Cohort study of depressed mood during pregnancy and after childbirth
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7307.257 (Published 04 August 2001) Cite this as: BMJ 2001;323:257
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Dear editor,
three years after the publication of this article details on study
aims and design are no longer available by hyperlink from the participants
and methods section - which leaves me with doubts as to confounding
factors (eg maternal antidepressant use). I would appreciate updating the
link or better to make authors responsible for maintaining the electronic
references for a specified number of years (30 ?)
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir
We read with interest the correspondence regarding Depressed Mood during
Pregnancy and after Childbirth 1 2 3. We feel that the study by Evans et
al4, highlights two very important points.
Firstly the use of screening instruments should be used as an adjunct
to clinical judgment. We found in our study of antenatal depression in
Hereford, that the Edinburgh Post Natal Depression Scale used antenatally
gave variable results if patients were re-tested a week latter. Perhaps
this use of the rating scale is identifying depressive symptoms rather
than a more stable depressive disorder.
Surely the most important point is, however, that the illness of antenatal
depression has been given a higher profile by the Evan’s paper. The
consequences of antenatal depression - to the pregnancy, the health of the
mother and the subsequent development of the child are great.
Locally we have found that our study has managed to increase the awareness
of the illness and has helped promote links between the Psychiatric
Service, General Practitioners, Health Visitors and Midwives.
Psychosocial interventions may be initiated at a time when a woman is in
close contact with Health Professionals. We feel that Evans et al should
be congratulated for undertaking this difficult study.
Dr Sue Lamerton, Specialist Registrar in Psychiatry,
Etnam Street Community Mental Health Centre, Leominster
Sue@doclamerton.freeserve.co.uk
Janie Wilson – GP
Cantilupe Surgery,
Hereford
Helen Sudlow – Clinical Governance Co-ordinator,
Belmont Abbey (previously Health Visitor)
References
1 Lappin J. Time Points for assessing perinatal mood must be optimised.
BMJ 2001;325:1367 (8 December)
2 Sheehan J, Crotty F.M. Treatment for depression is important
confounding variable. BMJ 2001;325:1367 (8 December)
3 Oates M.R, Lee A. Data do not support idea that depression is more
common antenatally than postnatally. BMJ 2001;325:1367-136(8 December)
4 Evans J, Heron J, Francomb H, Oke S, Golding J, on behalf of the
Avon Longitudinal Study of Parents and Children Study Team. Cohort study
of depressed mood during pregnancy and after childbirth. BMJ 2001;
323:257-60 (4 August).
Competing interests: No competing interests
Understanding that there is not a specific personality type who will
suffer from postnatal depression and that birth itself seems to be the
trigger for depression, I would like to ask if you know of any studies
showing the diference in the type of birth women have experienced.
Research has shown that when babies are not separated from their mothers
after birth and enjoy full rooming-in there is less depression in mothers.
I suggest that there also might be less depression after birth when a
woman has been accompanied by a female companion (Doula) during labour and
birth.
Thougthful greetings
Christina Hurst-Prager
Mother Nurture,
London
Competing interests: No competing interests
Dear Editor,
Cohort study of depressed mood during pregnancy and after childbirth
Evans et al BMJ 2001;323: 257-60
This epidemiological study has confirmed the findings of many working
in the area of perinatal psychiatry ie that depressed mood is common
during pregnancy.(1) However we wish to raise a point for clarification.
The rates of depression reported in this study are remarkedly low
considering that self rating questionnaires were used. Moreover the
authors accept that the specificity of the Edinburgh scale is 78% 'for all
forms of depression'. ie RDC definite and probable major, and also
definite minor depression. However the caseness rates which they obtained
for example 32 weeks antepartum and 8 weeks postpartum were 13.5%and 9%;
but a specificity of 78% implies that they would get caseness rates of 22%
just as false positives.The expected rates would be higher since there
would be true positives. Even though other studies(2) have shown higher
specificity rates for the Edinburgh scale against RDC depression (87%),
the study of Evans et al would still be expected to give false positives
of 13%.
Evans et al also made a point that they found no evidence of a sub
group of women with a specific type or 'severity' of symptoms, followed by
an indication from our work (3) that there is a small sub group of women
with postnatal depression who have positive thyroid antibody status. But
they gave no indication that they looked at thyroid antibody status or
thyroid function.
References
1.Management of postnatal depression, Drug and Therapeutics
Bulletin 2000, 38 5 33-37
Which Ltd London
2Thompson WM, Harris B,Lazarus J, Richards C. A comparison of the
performance of rating scales in the diagnosis of postnatal depression.
Acta Psychiatr Scand 1998 98 224-27
3 Harris B,Othman S, Davies JA, Weppner CJ, Richards CJ, Newcombe RG
et al Association between postpartum thyroid dysfunction and thyroid
antibodies and depression BMJ 1992
305: 152-56
Dr Brian Harris
former senior lecturer in Psychiatry UWCM
Dr Robert Newcombe
Senior Lecturer Medical Statistcs UWCM
Dr John Lazarus
Reader in Endocrinological Medicine UWCM
Competing interests: No competing interests
Editor – Evans et al. have studied depressive symptoms reported by
women during and after pregnancy (1). We feel that depression during
pregnancy is important, but has received comparatively little attention,
both from research groups and in mainstream medical teaching. The study
performed has begun to address this, with the results showing that a
significant proportion of women experience depressive symptoms in the pre-
and post-natal periods. However, there are a number of interesting areas
which were not adequately covered by this study.
Information regarding potential confounders would have been helpful.
These include past psychiatric history (particularly pre-existing
depressive illness), antidepressant treatment (pharmacological and non-
pharmacological interventions) and life events. Without this, it is
difficult to determine whether changes in depressive symptoms are related
to the stage in pregnancy. For example, it is possible that the slight
decrease in the frequency of depressive symptoms following delivery could
be explained by starting antidepressant medication following the birth.
The use of a matched control group of non-pregnant women from the
same population would have allowed changes in mood to be interpreted in
the light of background levels of depressive symptoms.
Despite the inclusion of limited demographic data for the Avon population
on the study website (2), no sample-specific data are provided. The
external validity of the study is reduced.
Finally, the authors have cited work which suggests that maternal
depression can endanger the foetus (3,4). Given this, the inclusion of
symptom scores from the 742 women whose babies died would have been of
interest. Higher symptom scores may be associated with foetal and neonatal
death in this sample. Such data would contribute to discussion of the
impact of maternal depression in pregnancy on the foetus.
This study has highlighted important issues that should be addressed
in future work.
Jenny Goldblatt
Neshika Samarasekera
Fidelista Mure
Rebecca Southcott
Thomas Nichols
4th year medical students, Department of Epidemiology and Public
Health, University of Newcastle upon Tyne, NE2 4HH
(1) Evans E, Heron R, Francomb H, Oke S, Golding J. Cohort study of
depressed mood during pregnancy and after childbirth. BMJ 2001 ; 323: 257-
260
(2) WHO Alspace study website. Available at www.ich.bris.ac.uk/alspacext
(3) Pagel MD, Smilkstein G, Regen H, Montano D. Psychosocial influences on
new born outcome: a controlled prospective study. Soc Sci Med 1990; 30:
597-604
(4). Hedegaard M, Henriksen TB, Sabroe S, Secher NJ. Psychological
distress in pregnancy and preterm delivery. BMJ 1993; 307: 234-239
Competing interests: No competing interests
Cohort study of depressed mood during pregnancy and after childbirth.
EDITOR- The study by Evans et al (2001) reported that scores on the
Edinburgh Postnatal Depression scale were higher during pregnancy than at
8 weeks or 8 months postpartum. However no information is provided on the
number of women in the postpartum group who were currently on treatment
for postpartum depression. Treatment includes both pharmacological and non
-pharmacological means. The absence of this information brings the results
of the study into question. Effect of treatment is a significant
confounding variable. Women during pregnancy are reluctant to take anti-
depressant medication. Whereas, postpartum, many will have already
attended their general practitioners and have been commenced on treatment
by 8 weeks postpartum when the study measurements were administered. The
conclusion, therefore, that symptoms of depression are not more common or
severe after childbirth than during pregnancy cannot be supported unless
information regarding numbers of women on treatment for depression are
included.
Competing interests: Nil
1. Evans J, Heron J, Francomb H, Oke S, Golding J. Cohort study of
depressed mood during pregnancy and after childbirth. BMJ 2001: 323: 257-
260.
Dr. J Sheehan, Consultant in liaison psychiatry
Rotunda Hospital, Dublin
Dr. F.M. Crotty, special lecturer in psychiatry
Mater Misericordiae Hospital, Dublin.
Competing interests: No competing interests
EDITOR,-Jonathan Evans and colleagues report an increased rate of
depressive symptoms during pregnancy.1 The authors concluded that research
and clinical efforts need to be undertaken to understand and adequately
treat antenatal depression.
From the literature an involvement of tryptophan metabolism in the
pathogenesis of depression appears likely. In general, disturbed
availability of tryptophan and 5-hydroxytryptamine (serotonin) are
important for the susceptibility of depression.2 We have reported
decreasing serum tryptophan concentrations during the course of
pregnancy.3 Lower tryptophan concentrations during pregnancy correlated
with immune system activation as indicated by increasing neopterin
concentrations. The associations between decreased tryptophan and
increased immune activation points to a role of the enzyme indoleamine
(2,3)-dioxygenase (IDO) which accelerates tryptophan catabolism via the
kynurenine pathway. IDO is inducible by the cytokine interferon-g as it is
the case for neopterin production. More recently, in a murine model system
the importance of activated IDO for immunosuppression in gestation has
been demonstrated.4 IDO expression in the placenta seems to be necessary
for the survival of the conceptus by suppressing unwanted T-cell response
against the allogeneic challenge by the conceptus. Thus, accelerated
catabolism of tryptophan due to activation of IDO results in decreased
tryptophan availability, which is not only closely related to pregnancy
but also in other clinical conditions linked with immune activation.5 Then
available data on tryptophan catabolism during pregnancy suggest it will
be important to compare tryptophan concentrations with the risk of
depression during pregnancy.
Elisabeth Sölder, research assistant
Department of Gynaecology
Barbara Sperner-Unterweger, professor of psychiatry
Department of Psychiatry
Dietmar Fuchs, professor of medical chemistry
Institute of Medical Chemistry and Biochemistry, Leopold Franzens
University,
A-6020 Innsbruck, Austria
dietmar.fuchs@uibk.ac.at
1 Evans J, Heron J, Francomb H, Oke S, Goldin J. Cohort study of
depressed mood during pregnancy and after childbirth. BMJ 2001;323:257-60.
2 Price LH, Malison RT, McKougle CJ, Pelton GH, Heninger GR. The
neurobiology of tryptophan depletion in depression: effects of intravenous
tryptophan infusion. Biol Psychiatry 1998;43:339 -347.
3 Schröcksnadel H, Baier-Bitterlich G, Dapunt O, Wachter H, Fuchs D.
Decreased plasma tryptophan in pregnancy. Obstet Gynecol 1996;88:47-50.
4 Munn DH, Zhou M, Attwood T, Bondarev I, Conway SJ, Marshall B, et al.
revention of allogeneic fetal rejection by tryptophan catabolism. Science
1998;281:1191-3.
5 Murr C, Widner B, Sperner-Unterweger B, Ledochowski M, Schubert C, Fuchs
D. Immune reaction links disease progression in cancer patients with
depression. Med Hypotheses 2000;55:137-40.
Competing interests: No competing interests
Evans et al (1) studied perinatal mood using the Edinburgh Postnatal
Depression Scale. They claim that, "symptoms of depression are not more
common or severe after childbirth than during pregnancy". Their second
major
conclusion is that, "depression during pregnancy is more common than
postnatal depression". These two findings have potentially far-reaching
implications but caution may be needed in using their data to draw these
conclusions.
Use of the EPDS has been validated only for use in the early
postpartum
period (2), and has been shown to correctly predict depression in most
(73%)
woman with a score above 12. Below this threshold of 12, analysis of
scores
should be made with care. Variability of 1-2 points in a score less than
12,
such as those highlighted by the authors, have not been proven to indicate
depression severity. The interpretation of raised mean scores, such as
6.72
at 32/40 gestation compared with 5.84 at 8/52 postpartum, as indicative of
greater severity of depression may then be inaccurate. Rather, the
difference in mean scores should be considered with respect only to those
scores above12, but the authors have not done this. Instead, they
evaluated
change in average score.
Factors assessed by depressive symptom checklists tend to be
associated with
many psychiatric disturbances, including anxiety and related stresses such
as adverse living conditions (3). So non-specific stressors leading to
higher levels of anxiety could transiently increase a woman's EPDS score
at
any given time. The choice of time intervals at 18/40 and 32/40 coincide
with times of obstetric care contact for antenatal screening and birth
plan
discussion. Consideration of these choices adds to mounting anxiety in
pregnancy secondary to many factors, including experience of pregnancy as
a
loss of control and anticipation of a major life transition.
The study found a higher number of women to be depressed at 32/40
than at
8/52pp. However, there may be a higher frequency of postpartum depression
before 8/52pp which the study is not detecting. Postpartum depression
presents most frequently within a month of childbirth; swift recognition
and
appropriate treatment would lead to an improvement in symptoms by 8/52pp.
The authors are right to highlight the importance of perinatal mood
assessment. However, timepoints for administration of the EPDS should be
carefully selected to avoid a false picture being given.
Julia Lappin, SHO in Psychiatry
The Maudsley Hospital
1. 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.
2. Cox JL, Holden JM & Sagovsky R. Detection of Postnatal
Depression -
Development of the 10-item Edinburgh Postnatal Depression Scale. BMJ
1987;150:782-786.
3. Garrison WT & Earls FJ. Epidemiological perspectives on
maternal
depression and the young child. In: Maternal Depression and Child
Development. Field T & Tronick EZ, eds (New Developments for Child
Development, no.34). San Francisco: Jossey-Bass, pp13-30.
Competing interests: No competing interests
Dear Sir,
Evans et al (1) administered the Edinburgh Postnatal Depression Scale
(EPDS) to pregnant and post partum women. The EPDS scores rose through
pregnancy and fell following delivery. The number of women scoring above
a cut-off point of 12 in pregnancy was higher at 32 weeks than at 18, and
fell at 8 weeks and further at 8 months post partum.
At most points throughout the authors are careful not to use the term
depression, or illness, but refer to depressive symptoms. They
acknowledge that a cut off score on a screening schedule is not a clinical
diagnosis. This caution is abandoned in their conclusion, that antenatal
depression is commoner than post natal depression and that antenatal
depression might benefit from treatment, not only for the benefit of the
mother but also for her infant. These implications for practice were
widely quoted in the media on the morning of publication.
The authors’ findings are insufficient to support their conclusion,
showing only that EPDS scores rise during pregnancy. In the absence of
normative data on common emotional changes during pregnancy, and the
properties of the EPDS items in relation to other established dimensions
of depressive illness at this time, we cannot ascertain how many women
were suffering from a depressive episode that required treatment for its
resolution. This is highlighted by the authors’ observation that half of
the women who scored above the threshold at 32 weeks fell below that score
at 8 weeks postpartum, presumably without treatment. The comment in the
discussion that the benefits of psychotropic medication may outweigh the
risks in pregnancy may be seen to encourage treatment with antidepressants
in late pregnancy. Whilst the risks of teratogenesis in early pregnancy
are low, there is no reassuring evidence on the safety of antidepressants
in late pregnancy.
An alternative and simpler explanation for rising score during
pregnancy is that certain items on the EPDS may pick up common concerns
and psychological distress in pregnancy. For example item four relates to
feeling worried and anxious for no very good reason, whilst item six
relates to coping less well than usual.
We are concerned that a non-specialised readership will misunderstand
the Evans et al’s study as relating to depressive illness of a severity
that requires treatment with antidepressants or referral to psychiatric
services, or even hospital admission. To state that this level of
depressive disorder is more common and more severe antenatally than
postnatally is neither supported by the data nor by the evidence cited in
the paper that women are at an increased risk of severe mental illness
following childbirth.
What Evans et al have demonstrated is the need for rigorous clinical
research to further explore the relationship between cut-off scores on
screening schedules and the nature of possible underlying depressive
disorder, together with exploration of the possible treatment needs of
those identified in this way.
Yours sincerely
Dr A Lee
Consultant Psychiatrist
University Hospital, Nottingham
Dr M R Oates
Snr Lecturer and Consultant in Perinatal Psychiatry
University Hospital, Queens Medical Centre, Nottingham, NG7 2UH
Margaret.Oates@nottingham.ac.uk
1 Evans J, Heron J, Francombe H, Oke S, Golding J. Cohort study of
depressed mood during pregnancy and after childbirth. BMJ 2001; 7307:257-
260 (4 August)
We declare no competing interest
Competing interests: No competing interests
Re: dead link
Apologies for the deadlink. The correct link for the Avon
Longitudinal Study of Parents and Children is now
http://www.alspac.bris.ac.uk/welcome/index.shtml
Details of the methodology of the study can be found on this website.
Competing interests:
None declared
Competing interests: No competing interests