year illicit drug use disorder. Race/ethnicity was also associated with SPD. However, this association was not the same in pregnant and postpartum women. An estimated 20.9 % of pregnant women with SPD were black, compared with 13.1 % of pregnant women without SPD. Among postpartum women, there was no association between being black and having past month SPD, but fewer postpartum women with SPD were
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Fig. 1 Prevalence (and 95 % CI) of SPD among females aged 18–44 by pregnancy or postpartum status: annual averages, National Surveys on Drug Use and Health, 2008–2012. Source 2008–2010 (revised 3/12) and 2011–2012 SAMHSA NSDUHs
Hispanic (14.5 %) than women without SPD (21.7 %). Number of biological children in the household, and health insurance status were not associated with SPD. Adjusted Odds of SPD by Pregnancy Status Evaluating the adjusted odds of past month SPD among women aged 18–44 indicated that nonpregnant/nonpostpartum women had 50 % greater odds of SPD than pregnant women [odds ratio (OR) 1.51, p \ 0.001; Table 3]. The odds of SPD was also higher among postpartum women than pregnant women; however, this difference only approached significance (OR 1.27, p = 0.051). MHT Prevalence and Pattern of MHT Only 38.5 % of pregnant women, 49.5 % of postpartum women, and 51.5 % of nonpostpartum/nonpregnant women with past month SPD reported receiving MHT in the past year (Fig. 2). The prevalence of MHT among pregnant women ranged from 35.5 % among second trimester women to 43.8 % among third trimester women. The prevalence of MHT in the postpartum period ranged between 44.8 % (3–5 months) to 53.6 % (9–12 months). The prevalence of
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past year MHT was lower among pregnant women than among postpartum women (p = 0.036) and nonpregnant/ nonpostpartum controls (p = 0.002). The prevalence of MHT was lower among never married pregnant or postpartum women (36.6 %; Table 1) than among their nonpregnant/nonpostpartum counterparts (46.1 %). Similarly, the prevalence of MHT was lower among pregnant and postpartum women with an employment status of ‘‘other’’ (45.5 %) than among their nonpregnant/nonpostpartum counterparts (60.7 %). A similar pattern of SPD prevalence (lower in pregnant/postpartum women than their nonpregnant/nonpostpartum counterparts) was seen among women making \$20,000 annually, women with a family income below the federal poverty threshold, women with one or two biological children living in the household, women with insurance, those with a health problem, and women who did not smoke cigarettes in the past month. The prevalence of MHT across pregnancy/postpartum status did not differ by age, race/ethnicity, education, rapid repeat birth, health status, and history of depression or anxiety. Correlates of MHT Receipt Among Pregnant and Postpartum Women Pregnant and postpartum women with past month SPD who received MHT in the past year were more likely to be
Matern Child Health J Table 1 Weighted prevalence of past month SPD and past year use of MHT by pregnancy/postpartum status and selected characteristics, among women aged 18–44, percentage and standard error (SE) Covariates
SPD
MHT among women with SPD
Nonpregnant and nonpostpartum (*80,400)1
Pregnant (*4,600)
Postpartum (*8,000)
Nonpregnant and nonpostpartum (*6,700)1
Pregnant or postpartum (*900)
18–25
9.4 (0.18)
8.2 (0.63)
8.0 (0.49)
39.4 (0.94)
40.6 (2.51)
26–34
7.2 (0.28)
3.2 (0.63)
4.5 (0.62)
56.3 (1.99)
50.5 (5.65)
61.3 (2.10)
* (*)
Age group
35–44
a,b
5.9
(0.25)
0.8
b,c
(0.48)
a,c
3.2
(0.87)
Race/ethnicity White
7.8 (0.17)
4.6 (0.51)
5.9 (0.52)
60.9 (1.11)
55.4 (3.79)
Black
8.0 (0.38)
7.5 (1.37)
6.7 (0.90)
37.1 (2.77)
34.7 (5.59)
Other
5.6 (0.43)
2.9 (0.93)
4.7 (1.50)
33.2 (3.40)
* (*)
Hispanic
6.1 (0.33)
4.5 (0.87)
3.7 (0.64)
33.1 (2.73)
* (*)
Married
4.9a,b (0.20)
2.4b,c (0.43)
3.6a,c (0.43)
55.6 (2.14)
52.3 (5.02)
Widowed, divorced, or separated
10.3 (0.47)
9.9 (2.17)
15.0 (3.05)
61.6 (2.44)
* (*)
Never married
9.0 (0.20)
8.4 (0.83)
7.0 (0.57)
46.1d (1.18)
36.6 (3.15)
Marital status
Education Less than high school
12.1 (0.52)
9.1 (1.31)
6.5 (0.79)
43.5 (2.32)
41.1 (4.49)
High school
9.3 (0.29)
7.0 (0.96)
8.4 (0.94)
47.9 (1.59)
41.9 (4.49)
Some college
7.5 (0.26)
4.4 (0.78)
5.3 (0.70)
55.6 (1.66)
49.1 (4.97)
College graduate
3.6 (0.19)
1.1 (0.34)
2.2 (0.52)
61.8 (2.61)
* (*)
Employment status Employed full time
5.2 (0.17)
3.4 (0.47)
4.7 (0.61)
50.5 (1.74)
46.6 (5.39)
Employed part time
7.1 (0.27)
3.7 (0.73)
4.2 (0.65)
44.6 (1.98)
39.7 (5.26)
Unemployed
13.0 (0.59)
10.6 (2.22)
11.2 (1.93)
42.9 (2.42)
* (*)
Other (including not in labor force)
10.8 (0.39)
5.8 (0.82)
5.8 (0.60)
60.7d (1.72)
45.5 (4.20)
\$20,000
11.8 (0.36)
9.3 (1.07)
8.7 (0.89)
51.4d (1.53)
42.0 (3.87)
$20,000–$49,999
7.9 (0.25)
5.7 (0.78)
6.0 (0.66)
48.8 (1.63)
43.6 (4.34)
$50,000–$74,999
5.6a (0.32)
2.6b,c (0.68)
5.2a (1.07)
58.9 (2.81)
* (*)
C$75,000
4.3 (0.21)
1.6 (0.55)
2.2 (0.48)
51.6 (2.48)
* (*)
Below FPL
12.0 (0.39)
9.2 (1.20)
8.5 (0.84)
49.2d (1.62)
39.0 (3.87)
100–199 % FPL
8.7 (0.31)
6.1 (0.92)
4.9 (0.59)
50.3 (1.88)
50.7 (4.80)
C200 % FPL
5.3a,b (0.16)
2.5b,c (0.39)
3.9a,c (0.55)
54.0 (1.56)
51.8 (5.69)
Income
Federal poverty level (FPL)
Rapid repeat birth Current
N/A
5.9 (1.13)
6.1 (0.80)
N/A
44.4 (5.43)
Past
5.9a (0.34)
2.0b,c (0.71)
6.4a (1.34)
52.4 (2.90)
* (*)
Neither
7.7 (0.16)
4.9 (0.47)
5.1 (0.44)
51.3 (1.04)
47.8 (3.50)
0
8.6a (0.20)
5.1c (0.55)
N/A
48.4 (1.19)
N/A
1
7.2 (0.33)
4.5 (0.65)
6.0 (0.57)
56.4d (2.32)
45.9 (4.28)
2
5.4 (0.27)
4.5 (1.16)
4.9 (0.67)
55.9d (2.87)
42.7 (5.94)
C3
6.5 (0.43)
5.2 (1.81)
5.2 (0.74)
52.5 (3.46)
* (*)
6.8 (0.16)
4.5 (0.40)
5.3 (0.42)
56.5d (1.15)
49.4 (3.11)
Number of biological children in the household
Health insurance Has insurance
123
Matern Child Health J Table 1 continued Covariates
Does not have insurance
SPD
MHT among women with SPD
Nonpregnant and nonpostpartum (*80,400)1
Pregnant (*4,600)
Postpartum (*8,000)
Nonpregnant and nonpostpartum (*6,700)1
Pregnant or postpartum (*900)
9.3 (0.33)
7.6 (1.88)
6.0 (0.89)
37.4 (1.70)
* (*)
Health status Excellent
3.1 (0.17)
1.8 (0.34)
2.4 (0.44)
38.9 (2.96)
* (*)
Very good
5.6 (0.19)
3.5 (0.50)
4.5 (0.57)
48.1 (1.72)
50.7 (4.95)
Good
9.8 (0.31)
8.8 (1.17)
7.7 (0.90)
49.7 (1.68)
44.5 (4.60)
Fair/poor
22.1 (0.81)
19.9 (4.14)
19.6 (2.81)
63.6 (1.90)
* (*)
None
6.2a,b (0.16)
3.5b,c (0.38)
4.7a,c (0.40)
46.4 (1.29)
44.4 (3.65)
One
9.3 (0.35)
9.5 (1.35)
6.6 (0.82)
53.6d (1.88)
43.3 (4.83)
Two or more History of depression
16.3 (0.86)
* (*)
17.5 (3.98)
73.8 (2.43)
* (*)
Yes
22.5 (0.55)
16.3 (1.84)
18.6 (1.77)
74.9 (1.15)
73.6 (3.57)
No
4.1 (0.12)
3.1 (0.36)
3.3 (0.31)
23.6 (1.22)
21.6 (3.32)
Yes
22.9 (0.61)
15.8 (2.21)
17.7 (2.30)
79.2 (1.21)
77.7 (4.02)
No
5.0 (0.13)
3.7 (0.39)
4.2 (0.34)
32.8 (1.22)
32.6 (3.13)
Health problems
History of anxiety
Past month cigarette use Yes
13.1 (0.36)
11.8 (1.45)
10.9 (1.04)
55.9 (1.36)
55.6 (4.04)
No
5.1 (0.14)
3.5 (0.39)
3.8 (0.37)
47.1d (1.42)
38.4 (3.69)
18.1 (0.68) 6.4 (0.14)
19.3 (3.05) 4.0 (0.39)
25.4 (4.98) 5.0 (0.37)
53.1 (2.10) 51.1d (1.12)
* (*) 44.0 (3.06)
No illicit drug use
5.5 (0.15)
3.4 (0.39)
4.4 (0.38)
50.1d (1.33)
42.8 (3.39)
Illicit drug use, no SUD
11.1 (0.38)
8.3 (1.34)
10.6 (1.65)
50.9 (1.84)
* (*)
Illicit drug SUD
32.2 (1.28)
31.2 (4.65)
31.0 (4.61)
58.4 (2.30)
* (*)
Past year alcohol use disorder Yes No Past year illicit drug use
Source: 2008–2010 (revised 3/12) and 2011–2012 SAMHSA National Surveys on Drug Use and Health (NSDUHs) N/A not applicable, SUD substance use disorder, * low precision, no estimate reported 1
SAMHSA does not permit the reporting of exact sample sizes from the restricted data file to protect against the accidental identification of respondents. Totals may not equal pregnant and postpartum women separately due to rounding
a
Difference between estimate and pregnant SPD estimate, p \ 0.05
b
Difference between estimate and postpartum SPD estimate, p \ 0.05
c
Difference between estimate and Nonpregnant and Nonpostpartum SPD estimate, p \ 0.05
d
Difference between estimate and pregnant/postpartum MHT/counseling estimate, p \ 0.05
white; have health insurance; have a history of depression or anxiety; and have used cigarettes in the past month (Table 2). Not receiving MHT was associated with being black or of an ‘‘other’’ race/ethnicity, and having never been married. Age, education, employment, income, poverty, rapid repeat birth, the number of biological children in the household, health status and significant health problems, past year illicit drug use, and past year alcohol or illicit drug use disorder were not associated with past year MHT among pregnant and postpartum women with SPD.
123
Adjusted Odds of MHT Receipt Postpartum women with past month SPD had significantly greater odds of having MHT in the past year than pregnant women (OR 1.77, p = 0.045), after controlling for age, race/ethnicity, marital status, education, employment status, poverty status, history of rapid repeat birth, number of biological children in the household, health insurance, physical health status, number of physical health problems, history of depression or anxiety, past month cigarette use,
Matern Child Health J Table 2 Correlates of past month SPD and past year use of MHT among pregnant and postpartum women, aged 18–44, percentage and standard error (SE) Characteristic
Pregnant women
Postpartum women
Pregnant or postpartum women with SPD
SPD % (SE)
No SPD % (SE)
SPD % (SE)
No SPD % (SE)
MHT % (SE)
No MHT % (SE)
18–25
65.3 (4.71)**
36.9 (1.08)
48.4 (3.53)**
31.8 (0.71)
47.4 (4.04)
59.1 (4.00)
26–34
32.5 (4.74)**
49.6 (1.26)
41.2 (3.87)*
50.1 (0.94)
42.2 (4.58)
35.2 (3.82)
35–44
2.3 (1.29)**
13.6 (1.00)
10.4 (2.63)**
18.1 (0.91)
10.3 (3.34)
5.7 (1.95)
Age group
Race/ethnicity White
56.7 (4.24)
59.8 (1.32)
61.4 (3.48)
56.4 (1.03)
72.2 (3.60)**
49.4 (3.87)
Black
20.9 (3.44)*
13.1 (0.75)
17.0 (2.21)
13.6 (0.63)
13.8 (2.68)*
22.1 (2.83)
Other
4.6 (1.45)*
7.9 (0.90)
7.2 (2.19)
8.3 (0.61)
2.6 (0.73)*
9.6 (2.76)
Hispanic
17.7 (3.14)
19.2 (1.05)
14.5 (2.31)**
21.7 (0.92)
11.5 (2.61)
19.0 (2.75)
Marital status Married
30.3 (4.30)**
62.8 (1.19)
42.2 (3.57)**
63.9 (0.94)
43.8 (4.38)
33.9 (3.70)
Widowed, divorced, or separated
13.2 (2.72)*
6.1 (0.61)
17.8 (3.32)**
5.7 (0.53)
20.2 (4.14)
13.0 (2.71)
Never married
56.5 (4.21)**
31.1 (1.09)
40.1 (3.30)**
30.3 (0.88)
36.1 (3.81)**
53.0 (3.73)
Less than high school
31.2 (3.83)**
15.7 (0.87)
20.0 (2.35)
16.4 (0.75)
21.1 (2.90)
25.7 (2.86)
High school
37.8 (4.14)**
25.2 (1.11)
42.5 (3.52)**
26.5 (0.77)
37.3 (4.20)
43.9 (3.35)
Some college
24.2 (3.67)
Education
26.4 (1.12)
25.2 (2.97)
25.6 (0.85)
26.7 (3.39)
23.5 (2.91)
6.9 (2.14)**
32.6 (1.29)
12.3 (2.65)**
31.5 (0.94)
15.0 (3.59)
6.9 (1.81)
Employed full time
29.3 (3.61)**
42.0 (1.24)
32.5 (3.42)
37.9 (0.93)
31.9 (4.33)
31.1 (3.20)
Employed part time
13.3 (2.51)
17.4 (0.94)
13.7 (1.97)*
17.9 (0.70)
11.8 (2.10)
15.2 (2.16)
College graduate Employment status
Unemployed
15.6 (3.13)**
12.0 (2.09)**
5.5 (0.36)
15.0 (3.17)
11.6 (1.72)
Other (including not in labor force)
41.8 (4.21)
34.0 (1.19)
6.7 (0.47)
41.8 (3.33)
38.8 (0.89)
41.4 (3.96)
42.1 (3.49)
\$20,000 $20,000–$49,999
44.2 (4.10)** 37.2 (4.13)
21.8 (0.97) 31.3 (1.15)
37.5 (3.46)** 35.6 (3.20)
22.6 (0.76) 32.2 (0.89)
36.2 (4.08) 34.2 (3.73)
42.5 (3.38) 37.7 (3.31)
$50,000–$74,999
8.8 (2.24)**
16.6 (0.92)
15.9 (3.01)
16.7 (0.74)
18.0 (4.06)
9.9 (1.88)
C$75,000
9.7 (3.09)**
30.2 (1.30)
11.0 (2.27)**
28.6 (0.94)
11.5 (3.13)
9.9 (2.10)
Below FPL
43.6 (4.18)**
21.8 (1.02)
43.7 (3.65)**
27.0 (0.86)
37.0 (4.15)
49.2 (3.59)
100–199 % FPL
27.3 (3.64)
21.2 (1.02)
21.6 (2.53)
23.8 (0.76)
25.9 (3.42)
21.4 (2.62)
C200 % FPL
29.0 (3.74)**
57.0 (1.28)
34.6 (3.64)**
49.2 (1.00)
37.1 (4.37)
29.3 (3.53)
23.6 (3.98)
19.0 (0.98)
22.0 (2.68)
19.4 (0.76)
21.8 (3.15)
23.2 (3.11)
9.8 (0.80)
12.5 (2.42)
10.4 (0.64)
7.9 (2.17)
11.4 (2.62)
72.5 (4.05)
71.2 (1.15)
65.6 (3.17)
70.1 (0.91)
70.4 (3.61)
65.5 (3.49)
0
43.9 (4.03)
41.4 (1.19)
N/A
N/A
12.3 (2.23)
15.5 (2.06)
1
30.2 (3.70)
32.3 (1.18)
43.1 (3.40)
38.6 (0.95)
38.8 (4.04)
38.9 (3.40)
2
15.7 (3.64)
16.9 (0.94)
30.7 (3.38)
33.9 (0.92)
24.1 (3.79)
27.5 (3.56)
C3 Health insurance
10.3 (3.36)
9.5 (0.84)
26.2 (3.22)
27.5 (0.90)
24.7 (3.97)
18.1 (3.16)
Insured
86.2 (3.10)
91.6 (0.78)
80.2 (2.68)
82.3 (0.77)
88.3 (3.08) *
76.9 (3.05)
Uninsured
13.8 (3.10)
8.4 (0.78)
19.8 (2.68)
17.7 (0.77)
11.7 (3.08)
23.1 (3.05)
Income
Federal poverty level (FPL)
Rapid repeat birth Current Past Neither
3.9 (1.37)**
Number of biological children in the household
Health status
123
Matern Child Health J Table 2 continued Characteristic
Pregnant women
Postpartum women
Pregnant or postpartum women with SPD
SPD % (SE)
SPD % (SE)
MHT % (SE)
No SPD % (SE)
No SPD % (SE)
No MHT % (SE)
Excellent
13.2 (2.35)**
35.8 (1.25)
13.9 (2.43)**
32.5 (0.92)
10.4 (2.11)
16.6 (2.76)
Very good
27.6 (3.41)**
38.6 (1.18)
33.5 (3.40)*
40.5 (0.91)
34.9 (4.29)
28.9 (2.83)
Good
42.1 (4.18)**
22.1 (0.95)
32.3 (3.25)**
22.2 (0.79)
34.2 (3.85)
36.3 (3.56)
Fair/poor
17.2 (3.44)**
3.5 (0.43)
20.3 (2.84)**
4.8 (0.42)
20.6 (3.42)
18.2 (2.89)
56.8 (4.37)** 36.6 (4.23)**
79.4 (0.96) 17.8 (0.91)
66.9 (3.08)** 22.6 (2.60)
78.7 (0.75) 18.5 (0.73)
61.5 (4.16) 25.4 (3.56)
65.7 (3.26) 28.4 (3.06)
6.6 (2.61)
2.8 (0.34)
10.4 (2.53)**
2.8 (0.28)
13.1 (3.38)
5.9 (1.91)
Yes
44.3 (4.14)**
11.5 (0.75)
48.2 (3.39)**
12.2 (0.62)
75.1 (3.66)**
23.0 (2.96)
No
55.7 (4.14)
88.5 (0.75)
51.8 (3.39)
87.8 (0.62)
24.9 (3.66)
77.0 (2.96)
30.1 (3.42)**
8.0 (0.51)
50.4 (4.42)**
12.3 (2.12)
Health problems 0 1 C2 History of depression
History of anxiety Yes
29.3 (3.80)**
7.9 (0.62)
No
70.7 (3.80)
92.1 (0.62)
69.9 (3.42)
92.0 (0.51)
49.6 (4.42)
87.7 (2.12)
Yes
39.4 (4.13)**
14.9 (0.82)
46.3 (3.51)**
21.7 (0.75)
53.3 (4.32)**
36.2 (3.29)
No
60.6 (4.13)
85.1 (0.82)
53.7 (3.51)
78.3 (0.75)
46.7 (4.32)
63.8 (3.29)
Past month cigarette use
Past year alcohol use disorder Yes
21.8 (3.32)**
10.3 (2.25)**
1.7 (0.21)
17.6 (3.42)
10.9 (1.87)
No
78.2 (3.32)
95.4 (0.47)
4.6 (0.47)
89.7 (2.25)
98.3 (0.21)
82.4 (3.42)
89.1 (1.87)
Past year illicit drug use No illicit drug use
59.9 (4.08)**
86.6 (0.78)
72.2 (3.09)**
89.4 (0.55)
63.5 (4.08)
72.2 (2.87)
Illicit drug use, no SUD
19.8 (3.01)**
11.1 (0.73)
19.8 (2.90)**
9.6 (0.53)
21.2 (3.88)
18.7 (2.41)
Illicit drug SUD
20.3 (3.32)**
2.3 (0.27)
8.1 (1.39)**
1.0 (0.14)
15.3 (2.48)
9.1 (1.71)
Yes
38.5 (4.04)**
10.4 (0.72)
49.5 (3.53)**
11.7 (0.60)
100
N/A
No
61.5 (4.04)
89.6 (0.72)
50.5 (3.53)
88.3 (0.60)
N/A
100
Past year MHT
Source: 2008–2010 (revised 3/12) and 2011–2012 SAMHSA National Surveys on Drug Use and Health (NSDUHs) N/A not applicable, SUD substance use disorder, – low precision, no estimate reported * Difference (t test of proportion) between SPD and no SPD or MHT and no MHT, p \ 0.05 ** Difference (t test of proportion) between SPD and no SPD or MHT and no MHT, p \ 0.01
and past year alcohol and illicit drug use. The odds of past year MHT was not significantly different among nonpregnant/nonpostpartum women and pregnant women.
Discussion In a nationally representative sample, the prevalence of past month SPD was 4.8 % among pregnant women and 5.4 % among postpartum women. These prevalence estimates appear lower than those reported by Ahluwalia, Mack, and Mokdad (12.3 %) [20], Skari et al. [13] (9 %),
123
and Saurel-Cubizolles et al. [32] (8.7 %). However, there are methodological differences that may account for differences in prevalence and patterns over time. Our study used the K6 instrument to detect SPD, whereas Skari et al. [13] and Saurel-Cubizolles et al. [32] examined clinically significant distress using the General Health Questionnaire, and Ahluwalia et al. [20] used a measure of stress and anxiety frequency from Health Related Quality of Life indicators used in the Behavioral Risk Factor Surveillance System. Thus, the prevalence estimates may reflect differences in both instrumentation and the cut point for distress. Furthermore, we report on the overall average prevalence during the first year postpartum, whereas Skari
Matern Child Health J Table 3 Adjusted odds of SPD among women aged 18–44 and adjusted odds of MHT among women aged 18–44 with SPD Covariate
Serious psychological distress B (SE)
Mental health treatment
OR (95 % CI)
p value
B (SE)
OR (95 % CI)
p value
Pregnancy status Pregnant
Reference
1.00
–
Reference
1.00
–
Postpartum
0.24 (0.12)
1.27 (1.00, 1.62)
0.051
0.57 (0.28)
1.77 (1.01, 3.09)
0.045
Not pregnant or postpartum
0.41 (0.10)
1.51 (1.24, 1.82)
\0.001
0.32 (0.27)
1.38 (0.81, 2.33)
0.237
Age group 18–25
Reference
1.00
–
Reference
1.00
–
26–34 35–44
-0.09 (0.06) -0.28 (0.07)
0.92 (0.82, 1.02) 0.76 (0.65, 0.88)
0.116 \0.001
0.33 (0.12) 0.64 (0.15)
1.40 (1.11, 1.76) 1.89 (1.42, 2.53)
0.005 \0.001
Race/ethnicity White
Reference
1.00
–
Reference
1.00
–
Black
-0.16 (0.06)
0.85 (0.76, 0.95)
0.005
-0.40 (0.13)
0.67 (0.52, 0.88)
0.003
Other
-0.18 (0.09)
0.83 (0.70, 0.99)
0.039
-0.94 (0.18)
0.39 (0.28, 0.55)
\0.001
Hispanic
-0.42 (0.07)
0.66 (0.58, 0.75)
\0.001
-0.66 (0.16)
0.52 (0.38, 0.71)
\0.001
Marital status Married
Reference
1.00
–
Reference
1.00
–
Widowed/divorced/separated
0.34 (0.07)
1.41 (1.23, 1.61)
\0.001
0.16 (0.16)
1.17 (0.86, 1.61)
0.316
Never married
0.09 (0.06)
1.09 (0.96, 1.23)
0.173
0.09 (0.13)
1.09 (0.84, 1.41)
0.499
-0.02 (0.06)
0.98 (0.87, 1.10)
0.718
-0.07 (0.14)
0.93 (0.71, 1.23)
0.625 –
Education Less than high school High school
Reference
1.00
–
Reference
1.00
Some college
-0.17 (0.05)
0.84 (0.76, 0.93)
0.001
0.21 (0.11)
1.24 (1.00, 1.53)
0.050
College graduate Employment status
-0.53 (0.07)
0.59 (0.51, 0.68)
\0.001
0.52 (0.15)
1.69 (1.27, 2.25)
\0.001
Employed full time
Reference
1.00
–
Reference
1.00
–
Employed part time
0.12 (0.06)
1.13 (1.01, 1.26)
0.026
-0.10 (0.12)
0.91 (0.71, 1.16)
0.437
Unemployed
0.48 (0.07)
1.61 (1.41, 1.84)
\0.001
0.09 (0.14)
1.10 (0.83, 1.46)
0.511
Other (including not in the labor force)
0.42 (0.06)
1.52 (1.36, 1.70)
\0.001
0.19 (0.12)
1.20 (0.95, 1.53)
0.125
0.32 (0.05)
1.37 (1.23, 1.53)
\0.001
0.14 (0.11)
1.15 (0.92, 1.44)
0.208
Federal poverty level (FPL) Below FPL 100–199 % FPL
0.17 (0.05)
1.19 (1.07, 1.32)
0.002
0.07 (0.11)
1.08 (0.86, 1.35)
0.529
C200 % FPL
Reference
1.00
–
Reference
1.00
–
Current
0.21 (0.14)
1.23 (0.93, 1.63)
0.152
0.04 (0.33)
1.05 (0.55, 1.99)
0.893
Past
-0.06 (0.10)
0.94 (0.78, 1.14)
0.539
-0.14 (0.20)
0.87 (0.58, 1.30)
0.497
Neither
Reference
1.00
–
Reference
1.00
–
0
0.25 (0.08)
1.29 (1.11, 1.50)
0.001
0.02 (0.18)
1.02 (0.71, 1.46)
0.910
1 2
0.11 (0.08) Reference
1.12 (0.97, 1.30) 1.00
0.134 –
0.12 (0.18) Reference
1.13 (0.80, 1.59) 1.00
0.503 –
C3
0.13 (0.09)
1.13 (0.95, 1.36)
0.171
0.01 (0.22)
1.01 (0.65, 1.57)
0.971
Rapid repeat birth
Number of biological children in the household
Health insurance Insured
Reference
1.00
–
Reference
1.00
–
Uninsured
-0.01 (0.05)
0.99 (0.90, 1.09)
0.774
-0.92 (0.10)
0.40 (0.33, 0.49)
\0.001
Reference
1.00
–
Reference
1.00
–
Health status Excellent Very good
0.44 (0.07)
1.55 (1.36, 1.76)
\0.001
-0.08 (0.15)
0.93 (0.70, 1.23)
0.604
Good
0.89 (0.07)
2.43 (2.13, 2.78)
\0.001
-0.12 (0.15)
0.89 (0.66, 1.19)
0.440
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Matern Child Health J Table 3 continued Covariate
Fair/poor
Serious psychological distress
Mental health treatment
B (SE)
OR (95 % CI)
p value
B (SE)
OR (95 % CI)
p value
1.66 (0.08)
5.24 (4.51, 6.08)
\0.001
0.18 (0.16)
1.20 (0.87, 1.65)
0.277
Health problems 0
Reference
1.00
–
Reference
1.00
–
1
0.24 (0.05)
1.27 (1.15, 1.41)
\0.001
0.18 (0.10)
1.20 (0.98, 1.47)
0.080
C2
0.60 (0.08)
1.82 (1.57, 2.11)
\0.001
0.43 (0.16)
1.54 (1.12, 2.11)
0.008
Yes
0.33 (0.05)
1.39 (1.26, 1.53)
\0.001
0.11 (0.10)
1.11 (0.91, 1.36)
0.306
No
Reference
1.00
–
Reference
1.00
–
Yes
0.71 (0.06)
2.04 (1.81, 2.30)
\0.001
0.11 (0.12)
1.11 (0.88, 1.41)
0.373
No
Reference
1.00
–
Reference
1.00
–
No illicit drug use
Reference
1.00
–
Reference
1.00
–
Illicit drug use, no SUD Illicit drug SUD
0.37 (0.05) 1.28 (0.07)
1.44 (1.30, 1.61) 3.58 (3.11, 4.13)
\0.001 \0.001
-0.12 (0.11) 0.25 (0.14)
0.89 (0.71, 1.10) 1.28 (0.98, 1.67)
0.273 0.069
Yes
N/A
N/A
N/A
1.70 (0.09)
5.50 (4.58, 6.60)
\0.001
No
N/A
N/A
N/A
Reference
1.00
–
Yes
N/A
N/A
N/A
1.30 (0.10)
3.66 (2.98, 4.49)
\0.001
No
N/A
N/A
N/A
Reference
1.00
–
Past month cigarette use
Past year alcohol use disorder
Past year illicit drug use
History of depression
History of anxiety
Source: 2008–2010 (revised 3/12) and 2011–2012 SAMHSA National Surveys on Drug Use and Health (NSDUHs) 95 % CI confidence interval, N/A variable not included in model, OR odds ratio, SUD substance use disorder
et al. [13] report prevalence estimates a few days after birth. Additionally, the study by Saurel-Cubizolles and et al. [32] was conducted in France; cultural variation potentially could affect the comparability of results. Our finding that the prevalence of past month distress was lower among pregnant and postpartum women than among nonpregnant/nonpostpartum women was consistent with other studies that have compared prevalence estimates in these groups. Ahluwalia et al. [20] found that frequent mental distress was more common among nonpregnant women than among pregnant women. Similarly, Wallace et al. [33] and Saurel-Cubizolles et al. [32] found that the lowest prevalence of psychological distress was among pregnant women, compared with postpartum and nonpregnant/nonpostpartum women. This study demonstrates a linear increase in past month SPD prevalence in pregnant, postpartum, and nonpregnant/ nonpostpartum women who had at least one biological child in the household. Previous within-person studies generally have found women to have stable or decreasing levels of psychological distress from pregnancy through postpartum [10, 11, 13, 14, 34]. However, comparisons
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must be made with caution because studies examining symptom course in individuals often examine changes in overall mean levels of psychological distress [10, 11, 14] and not among individuals meeting a clinical cut point for SPD. It may be that the patterns are different for women reaching clinical thresholds than for women with lower distress scores. Both of these possibilities present an opportunity for future research. Correlates of past month SPD were similar in pregnant and postpartum women. Notably, more than 4 times as many pregnant and postpartum women with SPD reported past year alcohol or illicit drug use disorders than pregnant and postpartum women without SPD; more than twice as many women with SPD reported past month cigarette use than women without SPD. This suggests that physicians who identify pregnant or postpartum women with SPD may need to pay particular attention to smoking, alcohol, and drug use behaviors. Physicians identifying these behaviors in pregnant and postpartum women should also be aware of the increased odds of SPD in these women. Other correlates indicated that younger women, unmarried women, and women of lower socioeconomic status (less education,
Matern Child Health J
Fig. 2 Prevalence (and 95 % CI) of MHT among women with SPD, aged 18–44, by pregnancy or postpartum status: annual averages, National Surveys on Drug Use and Health, 2008–2012. Source 2008–2010 (revised 3/12) and 2011–2012 SAMHSA NSDUHs
lower income, unemployment, and poverty) had the highest prevalence of past month SPD. Perhaps the most important finding was that pregnant women with past month SPD were less likely than postpartum women to report MHT, even after we controlled for potential confounders. These findings were similar to those identified in the National Epidemiologic Survey on Alcohol and Related Conditions, which found that pregnant women with psychiatric disorders were less likely to seek MHT than were nonpregnant women with psychiatric disorders [23]. This may be a result of the lack of screening for mental health problems among obstetrical patients. For example, Birndorf et al. [35] reported that among patients in one obstetrical practice, only 30 % of women who screened positive for depression had discussed the symptoms with their ob-gyn, although 82 % said they would be willing to discuss the symptoms and all of them reported that they would seek MHT if their ob-gyn referred them. Other studies have reported similarly low rates of problem recognition and treatment receipt [36, 37]. Examination of the correlates of MHT among pregnant and postpartum women with past month SPD indicated that non-Hispanic black women and women of an ‘‘other’’ race, unmarried women, and uninsured women had particularly low rates of MHT although all women may benefit from screening. There are a few limitations to this study that should be acknowledged. First, NSDUH is a cross-sectional survey
and not appropriate for the individual course of psychological distress analyses. In NSDUH, individuals who may have had elevated psychological distress in their first trimester are not the same women with elevated distress in the postpartum period. Thus, it is not possible to compare the pattern of prevalence estimates directly to studies that provide longitudinal analyses of distress over time. Second, sample size limitations made comparisons of each trimester and postpartum period imprecise, as evidenced by large confidence intervals. Moreover, the small sample size necessitated combining pregnant and postpartum women with SPD to examine correlates of MHT. Although pregnant and postpartum women with SPD were similar in most characteristics, there were a few significant differences. Compared to pregnant women with SPD, postpartum women with SPD were older, more likely to be married, and less likely to have had a past year alcohol or drug use disorder (results not shown). Future research with a larger sample is needed to determine if there are unique correlates of MHT in pregnant or postpartum women with SPD. Third, misclassification is a concern. NSDUH collects data on past month psychological distress; therefore, women who have just entered a new period (e.g., 1 week into the first postpartum period) may be reporting distress from the prior period. This is more likely to affect estimates using the shorter time increments (trimester and
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Matern Child Health J
postpartum months) than the combined pregnant and postpartum categories. In addition, measures of MHT reflect any treatment in the past year, so a woman who reported MHT may have received that treatment before, during, or after pregnancy. A similar misclassification can be seen with past year alcohol use disorders and illicit drug use. Pregnant women who report past year drug use may be reporting use prior to pregnancy, whereas postpartum women reporting use are almost assuredly reporting use during pregnancy or the postpartum period. Additional misclassification may have arisen if women who put newborns up for adoption were classified as being nonpregnant/nonpostpartum. However, results from the National Survey of Family Growth suggest that voluntary placement of infants is rare [38]. Women who experienced miscarriages, abortions, or infant deaths also may have been misclassified as being nonpregnant/nonpostpartum women. In these analyses, response bias may have arisen if women close to delivery were less likely to participate in NSDUH. Evaluation of the unweighted frequency of response for each month of pregnancy suggests that this may have occurred: 13.2 % of pregnant women reported being in their eighth month of pregnancy, whereas only 7.1 % of pregnant women were in their ninth month. If past month SPD or past year MHT in pregnant or postpartum women was associated with this potential nonresponse, the direction and magnitude of this bias would be unknown. Even if this potential response bias were not related to SPD or MHT, it would still result in decreased statistical power. Despite these limitations, the prevalence of past month SPD in pregnant and postpartum women is not negligible. An estimated 4.8 % of pregnant women and 5.4 % of postpartum women had SPD; this equates to an estimated 111,000 pregnant and 234,000 postpartum women annually. Moreover, of the women with SPD, more than half did not receive MHT in the past year. Pregnancy and the postpartum period are times of increased contact with medical professionals, providing opportunities for mental health screening and referral to treatment. Some practitioners have recommended [39, 40] and implemented [41, 42] screening and intervention programs; however, the results of this study suggest that there is room for improvement. Acknowledgments The authors would like to acknowledge Christine Ulbricht for her contributions in the early design phase of this project. The National Survey on Drug Use and Health (NSDUH) is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Behavioral Health Statistics and Quality (CBHSQ). This study was funded and approved under SAMHSA Contract No. 284-2010-0003C, Project No. 0212800.002, which was supported by funding from the National Institute of Mental Health (NIMH). The views expressed in this manuscript do not necessarily represent the views of the National Institutes of Health or the Federal Government.
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