- Email: [email protected]
Point prevalence of psychiatric disorders during the second trimester of pregnancy: A population-based study
Point prevalence of psychiatric disorders during the second trimester of pregnancy: A population-based study Liselott Andersson, MD,a,b Inger Sundström-Poromaa, MD, PhD,a Marie Bixo, MD, PhD,a Marianne Wulff, MD, PhD,a Karin Bondestam, MD,a and Monica Åström, MD, PhDc Umeå and Luleå, Sweden OBJECTIVE: This study was undertaken to determine the point prevalence of psychiatric disorders during the second trimester of pregnancy in a population-based sample of pregnant women. STUDY DESIGN: Participants were 1795 consecutive pregnant women attending routine ultrasound screening at two obstetric clinics in Northern Sweden during 1 year. The Primary Care Evaluation of Mental Disorders (PRIME-MD) was used for evaluating. RESULTS: Overall, 1734 (96.6%) of the women filled in the PRIME-MD patient questionnaire. Psychiatric disorders were present in 14.1% of the women. Major depression was prevalent in 3.3% of patients and minor depression in 6.9% of patients. Anxiety disorders were encountered in 6.6% of patients. Women with psychiatric disorders displayed significantly more somatic symptoms and more pronounced fear of childbirth. Among diagnosed patients, only 5.5% had some form of treatment. CONCLUSION: The prevalence of mood and anxiety disorders in this unselected population of pregnant women was high and the majority of the women were found to be undiagnosed and untreated. (Am J Obstet Gynecol 2003;189:148-54.)
Key words: Depression, anxiety, pregnancy, population-based
Pregnancy is a period of physiologic, hormonal, and psychologic changes. Most women are childbearing at least once during a lifetime. In Sweden, the mean parity is 1.57 children and the mean age for the first childbirth is 28.2 years. Pregnant women are offered free antenatal care, and the participation rate is estimated to almost 100%. These antenatal visits focus mainly on risk identification and detection of pregnancy-induced somatic diseases and far less attention is paid to discovering mental disorders. Major depressive disorder is approximately two to three times as common in women as in men.1 The lifetime prevalence of major depression among women is estimated to 14% to 21%2,3 and the point prevalence is 1.4% to 3.5% in reproductive age.4 Furthermore, in depressed women, comorbid anxiety disorders are frequent. The point prevalence for anxiety disorders in
From the Department of Clinical Sciences, Obstetrics and Gynecology,a Umeå University, the Department of Obstetrics and Gynecology,b Sunderby Hospital, and the Department of Clinical Sciences, Psychiatry,c Umeå University. Supported by research grants from Pfizer AB, Stockholm, Sweden, Visare Norr, Umeå University Insamlingsstiftelsen and by grants to I. S-P. from the Swedish Society for Medical Research. Reprint requests: Liselott Andersson, MD, Department of Obstetrics and Gynecology, Sunderby Hospital, S-97180 Luleå, Sweden. E-mail: [email protected] © 2003, Mosby, Inc. All rights reserved. 0002-9378/2003 $30.00 +0 doi:10.1067/mob.2003.336
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women in reproductive age is approximately 2.4% to 3.3%.5 Depressive and anxiety disorders are strongly associated with the increased reporting of physical symptoms, more in women than in men.6 Among physical symptoms frequently reported by women in primary care are dizziness, headache, fatigue, joint and limb pain, palpitations, back pain, and bowel complaints.6 Overall, panic disorder, social phobia, obsessive-compulsive disorder, generalized anxiety, and eating disorders are encountered more often in women than in men.7 It is well known that women are at risk of developing affective disorders during the postpartum period and the point prevalence of postpartum depression has been estimated to 13%.8 However, Evans et al9 found depressive symptoms to be more frequent during pregnancy than postpartum, suggesting that antenatal depression is more common. During pregnancy, mood disorders more often seem to be influenced by socioeconomic status than during the postpartum period, suggesting different etiologic factors.10 Studies on preexisting panic disorder indicate a variable impact of pregnancy, either improvement or status quo, but postpartum worsening seems to be a more consistent phenomenon.11 Furthermore, obsessive-compulsive disorder may first appear or be exacerbated during pregnancy and the postpartum period.12 Less is known about eating disorders during pregnancy but bulimia nervosa seems to improve.13 However, the risk of postpartum depression seems to be higher among women with eating disorders.
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Although a great number of studies have investigated the prevalence of psychiatric disorders in limited samples of pregnant women, these studies have mainly focused on specific risk groups such as teenage mothers, women of low socioeconomic status, and certain ethnic groups.14 Furthermore, most studies have used different rating scales and/or criteria for diagnosing depression and only a minority has used modern criteria, adhering to DSM-IV (Diagnostic and Statistical Manual of Mental disorders). The aim of this study was to estimate the point prevalence of mood, anxiety and eating disorders, based on DSM-IV criteria, in an unselected population of pregnant women. Material and methods Study population. From October 2, 2000, to October 1, 2001, all women attending the second-trimester routine ultrasound screening at two different hospitals in northern Sweden (at Umeå University Hospital and at Sunderby Central Hospital) were approached for participation in the study. In Sweden, all pregnant women are invited to an ultrasound examination at 16 to 17 weeks of gestation, mainly for estimation of the date of childbirth. According to available statistics, approximately 97% of the Swedish pregnant population participate in this screening program.15 Umeå University Hospital serves a population of 134,428 people of which 27,063 are women in reproductive age. The corresponding figures for Sunderby Central Hospital are 115,600 and 19,277, respectively. There are no other available ultrasound screening facilities in these two cities. Exclusion criteria were (1) detection of malformation or miscarriage during the ultrasound examination, (2) inability to read and understand the questionnaire because of language difficulties, and (3) not providing informed consent. Psychiatric diagnosis. Diagnoses of psychiatric disorders were made by using the Primary Care Evaluation of Mental Disorders (PRIME-MD) system. The PRIME-MD system has been developed to help primary care physicians to screen, evaluate, and diagnose mental disorders. Given its utility and ease of use, PRIME-MD was considered to be a suitable tool for assessing the prevalence of psychiatric disorders in an obstetric outpatient setting. The PRIME-MD system has been constructed to conform to DSM-IV criteria and has been validated for use in primary care settings.16 Furthermore, a self-administered version of PRIME-MD, the PRIME-MD Patient Health Questionnaire, has been validated for use in obstetric-gynecologic patients.17 The agreement between PRIMEMD and independent psychiatric diagnosis derived by a structured interview is generally excellent across diagnostic modules with an overall accuracy of 88%.16 The PRIME-MD system, which is fully described elsewhere,16 consists of 2 components: a 1-page patient questionnaire
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(PQ) and a 12-page clinician evaluation guide (CEG), which is a structured interview for the clinician to follow when evaluating the responses on the PQ. The original CEG contains modules for mood, anxiety, eating disorders, alcohol abuse, social phobia, and obsessive-compulsive disorder. Clinicians administer only those modules that are indicated by the patient on the PQ. A modified form of the PRIME-MD patient questionnaire was used for this study containing 25 questions evaluating somatoform disorder, mood disorders, anxiety disorders (including social phobia and obsessive-compulsive disorder), and eating disorders. The modified PRIMEMD has been changed from the original PRIME-MD questionnaire in the following ways: (1) the question about dysmenorrhea has been changed in favor of a question regarding pelvic pain, (2) the 4 questions regarding alcohol abuse were omitted, and (3) a question about generally perceived health was changed into a question about fear of delivery. The PRIME-MD system evaluates the presence of 20 possible mental disorders, of which this study focused on 13 diagnoses. Among these 13 diagnoses of interest, 8 correspond to the specific requirements of DSM-IV (major depressive disorder, dysthymia, partial remission of major depressive disorder, generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, social phobia, and bulimia nervosa). An additional 4 diagnoses are considered to be “subthreshold” diagnoses, such as minor depressive disorder, anxiety not otherwise specified (NOS), eating disorder NOS, and binge eating disorder. Subthreshold diagnoses have fewer symptoms than required for a specific DSM-IV diagnosis but are included as they are associated with considerable impairment in function.18 Finally, a rule-out diagnosis of bipolar disorder was included. Alcohol abuse, somatoform disorders, and rule-out diagnoses of mood and/or anxiety caused by physical disorder, medication, or drugs were not assessed. The DSM-IV criteria for major depression and generalized anxiety are specified in the Appendix. Study design. Before attending the ultrasound examination, the women completed the PRIME-MD patient questionnaire. To pursue a diagnosis, a telephone interview, that used a computerized version of the clinical evaluation guide was conducted with the screen positive women. Along with the PQ, the women were asked to provide their name, date of birth, and telephone number. Furthermore, they were asked to sign an informed consent allowing for a telephone interview. The women were considered to be screen positive if any key question for mental disorders was indicated. The questions in the PQ concerning somatoform disorders were not followed up in the interview. The reason for this is that pregnant women normally have a lot of physical complaints related to the pregnancy, which makes it more difficult to diagnose somatoform disorders.
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The telephone interview with screen-positive women was made within 1 to 2 weeks after the visit. At the time of the telephone interview, the interviewer had no knowledge of the woman’s psychiatric and medical history, including problems concerning the actual pregnancy. In case of a PRIME-MD diagnosis, the woman was asked about current antidepressant drug therapy and/or psychotherapy. Those who were asking for help and/or had thoughts about committing suicide were immediately referred to psychiatric specialist care. One research nurse and four obstetricians performed the telephone interviews. All had participated in a 3-hour training session with PRIME-MD instructors and a psychiatrist before the study and one of the obstetricians had prior experience with PRIME-MD. The study was approved by the Ethics Committee, Umeå University, Sweden. Statistical analyses. Continuous variables were compared by use of the t test and are displayed as mean ± SD. Frequencies were compared between groups by χ2 test. All statistical analyses were performed with SPSS 10.0 (Chicago, Ill). A P value less than .05 was considered significant. Results Study population. There were 2269 women eligible for the study and of those 474 women were excluded. Reasons for exclusion were language difficulties (inability to read and/or speak Swedish, n = 86), refusal to participate (n = 10), other various reasons (n = 14), and too intense patient flow (n = 364). This left a total of 1795 women, 1095 at Umeå University Hospital and 700 at Sunderby Central Hospital. Of these included women, 1734 (96.6%) filled in the PRIME-MD screening questionnaire. Twenty-four women were excluded after their ultrasound examination because of a detected malformation or miscarriage. There were 105 (6.0%) questionnaires answered without providing written informed consent for a follow-up telephone interview. Among these were also those questionnaires where name and/or date of birth and/or telephone number was not provided. Overall, 1605 (89.4%) women filled in the PQ and consented to a telephone interview. Of these 1605 women, 790 (49.2%) were screen negative in that they did not trigger any of the key questions for mental disorders; 815 (50.8%) women indicated one or more of the key questions for mental disorders and also consented to a follow-up telephone interview. Forty-nine (3.1%) women were screen positive but could not be reached by telephone within the stipulated 14-day period. Hence, a telephone interview was conducted in 766 cases and the study population wherein a possible confirmation of a PRIME-MD diagnosis could be made consisted of 1556 subjects. Among women not consenting to a telephone interview, the prevalence of screen-positive patients (n = 62,
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59.0%) was higher than in the study population. The mean age of the study population was 29.4 ± 4.6 years, whereas excluded women were significantly older, 30.2 ± 5.3 years, P < .005. Three hundred ninety (25.1%) women reported pronounced fear of childbirth, 1149 (73.8%) did not display any fear, and 17 (1.1%) women did not answer this question. Prevalence of psychiatric disorders. Of the 1556 women in the study population, 220 (14.1%) had one or more PRIME-MD diagnoses. The prevalences of the psychiatric disorders detected by PRIME-MD in the total sample are summarized in Table I. Overall, major depressive disorder was present in 52 (3.3%) of the women and an additional 107 (6.9%) had a minor depressive disorder. The individual items reported by patients diagnosed with major and minor depressive disorder are presented in Table II. Most commonly, the women acknowledged fatigue or loss of energy, which was found in 88.7% of depressed women. Among the two key symptoms for major depression, the pregnant women in the study more often complained of diminished interest in daily activities (82.4% of depressed women) than of depressed mood (44.7% of depressed women). Anxiety disorders were present in 102 (6.6%) of the women and anxiety NOS was most common, found in 69 (4.4%). Obsessive-compulsive disorder was diagnosed in 20 (1.3%) women, social phobia in 6 (0.4%), and eating disorders in 3 (0.2%). Pronounced fear of the approaching childbirth was significantly more common in the women with psychiatric diagnoses than those without, 44.5% and 22.1%, respectively, P < .005. Comorbidity was often encountered. Of the 220 women with a psychiatric diagnosis, 53 (24.1%) had two or more diagnoses, 11 (5.0%) women had three or more diagnoses, and 1 woman had five diagnoses. Very few of the women who received a PRIME-MD diagnosis during the study course had treatment for their psychiatric condition; 208 (94.5%) of the women received no treatment for their mental disorder, 11 (5.0%) received some form of psychotherapy, and 1 had been prescribed antidepressant treatment. Physical symptoms were significantly more common in the women with any psychiatric diagnosis than in women without a diagnosis. This was, however, not true regarding pelvic pain and sexual problems (Table III). Comment The current study is probably unique in being based on an unselected population of pregnant women with the use of modern DSM-IV criteria for psychiatric diagnosis. Most other studies on pregnant women are based on smaller samples in which the women are attending physicians for apprehended or manifest disorder. The estimated point prevalences of mood and anxiety disorders
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Table I. Prevalence of psychiatric disorders detected by PRIME-MD Mental disorder Any psychiatric diagnosis Any mood disorder Major depressive disorder Dysthymia Partial remission of major depressive disorder Minor depressive disorder Bipolar disorder Any anxiety disorder Anxiety NOS Generalized anxiety disorder Panic disorder Obsessive-compulsive disorder Social phobia Eating disorder
Total sample (n = 1556) 220 (14.1%) 181 (11.6%) 52 (3.3%) 10 (0.6%) 11 (0.7%) 107 (6.9%) 1 102 (6.6%) 69 (4.4%) 4 (0.3%) 3 (0.2%) 20 (1.3%) 6 (0.4%) 3 (0.2%)
Table II. Frequency of items reported by the 159 patients diagnosed with major and minor depression Items Depressed mood Diminished interest in daily activities Decreased or increased appetite Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or inappropriate guilt Diminished ability to think or concentrate Recurrent thoughts of death
Frequency (No. [%]) 71 (44.7%) 131 (82.4%) 62 (39.0%) 92 (57.9%) 47 (29.6%) 151 (88.7%) 49 (30.8%) 44 (27.7%) 9 (5.7%)
in this study are lower than in a previous study that used the same type of test instrument in obstetric-gynecologic patients in which 20% of patients were diagnosed.17 In our material we noted a prevalence of 14.1% for all psychiatric diagnoses. A possible explanation for this discrepancy is that this population did not include gynecologic patients, and subsequently the findings in the current study probably more correctly reflect mental health among pregnant women. Furthermore, we have previously reported that prevalence rates of psychiatric disorders are high, approximately 30%, in gynecologic patients.19 The point prevalence of any mood disorder in the current study is 11.6% and mood disorders are thus the most common psychiatric disorders in this population, which is in agreement with studies on other pregnant and nonpregnant women.17 Anxiety disorders were relatively common in our study, 6.6%, with anxiety NOS being most frequent. The rate of anxiety disorders in this sample of pregnant women was clearly higher than the figure given by community-based studies of fertile women.4 Surprisingly, we found a quite low prevalence of
Table III. Frequency of physical symptoms by prevalence of any PRIME-MD diagnosis All physical symptoms (No. [% of patients reporting specific symptoms])*
Fatigue Nausea Headache Bowel complaints Back pain Dizziness Abdominal pain Insomnia Joint or limb pain Palpitations Pelvic pain Chest pain Dyspnea Sexual problems Fainting
Psychiatric diagnosis (n = 220)
No psychiatric diagnosis (n = 1336)
P value
211 (96.8%) 152 (70.4%) 129 (58.9%) 122 (56.2%) 115 (52.3%) 111 (50.5%) 106 (48.2%) 90 (41.5%) 79 (35.9%) 56 (25.7%) 54 (25.0%) 41 (18.8%) 31 (14.3%) 25 (11.6%) 15 (6.8%)
1104 (84.3%) 596 (45.6%) 541 (41.1%) 516 (39.5%) 521 (39.6%) 355 (27.0%) 347 (26.5%) 250 (19.1%) 281 (21.4%) 184 (14.0%) 265 (20.3%) 132 (10.0%) 86 (6.5%) 102 (7.8%) 40 (3.0%)
.0001 .0001 .0001 .0001 .0001 .0001 .0001 .0001 .0001 .0001 NS .0001 .0001 NS .001
NS, Not significant. *Not all patients answered all questions.
social phobia, 0.4%. The point prevalence of social phobia in women has been estimated earlier to 17.6%.20 In other studies, a lifetime prevalence of 15.5% was noted.21 One reason for the low rate in our study might be that these women were afraid to attend ultrasound screening or were among those who dropped out for various reasons. Another possible explanation might be that women with social phobia are so disabled that they choose not to become pregnant. Social phobia is more frequent among women and they are less likely to seek help than men.21 Another finding was that somatic symptoms were significantly more frequent among women with any psychiatric diagnosis than in those without. Kelly et al22 made a similar discovery in their study on 186 pregnant women. In our study, only two symptoms did not occur significantly more frequently in women with psychiatric PRIMEMD diagnoses, namely, pelvic pain and sexual problems. Accordingly, these results concur with previous well-documented findings that unspecified somatic complaints are associated with psychopathology, especially in women.6 Finally, we noted a significantly higher prevalence of pronounced fear of the approaching childbirth in women with a psychiatric diagnosis. Indeed, fear of childbirth was twice as common among diagnosed women as among the remaining study group. This result emphasizes the importance of special treatment for women with fear of childbirth. Psychotherapy has by Saisto et al23 been shown to be effective in reducing the rate of cesarean sections because of anxiety or concerns, and in shortening labor. A possible explanation for the success of psychotherapy in treating women with fear of
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childbirth might be that they more often have psychiatric disorders, which are more seldom discovered in the conventional antenatal care program. The prevalence of psychiatric disorder in our study was high, at least in the range of severe somatic pregnancy complications. Because most women with a diagnosis were untreated, it is plausible that the majority of them were unrecognized previously. A possible explanation is that women often present with atypical symptoms of depression and/or unspecified somatic complaints as symptoms of psychiatric disorder. Overall, somatic symptoms are common in otherwise healthy pregnant women. Furthermore, in our study the two most frequent symptoms in depressed women were fatigue or loss of energy and diminished interest in daily activities, not depressed mood as one might have expected. Spitzer et al17 found the frequency of unrecognized diagnosis to be 77% at obstetrics-gynecology outpatient care sites compared with 44% in primary care patients, suggesting that diagnosing is difficult without a test instrument. Because most women regularly attend antenatal care units during childbearing, the possibility of diagnosing and treating psychiatric disorders is excellent, particularly if a reliable test instrument such as PRIME-MD is used. Major depression is not only associated with a substantial patient suffering, disability, and lost productivity but also with an excess mortality, all of which are valid reasons for treatment. Furthermore, depression during pregnancy is not only associated with postpartum depression,10 but also with poor pregnancy outcome, for example, low birth weight and preterm birth.24 Whether major depression should be treated with serotonin reuptake inhibitors (SSRI) and/or with psychotherapy is controversial, and treatment decisions must be individualized and based on the choice of the pregnant woman and her physician, in cooperation. Thus far, data have not indicated that SSRI increase the risk for intrauterine death or major birth defects.25 Furthermore, fluoxetine does not seem to influence the development in children, indicating that these drugs probably are safe to take during pregnancy.25 Thus, the possibility to successfully treat pregnant women with psychiatric disorders ought to be just as good as in other situations. A limitation to the current investigation is that the assessment of psychiatric diagnoses were made at one time point only during pregnancy, raising questions whether symptoms were unchanged, transitory, or might have developed after the point of screening. Evans et al9 have noted a significant increase in depression scores between 18 to 32 weeks of pregnancy, but it remains uncertain if the same phenomenon is applicable to other psychiatric disorders. Another limitation is the exclusion of women with language difficulties. This study design made it impossible to include those women, but as rates of anxiety and depression among immigrants are likely to be increased, further study of this particular subset of pregnant women is mandated.
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In conclusion, this study has pointed out that psychiatric disorders are common in an unselected population of pregnant women and accompanied by significantly more somatic symptoms as well as fear of the approaching childbirth. The majority of these women are probably undiagnosed and untreated. Further research is needed to explore associations with complications of delivery, neonatal outcome and psychiatric health in the postpartum period as well as the relationship with previous reproductive, somatic and psychiatric health and socioeconomic factors. We thank all personnel involved in the ultrasound screening procedure at the two sites and especially Mrs Marie Wallgren and Mrs Yvonne Hoff who also provided invaluable help with the telephone interviews. REFERENCES
1. Weissman MM, Bland R, Joyce PR, Newman S, Wells JE, Wittchen HU. Sex differences in rates of depression: cross-national perspectives. J Affect Disord 1993;29:77-84. 2. Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 1994;51:8-19. 3. Wittchen HU, Essau CA, von Zerssen D, Krieg JC, Zaudig M. Lifetime and six-month prevalence of mental disorders in the Munich Follow-Up Study. Eur Arch Psychiatry Clin Neurosci 1992;241:247-58. 4. Hagnell O, Ojesjo L, Otterbeck L, Rorsman B. Prevalence of mental disorders, personality traits and mental complaints in the Lundby Study: a point prevalence study of the 1957 Lundby cohort of 2,612 inhabitants of a geographically defined area who were re-examined in 1972 regardless of domicile. Scand J Soc Med Suppl 1994;50:1-77. 5. Breslau N, Schultz L, Peterson E. Sex differences in depression: a role for preexisting anxiety. Psychiatry Res 1995;58:1-12. 6. Kroenke K, Spitzer RL. Gender differences in the reporting of physical and somatoform symptoms. Psychosom Med 1998;60:150-5. 7. Steiner M. Female-specific mood disorders. Clin Obstet Gynecol 1992;35:599-611. 8. O’Hara MW. Social support, life events, and depression during pregnancy and the puerperium. Arch Gen Psychiatry 1986;43:569-73. 9. Evans J, Heron J, Francomb H, Oke S, Golding J. Cohort study of depressed mood during pregnancy and after childbirth. BMJ 2001;323:257-60. 10. Gotlib IH, Whiffen VE, Mount JH, Milne K, Cordy NI. Prevalence rates and demographic characteristics associated with depression in pregnancy and the postpartum. J Consult Clin Psychol 1989;57:269-74. 11. Northcott CJ, Stein MB. Panic disorder in pregnancy. J Clin Psychiatry 1994;55:539-42. 12. Williams KE, Koran LM. Obsessive-compulsive disorder in pregnancy, the puerperium, and the premenstruum. J Clin Psychiatry 1997;58:330-6. 13. Morgan JF, Lacey JH, Sedgwick PM. Impact of pregnancy on bulimia nervosa. Br J Psychiatry 1999;174:135-40. 14. Miranda J, Azocar F, Komaromy M, Golding JM. Unmet mental health needs of women in public-sector gynecologic clinics. Am J Obstet Gynecol 1998;178:212-7. 15. Reports from the Swedish Council on Technology Assessment in Health Care (SBU). Int J Technol Assess Health Care 1999;15: 424-36. 16. Spitzer RL, Williams JB, Kroenke K, Linzer M, deGruy FV 3rd, Hahn SR, et al. Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study. JAMA 1994;272:1749-56.
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17. Spitzer RL, Williams JB, Kroenke K, Hornyak R, McMurray J. Validity and utility of the PRIME-MD patient health questionnaire in assessment of 3000 obstetric-gynecologic patients: the PRIMEMD Patient Health Questionnaire Obstetrics-Gynecology Study. Am J Obstet Gynecol 2000;183:759-69. 18. Lepine JP, Gastpar M, Mendlewicz J, Tylee A. Depression in the community: the first pan-European study DEPRES (Depression Research in European Society). Int Clin Psychopharmacol 1997;12:19-29. 19. Sundstrom IM, Bixo M, Bjorn I, Astrom M. Prevalence of psychiatric disorders in gynecologic outpatients. Am J Obstet Gynecol 2001;184:8-13. 20. Furmark T, Tillfors M, Everz P, Marteinsdottir I, Gefvert O, Fredrikson M. Social phobia in the general population: prevalence and sociodemographic profile. Soc Psychiatry Psychiatr Epidemiol 1999;34:416-24. 21. Weinstock LS. Gender differences in the presentation and management of social anxiety disorder. J Clin Psychiatry 1999;60(9 Suppl):9-13. 22. Kelly RH, Russo J, Katon W. Somatic complaints among pregnant women cared for in obstetrics: normal pregnancy or depressive and anxiety symptom amplification revisited? Gen Hosp Psychiatry 2001;23:107-13. 23. Saisto T, Salmela-Aro K, Nurmi JE, Kononen T, Halmesmaki E. A randomized controlled trial of intervention in fear of childbirth. Obstet Gynecol 2001;98:820-6. 24. Orr ST, Miller CA. Maternal depressive symptoms and the risk of poor pregnancy outcome: review of the literature and preliminary findings. Epidemiol Rev 1995;17:165-71. 25. Wisner KL, Gelenberg AJ, Leonard H, Zarin D, Frank E. Pharmacologic treatment of depression during pregnancy. JAMA 1999;282:1264-9.
Appendix DSM-IV criteria. Criteria for major depressive episode A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly caused by a general medical condition, or mood-incongruent delusions or hallucinations. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (for example, feels sad or empty) or observations made by others (for example, appears tearful). Note: In children and adolescents, can be irritable mood. 2. Marked diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others). 3. Significant weight loss when not dieting or weight gain (for example, change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
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6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms do not meet criteria for a mixed episode. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to the direct physiologic effects of a substance (for example, a drug of abuse, a medication) or a general medical condition (for example, hypothyroidism). E. The symptoms are not better accounted for by bereavement, that means, after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. Criteria for generalized anxiety disorder A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). B. The person finds it difficult to control the worry. C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children. 1. Restlessness or feeling keyed up or on the edge 2. Being easily fatigued 3. Difficult concentrating or mind going blank 4. Irritability 5. Muscle tension 6. Sleep disturbance (difficult falling or staying asleep, or restless unsatisfying sleep) D. The focus of the anxiety and worry is not confined to features of an axis I disorder, for example, the anxiety or worry is not about having a panic attack (as in panic disorder), being embarrassed in public (as in social phobia), being contaminated (as in obsessivecompulsive disorder), being away from home or close relatives (as in separation anxiety disorder), gaining weight (as in anorexia nervosa), having multiple physical complaints (as in somatization disorder), or
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having a serious illness (as in hypochondriasis), and the anxiety and worry do not occur exclusively during posttraumatic stress disorder. E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
O
F. The disturbance is not due to the direct physiologic effects of a substance (for example, a drug of abuse, a medication) or a general medical condition (for example, hyperthyroidism) and do not occur exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder.
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Key words: Depression, anxiety, pregnancy, population-based
Pregnancy is a period of physiologic, hormonal, and psychologic changes. Most women are childbearing at least once during a lifetime. In Sweden, the mean parity is 1.57 children and the mean age for the first childbirth is 28.2 years. Pregnant women are offered free antenatal care, and the participation rate is estimated to almost 100%. These antenatal visits focus mainly on risk identification and detection of pregnancy-induced somatic diseases and far less attention is paid to discovering mental disorders. Major depressive disorder is approximately two to three times as common in women as in men.1 The lifetime prevalence of major depression among women is estimated to 14% to 21%2,3 and the point prevalence is 1.4% to 3.5% in reproductive age.4 Furthermore, in depressed women, comorbid anxiety disorders are frequent. The point prevalence for anxiety disorders in
From the Department of Clinical Sciences, Obstetrics and Gynecology,a Umeå University, the Department of Obstetrics and Gynecology,b Sunderby Hospital, and the Department of Clinical Sciences, Psychiatry,c Umeå University. Supported by research grants from Pfizer AB, Stockholm, Sweden, Visare Norr, Umeå University Insamlingsstiftelsen and by grants to I. S-P. from the Swedish Society for Medical Research. Reprint requests: Liselott Andersson, MD, Department of Obstetrics and Gynecology, Sunderby Hospital, S-97180 Luleå, Sweden. E-mail: [email protected] © 2003, Mosby, Inc. All rights reserved. 0002-9378/2003 $30.00 +0 doi:10.1067/mob.2003.336
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women in reproductive age is approximately 2.4% to 3.3%.5 Depressive and anxiety disorders are strongly associated with the increased reporting of physical symptoms, more in women than in men.6 Among physical symptoms frequently reported by women in primary care are dizziness, headache, fatigue, joint and limb pain, palpitations, back pain, and bowel complaints.6 Overall, panic disorder, social phobia, obsessive-compulsive disorder, generalized anxiety, and eating disorders are encountered more often in women than in men.7 It is well known that women are at risk of developing affective disorders during the postpartum period and the point prevalence of postpartum depression has been estimated to 13%.8 However, Evans et al9 found depressive symptoms to be more frequent during pregnancy than postpartum, suggesting that antenatal depression is more common. During pregnancy, mood disorders more often seem to be influenced by socioeconomic status than during the postpartum period, suggesting different etiologic factors.10 Studies on preexisting panic disorder indicate a variable impact of pregnancy, either improvement or status quo, but postpartum worsening seems to be a more consistent phenomenon.11 Furthermore, obsessive-compulsive disorder may first appear or be exacerbated during pregnancy and the postpartum period.12 Less is known about eating disorders during pregnancy but bulimia nervosa seems to improve.13 However, the risk of postpartum depression seems to be higher among women with eating disorders.
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Although a great number of studies have investigated the prevalence of psychiatric disorders in limited samples of pregnant women, these studies have mainly focused on specific risk groups such as teenage mothers, women of low socioeconomic status, and certain ethnic groups.14 Furthermore, most studies have used different rating scales and/or criteria for diagnosing depression and only a minority has used modern criteria, adhering to DSM-IV (Diagnostic and Statistical Manual of Mental disorders). The aim of this study was to estimate the point prevalence of mood, anxiety and eating disorders, based on DSM-IV criteria, in an unselected population of pregnant women. Material and methods Study population. From October 2, 2000, to October 1, 2001, all women attending the second-trimester routine ultrasound screening at two different hospitals in northern Sweden (at Umeå University Hospital and at Sunderby Central Hospital) were approached for participation in the study. In Sweden, all pregnant women are invited to an ultrasound examination at 16 to 17 weeks of gestation, mainly for estimation of the date of childbirth. According to available statistics, approximately 97% of the Swedish pregnant population participate in this screening program.15 Umeå University Hospital serves a population of 134,428 people of which 27,063 are women in reproductive age. The corresponding figures for Sunderby Central Hospital are 115,600 and 19,277, respectively. There are no other available ultrasound screening facilities in these two cities. Exclusion criteria were (1) detection of malformation or miscarriage during the ultrasound examination, (2) inability to read and understand the questionnaire because of language difficulties, and (3) not providing informed consent. Psychiatric diagnosis. Diagnoses of psychiatric disorders were made by using the Primary Care Evaluation of Mental Disorders (PRIME-MD) system. The PRIME-MD system has been developed to help primary care physicians to screen, evaluate, and diagnose mental disorders. Given its utility and ease of use, PRIME-MD was considered to be a suitable tool for assessing the prevalence of psychiatric disorders in an obstetric outpatient setting. The PRIME-MD system has been constructed to conform to DSM-IV criteria and has been validated for use in primary care settings.16 Furthermore, a self-administered version of PRIME-MD, the PRIME-MD Patient Health Questionnaire, has been validated for use in obstetric-gynecologic patients.17 The agreement between PRIMEMD and independent psychiatric diagnosis derived by a structured interview is generally excellent across diagnostic modules with an overall accuracy of 88%.16 The PRIME-MD system, which is fully described elsewhere,16 consists of 2 components: a 1-page patient questionnaire
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(PQ) and a 12-page clinician evaluation guide (CEG), which is a structured interview for the clinician to follow when evaluating the responses on the PQ. The original CEG contains modules for mood, anxiety, eating disorders, alcohol abuse, social phobia, and obsessive-compulsive disorder. Clinicians administer only those modules that are indicated by the patient on the PQ. A modified form of the PRIME-MD patient questionnaire was used for this study containing 25 questions evaluating somatoform disorder, mood disorders, anxiety disorders (including social phobia and obsessive-compulsive disorder), and eating disorders. The modified PRIMEMD has been changed from the original PRIME-MD questionnaire in the following ways: (1) the question about dysmenorrhea has been changed in favor of a question regarding pelvic pain, (2) the 4 questions regarding alcohol abuse were omitted, and (3) a question about generally perceived health was changed into a question about fear of delivery. The PRIME-MD system evaluates the presence of 20 possible mental disorders, of which this study focused on 13 diagnoses. Among these 13 diagnoses of interest, 8 correspond to the specific requirements of DSM-IV (major depressive disorder, dysthymia, partial remission of major depressive disorder, generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, social phobia, and bulimia nervosa). An additional 4 diagnoses are considered to be “subthreshold” diagnoses, such as minor depressive disorder, anxiety not otherwise specified (NOS), eating disorder NOS, and binge eating disorder. Subthreshold diagnoses have fewer symptoms than required for a specific DSM-IV diagnosis but are included as they are associated with considerable impairment in function.18 Finally, a rule-out diagnosis of bipolar disorder was included. Alcohol abuse, somatoform disorders, and rule-out diagnoses of mood and/or anxiety caused by physical disorder, medication, or drugs were not assessed. The DSM-IV criteria for major depression and generalized anxiety are specified in the Appendix. Study design. Before attending the ultrasound examination, the women completed the PRIME-MD patient questionnaire. To pursue a diagnosis, a telephone interview, that used a computerized version of the clinical evaluation guide was conducted with the screen positive women. Along with the PQ, the women were asked to provide their name, date of birth, and telephone number. Furthermore, they were asked to sign an informed consent allowing for a telephone interview. The women were considered to be screen positive if any key question for mental disorders was indicated. The questions in the PQ concerning somatoform disorders were not followed up in the interview. The reason for this is that pregnant women normally have a lot of physical complaints related to the pregnancy, which makes it more difficult to diagnose somatoform disorders.
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The telephone interview with screen-positive women was made within 1 to 2 weeks after the visit. At the time of the telephone interview, the interviewer had no knowledge of the woman’s psychiatric and medical history, including problems concerning the actual pregnancy. In case of a PRIME-MD diagnosis, the woman was asked about current antidepressant drug therapy and/or psychotherapy. Those who were asking for help and/or had thoughts about committing suicide were immediately referred to psychiatric specialist care. One research nurse and four obstetricians performed the telephone interviews. All had participated in a 3-hour training session with PRIME-MD instructors and a psychiatrist before the study and one of the obstetricians had prior experience with PRIME-MD. The study was approved by the Ethics Committee, Umeå University, Sweden. Statistical analyses. Continuous variables were compared by use of the t test and are displayed as mean ± SD. Frequencies were compared between groups by χ2 test. All statistical analyses were performed with SPSS 10.0 (Chicago, Ill). A P value less than .05 was considered significant. Results Study population. There were 2269 women eligible for the study and of those 474 women were excluded. Reasons for exclusion were language difficulties (inability to read and/or speak Swedish, n = 86), refusal to participate (n = 10), other various reasons (n = 14), and too intense patient flow (n = 364). This left a total of 1795 women, 1095 at Umeå University Hospital and 700 at Sunderby Central Hospital. Of these included women, 1734 (96.6%) filled in the PRIME-MD screening questionnaire. Twenty-four women were excluded after their ultrasound examination because of a detected malformation or miscarriage. There were 105 (6.0%) questionnaires answered without providing written informed consent for a follow-up telephone interview. Among these were also those questionnaires where name and/or date of birth and/or telephone number was not provided. Overall, 1605 (89.4%) women filled in the PQ and consented to a telephone interview. Of these 1605 women, 790 (49.2%) were screen negative in that they did not trigger any of the key questions for mental disorders; 815 (50.8%) women indicated one or more of the key questions for mental disorders and also consented to a follow-up telephone interview. Forty-nine (3.1%) women were screen positive but could not be reached by telephone within the stipulated 14-day period. Hence, a telephone interview was conducted in 766 cases and the study population wherein a possible confirmation of a PRIME-MD diagnosis could be made consisted of 1556 subjects. Among women not consenting to a telephone interview, the prevalence of screen-positive patients (n = 62,
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59.0%) was higher than in the study population. The mean age of the study population was 29.4 ± 4.6 years, whereas excluded women were significantly older, 30.2 ± 5.3 years, P < .005. Three hundred ninety (25.1%) women reported pronounced fear of childbirth, 1149 (73.8%) did not display any fear, and 17 (1.1%) women did not answer this question. Prevalence of psychiatric disorders. Of the 1556 women in the study population, 220 (14.1%) had one or more PRIME-MD diagnoses. The prevalences of the psychiatric disorders detected by PRIME-MD in the total sample are summarized in Table I. Overall, major depressive disorder was present in 52 (3.3%) of the women and an additional 107 (6.9%) had a minor depressive disorder. The individual items reported by patients diagnosed with major and minor depressive disorder are presented in Table II. Most commonly, the women acknowledged fatigue or loss of energy, which was found in 88.7% of depressed women. Among the two key symptoms for major depression, the pregnant women in the study more often complained of diminished interest in daily activities (82.4% of depressed women) than of depressed mood (44.7% of depressed women). Anxiety disorders were present in 102 (6.6%) of the women and anxiety NOS was most common, found in 69 (4.4%). Obsessive-compulsive disorder was diagnosed in 20 (1.3%) women, social phobia in 6 (0.4%), and eating disorders in 3 (0.2%). Pronounced fear of the approaching childbirth was significantly more common in the women with psychiatric diagnoses than those without, 44.5% and 22.1%, respectively, P < .005. Comorbidity was often encountered. Of the 220 women with a psychiatric diagnosis, 53 (24.1%) had two or more diagnoses, 11 (5.0%) women had three or more diagnoses, and 1 woman had five diagnoses. Very few of the women who received a PRIME-MD diagnosis during the study course had treatment for their psychiatric condition; 208 (94.5%) of the women received no treatment for their mental disorder, 11 (5.0%) received some form of psychotherapy, and 1 had been prescribed antidepressant treatment. Physical symptoms were significantly more common in the women with any psychiatric diagnosis than in women without a diagnosis. This was, however, not true regarding pelvic pain and sexual problems (Table III). Comment The current study is probably unique in being based on an unselected population of pregnant women with the use of modern DSM-IV criteria for psychiatric diagnosis. Most other studies on pregnant women are based on smaller samples in which the women are attending physicians for apprehended or manifest disorder. The estimated point prevalences of mood and anxiety disorders
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Table I. Prevalence of psychiatric disorders detected by PRIME-MD Mental disorder Any psychiatric diagnosis Any mood disorder Major depressive disorder Dysthymia Partial remission of major depressive disorder Minor depressive disorder Bipolar disorder Any anxiety disorder Anxiety NOS Generalized anxiety disorder Panic disorder Obsessive-compulsive disorder Social phobia Eating disorder
Total sample (n = 1556) 220 (14.1%) 181 (11.6%) 52 (3.3%) 10 (0.6%) 11 (0.7%) 107 (6.9%) 1 102 (6.6%) 69 (4.4%) 4 (0.3%) 3 (0.2%) 20 (1.3%) 6 (0.4%) 3 (0.2%)
Table II. Frequency of items reported by the 159 patients diagnosed with major and minor depression Items Depressed mood Diminished interest in daily activities Decreased or increased appetite Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or inappropriate guilt Diminished ability to think or concentrate Recurrent thoughts of death
Frequency (No. [%]) 71 (44.7%) 131 (82.4%) 62 (39.0%) 92 (57.9%) 47 (29.6%) 151 (88.7%) 49 (30.8%) 44 (27.7%) 9 (5.7%)
in this study are lower than in a previous study that used the same type of test instrument in obstetric-gynecologic patients in which 20% of patients were diagnosed.17 In our material we noted a prevalence of 14.1% for all psychiatric diagnoses. A possible explanation for this discrepancy is that this population did not include gynecologic patients, and subsequently the findings in the current study probably more correctly reflect mental health among pregnant women. Furthermore, we have previously reported that prevalence rates of psychiatric disorders are high, approximately 30%, in gynecologic patients.19 The point prevalence of any mood disorder in the current study is 11.6% and mood disorders are thus the most common psychiatric disorders in this population, which is in agreement with studies on other pregnant and nonpregnant women.17 Anxiety disorders were relatively common in our study, 6.6%, with anxiety NOS being most frequent. The rate of anxiety disorders in this sample of pregnant women was clearly higher than the figure given by community-based studies of fertile women.4 Surprisingly, we found a quite low prevalence of
Table III. Frequency of physical symptoms by prevalence of any PRIME-MD diagnosis All physical symptoms (No. [% of patients reporting specific symptoms])*
Fatigue Nausea Headache Bowel complaints Back pain Dizziness Abdominal pain Insomnia Joint or limb pain Palpitations Pelvic pain Chest pain Dyspnea Sexual problems Fainting
Psychiatric diagnosis (n = 220)
No psychiatric diagnosis (n = 1336)
P value
211 (96.8%) 152 (70.4%) 129 (58.9%) 122 (56.2%) 115 (52.3%) 111 (50.5%) 106 (48.2%) 90 (41.5%) 79 (35.9%) 56 (25.7%) 54 (25.0%) 41 (18.8%) 31 (14.3%) 25 (11.6%) 15 (6.8%)
1104 (84.3%) 596 (45.6%) 541 (41.1%) 516 (39.5%) 521 (39.6%) 355 (27.0%) 347 (26.5%) 250 (19.1%) 281 (21.4%) 184 (14.0%) 265 (20.3%) 132 (10.0%) 86 (6.5%) 102 (7.8%) 40 (3.0%)
.0001 .0001 .0001 .0001 .0001 .0001 .0001 .0001 .0001 .0001 NS .0001 .0001 NS .001
NS, Not significant. *Not all patients answered all questions.
social phobia, 0.4%. The point prevalence of social phobia in women has been estimated earlier to 17.6%.20 In other studies, a lifetime prevalence of 15.5% was noted.21 One reason for the low rate in our study might be that these women were afraid to attend ultrasound screening or were among those who dropped out for various reasons. Another possible explanation might be that women with social phobia are so disabled that they choose not to become pregnant. Social phobia is more frequent among women and they are less likely to seek help than men.21 Another finding was that somatic symptoms were significantly more frequent among women with any psychiatric diagnosis than in those without. Kelly et al22 made a similar discovery in their study on 186 pregnant women. In our study, only two symptoms did not occur significantly more frequently in women with psychiatric PRIMEMD diagnoses, namely, pelvic pain and sexual problems. Accordingly, these results concur with previous well-documented findings that unspecified somatic complaints are associated with psychopathology, especially in women.6 Finally, we noted a significantly higher prevalence of pronounced fear of the approaching childbirth in women with a psychiatric diagnosis. Indeed, fear of childbirth was twice as common among diagnosed women as among the remaining study group. This result emphasizes the importance of special treatment for women with fear of childbirth. Psychotherapy has by Saisto et al23 been shown to be effective in reducing the rate of cesarean sections because of anxiety or concerns, and in shortening labor. A possible explanation for the success of psychotherapy in treating women with fear of
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childbirth might be that they more often have psychiatric disorders, which are more seldom discovered in the conventional antenatal care program. The prevalence of psychiatric disorder in our study was high, at least in the range of severe somatic pregnancy complications. Because most women with a diagnosis were untreated, it is plausible that the majority of them were unrecognized previously. A possible explanation is that women often present with atypical symptoms of depression and/or unspecified somatic complaints as symptoms of psychiatric disorder. Overall, somatic symptoms are common in otherwise healthy pregnant women. Furthermore, in our study the two most frequent symptoms in depressed women were fatigue or loss of energy and diminished interest in daily activities, not depressed mood as one might have expected. Spitzer et al17 found the frequency of unrecognized diagnosis to be 77% at obstetrics-gynecology outpatient care sites compared with 44% in primary care patients, suggesting that diagnosing is difficult without a test instrument. Because most women regularly attend antenatal care units during childbearing, the possibility of diagnosing and treating psychiatric disorders is excellent, particularly if a reliable test instrument such as PRIME-MD is used. Major depression is not only associated with a substantial patient suffering, disability, and lost productivity but also with an excess mortality, all of which are valid reasons for treatment. Furthermore, depression during pregnancy is not only associated with postpartum depression,10 but also with poor pregnancy outcome, for example, low birth weight and preterm birth.24 Whether major depression should be treated with serotonin reuptake inhibitors (SSRI) and/or with psychotherapy is controversial, and treatment decisions must be individualized and based on the choice of the pregnant woman and her physician, in cooperation. Thus far, data have not indicated that SSRI increase the risk for intrauterine death or major birth defects.25 Furthermore, fluoxetine does not seem to influence the development in children, indicating that these drugs probably are safe to take during pregnancy.25 Thus, the possibility to successfully treat pregnant women with psychiatric disorders ought to be just as good as in other situations. A limitation to the current investigation is that the assessment of psychiatric diagnoses were made at one time point only during pregnancy, raising questions whether symptoms were unchanged, transitory, or might have developed after the point of screening. Evans et al9 have noted a significant increase in depression scores between 18 to 32 weeks of pregnancy, but it remains uncertain if the same phenomenon is applicable to other psychiatric disorders. Another limitation is the exclusion of women with language difficulties. This study design made it impossible to include those women, but as rates of anxiety and depression among immigrants are likely to be increased, further study of this particular subset of pregnant women is mandated.
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In conclusion, this study has pointed out that psychiatric disorders are common in an unselected population of pregnant women and accompanied by significantly more somatic symptoms as well as fear of the approaching childbirth. The majority of these women are probably undiagnosed and untreated. Further research is needed to explore associations with complications of delivery, neonatal outcome and psychiatric health in the postpartum period as well as the relationship with previous reproductive, somatic and psychiatric health and socioeconomic factors. We thank all personnel involved in the ultrasound screening procedure at the two sites and especially Mrs Marie Wallgren and Mrs Yvonne Hoff who also provided invaluable help with the telephone interviews. REFERENCES
1. Weissman MM, Bland R, Joyce PR, Newman S, Wells JE, Wittchen HU. Sex differences in rates of depression: cross-national perspectives. J Affect Disord 1993;29:77-84. 2. Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 1994;51:8-19. 3. Wittchen HU, Essau CA, von Zerssen D, Krieg JC, Zaudig M. Lifetime and six-month prevalence of mental disorders in the Munich Follow-Up Study. Eur Arch Psychiatry Clin Neurosci 1992;241:247-58. 4. Hagnell O, Ojesjo L, Otterbeck L, Rorsman B. Prevalence of mental disorders, personality traits and mental complaints in the Lundby Study: a point prevalence study of the 1957 Lundby cohort of 2,612 inhabitants of a geographically defined area who were re-examined in 1972 regardless of domicile. Scand J Soc Med Suppl 1994;50:1-77. 5. Breslau N, Schultz L, Peterson E. Sex differences in depression: a role for preexisting anxiety. Psychiatry Res 1995;58:1-12. 6. Kroenke K, Spitzer RL. Gender differences in the reporting of physical and somatoform symptoms. Psychosom Med 1998;60:150-5. 7. Steiner M. Female-specific mood disorders. Clin Obstet Gynecol 1992;35:599-611. 8. O’Hara MW. Social support, life events, and depression during pregnancy and the puerperium. Arch Gen Psychiatry 1986;43:569-73. 9. Evans J, Heron J, Francomb H, Oke S, Golding J. Cohort study of depressed mood during pregnancy and after childbirth. BMJ 2001;323:257-60. 10. Gotlib IH, Whiffen VE, Mount JH, Milne K, Cordy NI. Prevalence rates and demographic characteristics associated with depression in pregnancy and the postpartum. J Consult Clin Psychol 1989;57:269-74. 11. Northcott CJ, Stein MB. Panic disorder in pregnancy. J Clin Psychiatry 1994;55:539-42. 12. Williams KE, Koran LM. Obsessive-compulsive disorder in pregnancy, the puerperium, and the premenstruum. J Clin Psychiatry 1997;58:330-6. 13. Morgan JF, Lacey JH, Sedgwick PM. Impact of pregnancy on bulimia nervosa. Br J Psychiatry 1999;174:135-40. 14. Miranda J, Azocar F, Komaromy M, Golding JM. Unmet mental health needs of women in public-sector gynecologic clinics. Am J Obstet Gynecol 1998;178:212-7. 15. Reports from the Swedish Council on Technology Assessment in Health Care (SBU). Int J Technol Assess Health Care 1999;15: 424-36. 16. Spitzer RL, Williams JB, Kroenke K, Linzer M, deGruy FV 3rd, Hahn SR, et al. Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study. JAMA 1994;272:1749-56.
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17. Spitzer RL, Williams JB, Kroenke K, Hornyak R, McMurray J. Validity and utility of the PRIME-MD patient health questionnaire in assessment of 3000 obstetric-gynecologic patients: the PRIMEMD Patient Health Questionnaire Obstetrics-Gynecology Study. Am J Obstet Gynecol 2000;183:759-69. 18. Lepine JP, Gastpar M, Mendlewicz J, Tylee A. Depression in the community: the first pan-European study DEPRES (Depression Research in European Society). Int Clin Psychopharmacol 1997;12:19-29. 19. Sundstrom IM, Bixo M, Bjorn I, Astrom M. Prevalence of psychiatric disorders in gynecologic outpatients. Am J Obstet Gynecol 2001;184:8-13. 20. Furmark T, Tillfors M, Everz P, Marteinsdottir I, Gefvert O, Fredrikson M. Social phobia in the general population: prevalence and sociodemographic profile. Soc Psychiatry Psychiatr Epidemiol 1999;34:416-24. 21. Weinstock LS. Gender differences in the presentation and management of social anxiety disorder. J Clin Psychiatry 1999;60(9 Suppl):9-13. 22. Kelly RH, Russo J, Katon W. Somatic complaints among pregnant women cared for in obstetrics: normal pregnancy or depressive and anxiety symptom amplification revisited? Gen Hosp Psychiatry 2001;23:107-13. 23. Saisto T, Salmela-Aro K, Nurmi JE, Kononen T, Halmesmaki E. A randomized controlled trial of intervention in fear of childbirth. Obstet Gynecol 2001;98:820-6. 24. Orr ST, Miller CA. Maternal depressive symptoms and the risk of poor pregnancy outcome: review of the literature and preliminary findings. Epidemiol Rev 1995;17:165-71. 25. Wisner KL, Gelenberg AJ, Leonard H, Zarin D, Frank E. Pharmacologic treatment of depression during pregnancy. JAMA 1999;282:1264-9.
Appendix DSM-IV criteria. Criteria for major depressive episode A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly caused by a general medical condition, or mood-incongruent delusions or hallucinations. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (for example, feels sad or empty) or observations made by others (for example, appears tearful). Note: In children and adolescents, can be irritable mood. 2. Marked diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others). 3. Significant weight loss when not dieting or weight gain (for example, change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
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6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms do not meet criteria for a mixed episode. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to the direct physiologic effects of a substance (for example, a drug of abuse, a medication) or a general medical condition (for example, hypothyroidism). E. The symptoms are not better accounted for by bereavement, that means, after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. Criteria for generalized anxiety disorder A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). B. The person finds it difficult to control the worry. C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children. 1. Restlessness or feeling keyed up or on the edge 2. Being easily fatigued 3. Difficult concentrating or mind going blank 4. Irritability 5. Muscle tension 6. Sleep disturbance (difficult falling or staying asleep, or restless unsatisfying sleep) D. The focus of the anxiety and worry is not confined to features of an axis I disorder, for example, the anxiety or worry is not about having a panic attack (as in panic disorder), being embarrassed in public (as in social phobia), being contaminated (as in obsessivecompulsive disorder), being away from home or close relatives (as in separation anxiety disorder), gaining weight (as in anorexia nervosa), having multiple physical complaints (as in somatization disorder), or
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having a serious illness (as in hypochondriasis), and the anxiety and worry do not occur exclusively during posttraumatic stress disorder. E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
O
F. The disturbance is not due to the direct physiologic effects of a substance (for example, a drug of abuse, a medication) or a general medical condition (for example, hyperthyroidism) and do not occur exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder.
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