Most people assume that pregnancy is a happy time of excitement and anticipation. While that can be the case for many pregnant people, others struggle through weeks or months of physical discomfort and mental health woes, including as many as 18 percent who experience clinical depression. While depression is relatively common in pregnancy, treatment varies, with many pregnant people forgoing antidepressant medications or psychotherapy treatment.
A new study conducted by the Bloomington-based HealthPartners Institute will be investigating factors that lead to depression treatment among pregnant individuals as well as how different forms of treatment impact birth outcomes. The research team, led by principal investigator Kristin Palmsten, a HealthPartners research investigator and epidemiologist, will survey hundreds of individual participants who were newly diagnosed with depression during pregnancy and take a deep dive into thousands more electronic medical records.
The five-year study is supported by a $3.1 million grant from the National Institute of Child Health and Human Development (NICHD), part of the National Institutes of Health. Palmsten said she believes that the results will provide important treatment information for individuals and physicians.
“Depression during and after pregnancy is common, but often it’s not well treated,” Palmsten said. “When it’s not well treated, it can add risk to pregnancy, birth and child development.”
Some data suggest that antidepressants are associated with poor birth outcomes, but these poor outcomes are also associated with depression. Palmsten said that the HealthPartners study will help clarify risk factors and also determine how all of these factors impact breastfeeding practices.
“Often there’s some hesitancy when prescribing antidepressants to people who are pregnant, so our study will provide more guidance for clinicians on that topic, too,” Palmsten said. “My hypothesis is that we’ll see better pregnancy and birth outcomes among people who receive treatment, be it talk therapy or medications. And my hope is that these data will lead to better depression treatment for people who are pregnant.”
Recently, when I spoke with Palmsten about her research, she was excited about the promise of her just weeks-old study and its potential for changing treatment protocols for pregnant people experiencing depression.
MinnPost: How did you get interested in conducting this study?
Kristin Palmsten: In my work, I focus mostly on maternal and child health. A big part of that is health during pregnancy. Mental health conditions, including depression, are really common in the general population and certainly also common during pregnancy. Pregnancy can be a joyful time. But it can also be a really challenging time, even under the best of circumstances.
Mental health concerns and pregnancy do not get enough attention. I believe that this is something we need to focus on as scientists so we can learn how to provide better evidence-based care for pregnant individuals and their providers.
MP: I’ve heard a lot about postpartum depression, but not that much about depression during pregnancy. Has it been getting more attention lately?
KP: I think it is, slowly. In the past, I’d done some research on antidepressants and pregnancy. Part of the shift comes from clinics. Newer screening guidelines have been put in place in the past five years, where every pregnant individual should be screened for depression during pregnancy. The goal of this research is to identify factors that predict whether pregnant individuals start psychotherapy and medication during pregnancy and assess the impact of those treatments on their pregnancies.
MP: Can you give me a sense of just how common depression is during pregnancy?
KP: Depression in pregnancy is actually really common. It’s a huge burden. Up to about 18 percent of pregnant individuals have depression, and that includes about 12 percent of pregnant individuals who have a new episode of depression during their pregnancy, meaning they had their first episode during pregnancy or they’ve had depression in the past but didn’t have it going into pregnancy and then developed it during pregnancy.
MP: Since depression during pregnancy is so common, do you know how often people receive depression treatment during a pregnancy?
KP: In our study, the comparative group is women who don’t initiate either antidepressants or psychotherapy during pregnancy. That’s what most individuals do when they have a new depression diagnosis during pregnancy. A lot of people aren’t using those clinical treatments that if used appropriately are recommended for use during pregnancy.
MP: What are the risks associated with not treating depression during pregnancy?
KP: There are a number of risks of not treating depression during pregnancy. When pregnant individuals aren’t treated with antidepressants or psychotherapy, that’s associated with some poor outcomes for the infant, like pre-term birth, low birthweight and small-for-gestational age. We also know that not treating depression has a bad impact on the pregnant parent. The negative impacts of untreated depression during pregnancy include poor self-care, smoking, use of alcohol or other substances, inadequate prenatal care and suicide attempts. Self-harm is a leading cause of postpartum death.
If untreated, depression during pregnancy is also associated with postpartum depression and behavioral problems in the child. Untreated depression has an impact on the parent and the child. The entire family is impacted by depression during pregnancy or postpartum. If you go out even further, there are all these ripple effects.
MP: Why do some pregnant individuals choose not to treat their depression?
KP: There are a number of reasons. One of the bigger ones is a general hesitation about the use of medications and pregnancy. Naturally, pregnant individuals are concerned about infant harm and want to avoid using anything that could cause harm to their developing fetus. So that’s a barrier.
Providers are also concerned about potential harm to a fetus during pregnancy, so they may not encourage their pregnant patients to try antidepressants. Medications do have side effects, but not all medications will cause birth defects. They might fail to consider the adverse effects of not treating depression.
There are also other hurdles, including not being able to access talk therapy or not being able to afford antidepressant medications. The pregnant individual might not have the social support needed to get to an in-person appointment or have easy access to transportation. All of these play a role in treatment as well.
MP: Can you sum up your study’s hypothesis?
KP: We are hypothesizing that clinical treatment — either antidepressants or psychotherapy —will be associated with a decreased risk of the negative outcomes we’re concerned about, including preterm birth, small-for-gestational age, low birthweight. We are also hypothesizing that either antidepressants or psychotherapy or a combination of the two during pregnancy will be associated with a longer continuation of breastfeeding for the infant.
There’s not that much out there in the literature about how untreated depression during pregnancy impacts breastfeeding. It is known that postpartum depression impacts breastfeeding.
MP: How will the study be conducted?
KP: There are two different components. We are going to be studying people who are pregnant and are newly diagnosed with depression. We’ll assess their histories of depression, types of clinical recommendations that their provider has given them, other health conditions, whether they are from rural or urban areas, their type of insurance coverage.
We’ll be offering a survey to people at HealthPartners clinics or to patients at other health systems. Another component will involve studying electronic health record data of pregnant patients to assess whether medications or psychotherapy had any effect on their infants’ outcomes.
The study will be conducted with a combination of survey and electronic health record data. The survey is important because some things you can’t get at with electronic health records, like whether patients tried other methods of treatment.
MP: Will the project include behavioral health recommendations for participants?
KP: No. We’ll just be observing what people do naturally and what providers do naturally. There isn’t any kind of intervention. We’ll just be studying the data that’s routinely collected, and doing a one-time survey that we’ll be running over a period of about 18 months. We’ll be inviting people who recently had a baby and had a new episode of depression during that pregnancy to participate. They will be offered a gift card for their participation.
MP: How many subjects will you enroll in this study?
KP: For the electronic health record part, we expect to study about 8,000 pregnancies. For the survey, we’re hoping to enroll close to 400 people.
MP: Do you need to contact all 8,000 study subjects for permission to access their electronic records?
KP: If we’re just studying reproductive medical data, we don’t need to get any sort of informed consent for people to participate. We access their records in a de-identified way so we don’t know details of who the individuals are.
People who we contact for the survey have indicated in their records that they are OK with doing research. We will exclude anyone who says it is not OK to contact then for research.
MP: Your study is supported by a large national grant. Was this a competitive application process?
KP: The application process was highly competitive. There were nearly 1,300 applications for the same type of grant that were received by the NICHD and reviewed in 2020. Our application scored at the top 4th percentile and was one of approximately 200 applications that were awarded.
MP: What do you hope your study will achieve?
KP: We are hoping to provide medically relevant information that helps patients and their providers make treatment decisions. We also want to learn more about what mental health interventions individuals who are pregnant are using to treat new episodes of depression.
MP: Why do you feel it is important to learn more about different interventions?
KP: One thing is just to get a better understanding of the different mental health interventions that are utilized. We hope that understanding the factors that go into decisions to start clinical depression treatment during pregnancy will give providers more information on how to counsel patients who are experiencing an episode of depression during pregnancy.
We’re also studying infant outcomes. We want to provide good evidence about potential harms or benefits of antidepressants and/or psychotherapy treatment on the infants we’re studying.
MP: Do physician groups have an official position on depression treatment during pregnancy?
KP: There are guidelines from the American College of Obstetricians and Gynecologists and the American Psychiatric Association that recommend psychiatric treatment of individuals during pregnancy. To me it seems like even though these recommendations are there they don’t feel reassuring to pregnant individuals and their providers. I think our study is really trying to make strides toward giving good information that will support these decision-making conversations between patients and their providers.
MP: What kind of information do you think would be helpful in making these decisions?
KP: The literature is confusing because we see that untreated depression is associated with some of the same poor outcomes that have been found in some studies of the use of antidepressants during pregnancy.
In the past, a lot of studies have compared individuals taking antidepressants during pregnancy to those who aren’t taking antidepressants and don’t have depression. That is like comparing apples to oranges. Pregnant people who are not taking antidepressants and do not have depression have a much lower baseline risk for some of these negative outcomes.
There is literature out there that suggests that antidepressants are associated with poor outcomes — it is important to understand that there are a lot of other factors that can explain those negative outcomes. But unfortunately, those older studies that are out there make people really hesitant to take antidepressants during pregnancy. With this research, we want to do a better job than past studies have done.
MP: It’s easy for me to understand why some people are hesitant to start a new medication during pregnancy. So much of what’s out there advises you to stay “pure” and cut out everything, like caffeine, alcohol, sushi, raw cheese.
KP: It is confusing for anyone who tries to understand or make a good decision about behavioral choices during pregnancy. It’s especially hard for the pregnant person who is experiencing depression, who thinks, “I want to do something about this, but I’ve read these things on blogs about the bad effects of antidepressants on the fetus.” The decision becomes really scary for people.
MP: Your survey will also be asking participants about a range of other alternative approaches they may have taken to treat their depression during pregnancy. Can you say more about why you are looking into that?
KP: We want to know more about what these different treatment methods are. Just because a pregnant individual doesn’t initiate antidepressants or psychotherapy, it doesn’t mean they aren’t doing anything to treat their depression. They might be getting involved in a community group or going to a support group or doing acupuncture or yoga. We don’t even really know what all the different options are. We just know that it would be really important to study infant outcome from those various approaches.
MP: Are there any theories about why depression is so common during pregnancy? Is it connected to hormonal fluctuations? To stress about impending life changes?
KP: There are a lot of different theories. The truth is that the reason likely varies from individual to individual. For many individuals, especially those who do not have adequate or appropriate support during their pregnancies, it could be a combination of factors related to being pregnant and having that be a difficult time in one’s life. We do know that it is important to take pregnant people’s overall health into account. A person’s mental health is just as important as their physical health.