Arch Womens Ment Health DOI 10.1007/s00737-015-0544-x
SHORT COMMUNICATION
The association between diabetes and postpartum depression Emily S. Miller 1,2
&
Marisa R. Peri 1 & Dana R. Gossett 1,2
Received: 14 December 2014 / Accepted: 5 July 2015 # Springer-Verlag Wien 2015
Abstract This study aims to estimate if diabetic women were more likely to experience postpartum depression symptoms than women without diabetes. This was a prospective cohort of women who received prenatal care at a hospital-affiliated prenatal clinic serving low-income women in Chicago, Illinois. For the primary analysis, women were divided by diabetes status (i.e., no diabetes or either gestational diabetes or pre-pregnancy diabetes). Postpartum depression was defined as a positive screen on the Patient Health Questionnaire-9. Rates of postpartum depression were compared, stratified by diabetic status. A multivariable logistic regression was performed to control for potential confounders. A planned secondary analysis compared women with pre-pregnancy diabetes to those without pre-pre-pregnancy diabetes. Three hundred and five women consented to participate of whom 100 (30.5 %) had gestational diabetes mellitus (GDM) and 33 (10.8 %) had pre-pregnancy diabetes. Compared to women without any diabetes, women with diabetes (either GDM or pre-pregnancy diabetes) had similar rates of antenatal [(OR) 0.69, 95 % CI) 0.44–1.08] and postpartum depression (OR 0.74, 95 % CI 0.33–1.66). However, postpartum depression was more common among women with pre-pregnancy diabetes (34.8 %) compared to non-diabetic women (16.7 %) (OR 2.67, 95 % CI 1.05–6.78). This association persisted even after adjusting for potential confounders (aOR 2.67, 95 % CI
* Emily S. Miller [email protected] 1
Northwestern University Feinberg School of Medicine, Chicago, IL, USA
2
Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
1.05–9.79). Gestational diabetes was not associated with increased rates of depression. However, women with prepregnancy diabetes are more likely to experience postpartum depression compared to women without pre-pregnancy diabetes, even after adjusting for related comorbidities. Keywords Diabetes . Gestational diabetes . Depression . Postpartum depression
Introduction Diabetes is a common complication of pregnancy with 7 % of pregnancies in the USA being affected by diabetes (Moyer and U.S. Preventive Services Task Force 2014). Diabetes in pregnancy carries known maternal risks, including that of preeclampsia and cesarean. Whether diabetes increases the risk of postpartum depression remains controversial. Outside of pregnancy, there is a significant bidirectional association between depression and diabetes that has important pathophysiologic and clinical implications (Roy and Lloyd 2012; Sumlin et al. 2014). It has been well demonstrated that depression can contribute to poor glycemic control and increased rates of diabetic complications (Sumlin et al. 2014), while diabetes may be involved in the pathophysiology of depression either due to the distress from the burden of disease or via intrinsic inflammatory mechanisms (Leonard and Maes 2012; Osborne and Monk 2013). Prior studies examining this relationship in pregnancy have arrived at conflicting results. The goal of our study was to elucidate this relationship in a prospective manner, using standard clinical diagnoses of diabetes and a validated self-report instrument to diagnose depression.
E.S. Miller et al.
Materials and methods This is a prospective cohort study of pregnant women seen for routine obstetric care at the resident continuity clinic of Northwestern University’s Obstetrics and Gynecology Department in Chicago, Illinois, between February 2012 and April 2014. The only exclusion criterion was non-English-speaking status. Women were approached during prenatal visits and invited to participate when study staff was available to obtain consent. Pre-gestational diabetes was diagnosed with either a previous clinical diagnosis of diabetes or hemoglobin A1c (HgA1c) of at least 6.5 % on first trimester screening. Non-diabetic women underwent routine antenatal gestational diabetes screening performed between 24 and 28 weeks of gestation. Women were then categorized as either having gestational diabetes mellitus (GDM or prepregnancy diabetes) or being non-diabetic for the primary analysis. Demographic data and clinical data abstracted from the medical record included age, gravidity, parity, prepregnancy BMI, race/ethnicity, smoking history, and other medication conditions. Other pregnancy-specific information obtained via the chart review included the number of prenatal visits attended, multiple gestation, gestational weight gain, and any diagnosis of preeclampsia. Delivery information collected included gestational age at delivery, birth weight, route of delivery, and NICU) admission. The participants’ breast-feeding status and postpartum BMI were abstracted from the medical records after their postpartum visit. Routine prenatal care at our center includes depression screening with the Patient Health Questionnaire-9 (PHQ-9). This screening takes place at the initial obstetric evaluation, once during the third trimester, and at the postpartum visit. Additionally, the PHQ-9 is administered if the patient reports symptoms concerning for depression at any other visit. The PHQ-9 contains questions that address the main DSM-IV criteria for diagnosing a depressive disorder, including anhedonia, decreased energy, lack of self-worth, and impairment of function. This questionnaire has been validated in a pregnant population and has a high sensitivity and specificity for depressive disorders (Kroenke et al. 2001). We utilized standard scoring of the PHQ-9 for diagnosis of depression: 0–4 was characterized as normal, 5–9 as mild depression, 10–14 as moderate, 15–19 as moderately severe, and a score of 20 or above as severe. For the primary analysis, women with any diabetes (both pre-pregnancy and gestational) were compared to those without diabetes. Demographic, clinical, and obstetric data were compared using Student’s t, Mann-Whitney U, chi-square, or Fisher’s exact tests, as appropriate. PHQ-9 scores as a continuous variable and a dichotomized depression screen variable
were then compared, stratified by depression status. To dichotomize PHQ-9 scores, a cutoff value of 5 or more was considered a positive screen for probable clinical depression. Demographic and clinical variables significantly (p
SHORT COMMUNICATION
The association between diabetes and postpartum depression Emily S. Miller 1,2
&
Marisa R. Peri 1 & Dana R. Gossett 1,2
Received: 14 December 2014 / Accepted: 5 July 2015 # Springer-Verlag Wien 2015
Abstract This study aims to estimate if diabetic women were more likely to experience postpartum depression symptoms than women without diabetes. This was a prospective cohort of women who received prenatal care at a hospital-affiliated prenatal clinic serving low-income women in Chicago, Illinois. For the primary analysis, women were divided by diabetes status (i.e., no diabetes or either gestational diabetes or pre-pregnancy diabetes). Postpartum depression was defined as a positive screen on the Patient Health Questionnaire-9. Rates of postpartum depression were compared, stratified by diabetic status. A multivariable logistic regression was performed to control for potential confounders. A planned secondary analysis compared women with pre-pregnancy diabetes to those without pre-pre-pregnancy diabetes. Three hundred and five women consented to participate of whom 100 (30.5 %) had gestational diabetes mellitus (GDM) and 33 (10.8 %) had pre-pregnancy diabetes. Compared to women without any diabetes, women with diabetes (either GDM or pre-pregnancy diabetes) had similar rates of antenatal [(OR) 0.69, 95 % CI) 0.44–1.08] and postpartum depression (OR 0.74, 95 % CI 0.33–1.66). However, postpartum depression was more common among women with pre-pregnancy diabetes (34.8 %) compared to non-diabetic women (16.7 %) (OR 2.67, 95 % CI 1.05–6.78). This association persisted even after adjusting for potential confounders (aOR 2.67, 95 % CI
* Emily S. Miller [email protected] 1
Northwestern University Feinberg School of Medicine, Chicago, IL, USA
2
Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
1.05–9.79). Gestational diabetes was not associated with increased rates of depression. However, women with prepregnancy diabetes are more likely to experience postpartum depression compared to women without pre-pregnancy diabetes, even after adjusting for related comorbidities. Keywords Diabetes . Gestational diabetes . Depression . Postpartum depression
Introduction Diabetes is a common complication of pregnancy with 7 % of pregnancies in the USA being affected by diabetes (Moyer and U.S. Preventive Services Task Force 2014). Diabetes in pregnancy carries known maternal risks, including that of preeclampsia and cesarean. Whether diabetes increases the risk of postpartum depression remains controversial. Outside of pregnancy, there is a significant bidirectional association between depression and diabetes that has important pathophysiologic and clinical implications (Roy and Lloyd 2012; Sumlin et al. 2014). It has been well demonstrated that depression can contribute to poor glycemic control and increased rates of diabetic complications (Sumlin et al. 2014), while diabetes may be involved in the pathophysiology of depression either due to the distress from the burden of disease or via intrinsic inflammatory mechanisms (Leonard and Maes 2012; Osborne and Monk 2013). Prior studies examining this relationship in pregnancy have arrived at conflicting results. The goal of our study was to elucidate this relationship in a prospective manner, using standard clinical diagnoses of diabetes and a validated self-report instrument to diagnose depression.
E.S. Miller et al.
Materials and methods This is a prospective cohort study of pregnant women seen for routine obstetric care at the resident continuity clinic of Northwestern University’s Obstetrics and Gynecology Department in Chicago, Illinois, between February 2012 and April 2014. The only exclusion criterion was non-English-speaking status. Women were approached during prenatal visits and invited to participate when study staff was available to obtain consent. Pre-gestational diabetes was diagnosed with either a previous clinical diagnosis of diabetes or hemoglobin A1c (HgA1c) of at least 6.5 % on first trimester screening. Non-diabetic women underwent routine antenatal gestational diabetes screening performed between 24 and 28 weeks of gestation. Women were then categorized as either having gestational diabetes mellitus (GDM or prepregnancy diabetes) or being non-diabetic for the primary analysis. Demographic data and clinical data abstracted from the medical record included age, gravidity, parity, prepregnancy BMI, race/ethnicity, smoking history, and other medication conditions. Other pregnancy-specific information obtained via the chart review included the number of prenatal visits attended, multiple gestation, gestational weight gain, and any diagnosis of preeclampsia. Delivery information collected included gestational age at delivery, birth weight, route of delivery, and NICU) admission. The participants’ breast-feeding status and postpartum BMI were abstracted from the medical records after their postpartum visit. Routine prenatal care at our center includes depression screening with the Patient Health Questionnaire-9 (PHQ-9). This screening takes place at the initial obstetric evaluation, once during the third trimester, and at the postpartum visit. Additionally, the PHQ-9 is administered if the patient reports symptoms concerning for depression at any other visit. The PHQ-9 contains questions that address the main DSM-IV criteria for diagnosing a depressive disorder, including anhedonia, decreased energy, lack of self-worth, and impairment of function. This questionnaire has been validated in a pregnant population and has a high sensitivity and specificity for depressive disorders (Kroenke et al. 2001). We utilized standard scoring of the PHQ-9 for diagnosis of depression: 0–4 was characterized as normal, 5–9 as mild depression, 10–14 as moderate, 15–19 as moderately severe, and a score of 20 or above as severe. For the primary analysis, women with any diabetes (both pre-pregnancy and gestational) were compared to those without diabetes. Demographic, clinical, and obstetric data were compared using Student’s t, Mann-Whitney U, chi-square, or Fisher’s exact tests, as appropriate. PHQ-9 scores as a continuous variable and a dichotomized depression screen variable
were then compared, stratified by depression status. To dichotomize PHQ-9 scores, a cutoff value of 5 or more was considered a positive screen for probable clinical depression. Demographic and clinical variables significantly (p
