Reducing Depression in Pregnancy: Designing Multimodal Interventions
Cunningham, Maddy, Zayas, Luis H., Social Work
Epidemiological and clinical evidence indicates that women have one-year prevalence rates of major depression estimated at 10 percent compared with 4 percent among men, and a lifetime risk of major depression of 20 percent to 25 percent in contrast to men's risk of 7 percent to 12 percent (American Psychiatric Association, 1994; Depression Guidelines Panel, 1993a; Kessler et al., 1994). Among low-income women from ethnic and racial minority groups, rates are higher than those of their white counterparts (Vera et al., 1991; Zayas & Busch-Rossnagel, 1992). Moreover, estimates suggest that 50 percent to 75 percent of individuals with depressive disorders are underdiagnosed and undertreated in primary care settings despite the availability of screening tools and treatments (Depression Guidelines Panel, 1993a, 1993b; Miranda & Munoz, 1994; Mulrow et al., 1995; Munoz et al., 1995; Perez-Stable, Miranda, Munoz, & Ying, 1990; Spitzer et al., 1994). Untreated minor depressive and dysthymic disorders can lead to major depressive disorder, disrupting personal and family functioning (Zung, Broadhead, & Roth, 1993).
For women of childbearing age, undiagnosed and untreated depression poses especially serious problems because it affects the mother directly and the infant indirectly through the mother's behaviors. Psychopharmacological treatments of depression can be efficacious in primary care settings (Depression Guidelines Panel, 1993a, b). Use of antidepressant medications during pregnancy is not considered in the Depression Guidelines (1993b), and there are sufficient contraindications for their use during pregnancy, which lead most physicians to limit their use with pregnant women (Coustan & Mochizuki, 1999). In light of this, psychosocial treatments during the perinatal period may be preferred, especially because cost-effective psychosocial interventions provided in primary care settings can reduce depressive symptomatology in general patient populations (Depression Guidelines Panel, 1993b; Munoz et al., 1995). More intervention research and services are needed to prevent the debilitating effects of prenatal depress ion on women and, subsequently, their children. We examined the literature on depression during pregnancy among low-income, inner-city women from ethnic minority groups and the effects of maternal depression on parenting infants and children. We then developed a psychosocial intervention model that bundles treatments focused on relieving depression, enhancing social support networks, and increasing mothers' repertoire of activities that stimulate their infants' development; this bundled intervention is undergoing extensive testing. Grouped this way, the interventions strategically target three areas important for women's psychological adjustment during pregnancy and in the postpartum period. Theoretically, such a model can have a two-generational effect--proximally on the mother and distally on the infant--and can be subjected to testing in both generations.
We prefer bundling interventions this way because, in reality, no single social work treatment can address the multiple factors that create and exacerbate problems in individual and family functioning. Moreover, bundled psychosocial interventions composed of well-developed, theoretically grounded, and empirically sound treatments lend themselves to evaluation and to influencing services design for a host of population groups.
Pregnancy, Poverty, and Depression
Research on white women during the past 20 years has shown that stress, social support, and depression during pregnancy are closely interrelated (for example, Gotlib, Whiffen, Mount, Milne, & Gordy, 1989; Norbeck & Anderson, 1989a, 1989b; O'Hara, 1986). The generalizability of research findings based on white women to African American and Hispanic women is questionable because both groups frequently are underrepresented in study samples, yet overrepresented in many sectors of the population, such as families living below the poverty level and mothers of early childbearing age. …