Am Fam Physician. 2019;100(6):365-366
Related editorial: Can We Prevent Perinatal Depression in the Primary Care Office?
Author disclosure: No relevant financial affiliations.
A 25-year-old woman presents to your office after having recently missed her period. A urine pregnancy test confirms that she is pregnant. She takes acyclovir for suppression of genital herpes, which she acquired as a teenager. She reports a history of depression and sexual abuse during adolescence. She states that her mood has been fine lately and that she is no longer taking an antidepressant.
Case Study Questions
1. Based on the U.S. Preventive Services Task Force (USPSTF) recommendation statement, which one of the following is the most appropriate course of action to prevent perinatal depression in this patient?
A. Encourage regular physical activity.
B. Prescribe an antidepressant (e.g., sertraline [Zoloft], nortriptyline [Pamelor]).
C. Prescribe an omega-3 fatty acid supplement.
D. Provide counseling or refer to counseling.
E. Monitor the patient for depression symptoms.
2. According to the USPSTF recommendation, which additional risk factors, if present in this patient, would increase the risk of perinatal depression?
A. Personal or family history of depression.
B. Specific socioeconomic risk factors (e.g., low income, adolescent or single parenthood).
C. First-time pregnancy.
D. Recent intimate partner violence.
3. Which one of the following statements accurately summarizes the USPSTF recommendation regarding implementation of interventions to prevent perinatal depression?
A. There are no data on the ideal timing for offering counseling or referral to counseling interventions.
B. Screening for risk factors for perinatal depression should begin during the second trimester.
C. Counseling interventions should be provided only by licensed psychologists.
D. Group counseling is ineffective.
E. Accurate screening tools are available for identifying women who are at risk of perinatal depression and who might benefit from preventive interventions.
1. The correct answer is D. The USPSTF recommends that physicians provide counseling or refer to counseling pregnant and postpartum women who are at increased risk of perinatal depression.1 The patient in this scenario is at increased risk of perinatal depression because of her history of depression and significant negative life event (sexual abuse). The USPSTF concluded with moderate certainty that counseling interventions to prevent perinatal depression, such as cognitive behavior therapy and interpersonal therapy, have a moderate net benefit for persons at increased risk. Conversely, there was limited or mixed evidence that other studied interventions such as physical activity, education, pharmacotherapy, dietary supplements, and health system interventions were effective in preventing perinatal depression.1
2. The correct answers are A, B, and D. Based on the populations included in the systematic evidence review, the USPSTF recommends a pragmatic approach to identifying those at risk of perinatal depression.2 This approach involves providing counseling interventions to women with one or more of the following characteristics: a history of depression, current depressive symptoms that do not reach a diagnostic threshold, certain socioeconomic risk factors such as low income or adolescent or single parenthood, recent intimate partner violence, or mental health–related factors such as elevated anxiety symptoms or a history of significant negative life events.1 First-time pregnancy is not considered a risk factor in this approach.
3. The correct answer is A. In the studies assessed by the USPSTF, most counseling interventions were initiated during the second trimester of pregnancy; however, there are no data on the ideal timing for offering or referral to counseling interventions. Therefore, the USPSTF suggests that referral could occur at any time, with ongoing assessment of risks that develop in pregnancy and the immediate postpartum period. The format of counseling interventions comprised mainly group and individual sessions with interventions delivered by psychologists, midwives, nurses, and other mental health professionals.1
The views expressed in this work are those of the authors and do not reflect the official policy or position of the University of Maryland, the U.S. Department of Health and Human Services, or the U.S. government.