Collaborative Care for Perinatal Depression Among Socioeconomically Disadvantaged Women: Adverse Neonatal Birth Events and Treatment Response.

OBJECTIVE: The study examined the effectiveness of a perinatal collaborative care intervention in moderating the effects of adverse neonatal birth events on risks of postpartum depressive symptoms and impaired functioning among women of lower socioeconomic status with antenatal depression. METHODS: A randomized controlled trial with blinded outcome assessments was conducted in ten public health centers, comparing MOMCare (choice of brief interpersonal psychotherapy, pharmacotherapy, or both) with intensive maternity support services (MSS-Plus). Participants had probable diagnoses of major depressive disorder or dysthymia during pregnancy. Generalized estimating equations estimated differences in depression and functioning measures between groups with and without adverse birth events within the treatment arms. A total of 160 women, 43% of whom experienced at least one adverse birth event, were included in the analyses. RESULTS: For women who received MOMCare, postpartum depression scores (measured with the Symptom Checklist-20) did not differ by whether or not they experienced an adverse birth event (mean±SD scores of .86±.51 for mothers with an adverse birth event and .83±.56 for mothers with no event; p=.78). For women who received MSS-Plus, having an adverse birth event was associated with persisting depression in the postpartum period (mean scores of 1.20±.0.61 for mothers with an adverse birth event and .93±.52 for mothers without adverse birth event; p=.04). Similar results were seen for depression response rates and functioning. CONCLUSIONS: MOMCare mitigated the risk of postpartum depressive symptoms and impaired functioning among women of low socioeconomic status who had antenatal depression and who experienced adverse birth events.

A randomized trial of collaborative depression care in obstetrics and gynecology clinics: socioeconomic disadvantage and treatment response.

OBJECTIVE: The authors evaluated whether an obstetrics-gynecology clinic-based collaborative depression care intervention is differentially effective compared with usual care for socially disadvantaged women with either no health insurance or with public coverage compared with those with commercial insurance. METHOD: The study was a two-site randomized controlled trial with an 18-month follow-up. Women were recruited who screened positive (a score of at least 10 on the Patient Health Questionnaire-9) and met criteria for major depression or dysthymia. The authors tested whether insurance status had a differential effect on continuous depression outcomes between the intervention and usual care over 18 months. They also assessed differences between the intervention and usual care in quality of depression care and dichotomous clinical outcomes (a decrease of at least 50% in depressive symptom severity and patient-rated improvement on the Patient Global Improvement Scale). RESULTS: The treatment effect was significantly associated with insurance status. Compared with patients with commercial insurance, those with no insurance or with public coverage had greater recovery from depression symptoms with collaborative care than with usual care over the 18-month follow-up period. At the 12-month follow-up, the effect size for depression improvement compared with usual care among women with no insurance or with public coverage was 0.81 (95% CI=0.41, 0.95), whereas it was 0.39 (95% CI=-0.08, 0.84) for women with commercial insurance. CONCLUSIONS: Collaborative depression care adapted to obstetrics-gynecology settings had a greater impact on depression outcomes for socially disadvantaged women with no insurance or with public coverage compared with women with commercial insurance.

Improving care for depression in obstetrics and gynecology: a randomized controlled trial.

OBJECTIVE: To evaluate an evidence-based collaborative depression care intervention adapted to obstetrics and gynecology clinics compared with usual care. METHODS: A two-site, randomized controlled trial included screen-positive women (Patient Health Questionnaire-9 score of at least 10) who met criteria for major depression, dysthymia, or both (Mini-International Neuropsychiatric Interview). Women were randomized to 12 months of collaborative depression management or usual care; 6-month, 12-month, and 18-month outcomes were compared. The primary outcomes were change from baseline to 12 months in depression symptoms and functional status. Secondary outcomes included at least 50% decrease and remission in depressive symptoms, global improvement, treatment satisfaction, and quality of care. RESULTS: Participants were, on average, 39 years old, 44% were nonwhite, and 56% had posttraumatic stress disorder. Intervention (n=102) compared with usual care (n=103) patients had greater improvement in depressive symptoms at 12 months (P<.001) and 18 months (P=.004). The intervention group compared with usual care group had improved functioning over the course of 18 months (P<.05), were more likely to have at least 50% decrease in depressive symptoms at 12 months (relative risk [RR] 1.74, 95% confidence interval [CI] 1.11-2.73), greater likelihood of at least four specialty mental health visits (6-month RR 2.70, 95% CI 1.73-4.20; 12-month RR 2.53, 95% CI 1.63-3.94), adequate dose of antidepressant (6-month RR 1.64, 95% CI 1.03-2.60; 12-month RR 1.71, 95% CI 1.08-2.73), and greater satisfaction with care (6-month RR 1.70, 95% CI 1.19-2.44; 12-month RR 2.26, 95% CI 1.52-3.36). CONCLUSION: Collaborative depression care adapted to women's health settings improved depressive and functional outcomes and quality of depression care. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01096316. LEVEL OF EVIDENCE: I.

Presenting symptoms of women with depression in an obstetrics and gynecology setting.

OBJECTIVE: To describe the presenting symptoms of women with depression in two obstetrics and gynecology clinics, determine depression diagnosis frequency, and examine factors associated with depression diagnosis. METHODS: Data were extracted from charts of women screening positive for depression in a clinical trial testing a collaborative care depression intervention. Bivariate and multivariable analyses examined patient factors associated with the diagnosis of depression by an obstetrician-gynecologist (ob-gyn). RESULTS: Eleven percent of women with depression presented with a psychologic chief complaint but another 30% mentioned psychologic distress. All others noted physical symptoms only or presented for preventive care. Ob-gyns did not identify 60% of women with a depression diagnosis. Depression severity was similar in women who were or were not diagnosed by their ob-gyns. Bivariate analyses showed four factors significantly associated with depression diagnosis: reporting a psychologic symptom as the chief complaint or associated symptom (72% compared with 18.6%, P<.001), younger age (35.5 years compared with 40.8 years, P<.005), being within 12 months postpartum (13.9% compared with 2.8%, P<.005), and a primary care-oriented visit (72% compared with 30%, P<.001). Multivariable analysis showed that reporting a psychologic symptom (adjusted odds ratio [OR] 8.90, 95% confidence interval [CI] 4.15-19.10, P<.001), a primary care oriented visit (adjusted OR 2.46, 95% CI 1.14-5.29, P=.03), and each year of increasing age (adjusted OR 0.96, 95% CI 0.93-0.96, P=.02) were significantly associated with a depression diagnosis. CONCLUSION: The majority of women with depression presented with physical symptoms; most women with depression were not diagnosed by their ob-gyn, and depression severity was similar in those diagnosed and those not diagnosed. LEVEL OF EVIDENCE: III.

Depression in pregnancy is associated with preexisting but not pregnancy-induced hypertension.

BACKGROUND: The aim was to examine whether depression is associated with preexisting hypertension or pregnancy-induced hypertension in a large sample of women attending a university-based obstetrics clinic. METHODS: In this prospective study, participants were 2398 women receiving ongoing prenatal care at a university-based obstetrics clinic from January 2004 through January 2009. Prevalence of depression was measured using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria based on the Patient Health Questionnaire-9 as well as the self-reported use of antidepressant medication. Evidence of preexisting hypertension, pregnancy-induced hypertension and preeclampsia/eclampsia was determined by obstetrician International Classification of Diseases, Ninth Revision codes. Logistic regression was used to quantify the association between hypertension in pregnancy and antenatal depression. RESULTS: After adjusting for sociodemographic variables, chronic medical conditions, smoking and prior pregnancy complications, women with preexisting hypertension had an increased risk of any depression (minor, major, use of antidepressants) [odds ratio (OR)=1.55, 95% confidence interval (CI) 1.08-2.23) and major depression and/or use of antidepressants (OR=1.65, 95% CI 1.10-2.48) compared to women without hypertension. No differences were seen in risk of depression in women with pregnancy-induced hypertension or preeclampsia/eclampsia compared to those without hypertension. CONCLUSION: Women with preexisting hypertension, but not pregnancy-induced hypertension, are more likely to meet criteria for an antenatal depressive disorder and/or to be treated with antidepressants and could be targeted by obstetricians for screening for depression and enhanced treatment.

Diabetes and depression in pregnancy: is there an association?

BACKGROUND: Prior studies have reported inconsistent findings regarding the association of antenatal depression with pregnancy-related diabetes. This study examined the association of diabetes and antenatal depression. METHODS: We conducted a cross-sectional analysis of baseline data from a prospective cohort study of pregnant women receiving prenatal care at a single University of Washington Medical Center clinic between January 2004 and January 2009. The primary exposure was diabetes in pregnancy (no diabetes, preexisting diabetes, or gestational diabetes [GDM]). Antenatal depression was defined by the Patient Health Questionnaire-9 (PHQ-9) score or current use of antidepressants. Antenatal depression was coded as (1) any depression (probable major or minor depression by PHQ-9 or current antidepressant use) and (2) major depression (probable major depression by PHQ-9 or current antidepressant use). Logistic regression was used to quantify the association between diabetes in pregnancy and antenatal depression. RESULTS: The prevalences of preexisting diabetes, GDM, any antenatal depression, and major antenatal depression were 9%, 18%, 13.6%, and 9.8%, respectively. In the unadjusted analysis, women with preexisting diabetes had 54% higher odds of any antenatal depression compared to those without diabetes (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.08-2.21). After adjusting for important covariates the association was attenuated (OR 1.16, 95% CI 0.79-1.71). Results were similar for antenatal major depression. GDM was not associated with increased odds for any antenatal depression or antenatal major depression. CONCLUSIONS: Neither preexisting diabetes nor GDM was independently associated with increased risk of antenatal depression.

Racial differences in the prevalence of antenatal depression.

OBJECTIVE: This study examined whether there were racial/ethnic differences in the prevalence of antenatal depression based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnostic criteria in a community-based sample of pregnant women. METHOD: Data were drawn from an ongoing registry of pregnant women receiving prenatal care at a university obstetric clinic from January 2004 through March 2010 (N =1997). Logistic regression models adjusting for sociodemographic, psychiatric, behavioral and clinical characteristics were used to examine racial/ethnic differences in antenatal depression as measured by the Patient Health Questionnaire. RESULTS: Overall, 5.1% of the sample reported antenatal depression. Blacks and Asian/Pacific Islanders were at increased risk for antenatal depression compared to non-Hispanic White women. This increased risk of antenatal depression among Blacks and Asian/Pacific Islanders remained after adjustment for a variety of risk factors. CONCLUSION: Results suggest the importance of race/ethnicity as a risk factor for antenatal depression. Prevention and treatment strategies geared toward the mental health needs of Black and Asian/Pacific Islander women are needed to reduce the racial/ethnic disparities in antenatal depression.

Prevalence and correlates of suicidal ideation during pregnancy.

Data are scarce regarding the prevalence and risk factors for antenatal suicidal ideation because systematic screening for suicidal ideation during pregnancy is rare. This study reports the prevalence and correlates of suicidal ideation during pregnancy. We performed cross-sectional analysis of data from an ongoing registry. Study participants were 2,159 women receiving prenatal care at a university obstetric clinic from January 2004 through March 2010. Multiple logistic regression identified factors associated with antenatal suicidal ideation as measured by the Patient Health Questionnaire. Overall, 2.7% of the sample reported antenatal suicidal ideation. Over 50% of women who reported antenatal suicidal ideation also reported major depression. In the fully adjusted model antenatal major depression (OR = 11.50; 95% CI 5.40, 24.48) and antenatal psychosocial stress (OR = 3.19; 95% CI 1.44, 7.05) were positively associated with an increased risk of antenatal suicidal ideation. We found that being non-Hispanic White was associated with a decreased risk of antenatal suicidal ideation (OR = 0.51; 95% CI 0.26-0.99). The prevalence of antenatal suicidal ideation in the present study was similar to rates reported in nationally representative non-pregnant samples. In other words, pregnancy is not a protective factor against suicidal ideation. Given the high comorbidity of antenatal suicidal ideation with major depression, efforts should be made to identify those women at risk for antenatal suicidal ideation through universal screening.

Depressive disorders during pregnancy: prevalence and risk factors in a large urban sample.

OBJECTIVE: To estimate the prevalence of major and minor depression, panic disorder, and suicidal ideation during pregnancy while also identifying factors independently associated with antenatal depressive disorders. METHODS: In this prospective study, participants were 1,888 women receiving ongoing prenatal care at a university obstetric clinic from January 2004 through January 2009. Prevalence of psychiatric disorders was measured using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria based on the Patient Health Questionnaire. Multiple logistic regression identified factors associated with probable major depressive disorder and any depressive disorder. RESULTS: Antenatal depressive disorders were present in 9.9% with 5.1% (97) meeting criteria for probable major depression and 4.8% (90) meeting criteria for probable minor depression. Panic disorder was present in 3.2% (61), and current suicidal ideation was reported by 2.6% (49). Among patients with probable major depression, 29.5% (28) reported current suicidal ideation. Psychosocial stress (odds ratio [OR], 1.29; 95% confidence interval [CI], 1.21-1.36), domestic violence (OR 3.45; 95% CI 1.46-8.12), chronic medical conditions (OR 3.05; 95% CI 1.63-5.69), and race (Asian: OR 5.81; 95% CI 2.55-13.23; or African American: OR 2.98; 95% CI 1.24-7.18) each significantly increased the odds of probable antepartum major depressive disorder, whereas older age (OR 0.92; 95% CI 0.88-0.97) decreased the odds. Factors associated with odds of any depression were similar overall except that Hispanic ethnicity (OR 2.50; 95% CI 1.09-5.72) also independently increased the odds of any depression. CONCLUSION: Antenatal major and minor depressive disorders are common and significantly associated with clinically relevant and identifiable risk factors. By understanding the high point prevalence and associated factors, clinicians can potentially improve the diagnosis and treatment rates of serious depressive disorders in pregnant women. LEVEL OF EVIDENCE: II.

A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction.

CONTEXT: Maternal depressive symptoms during pregnancy have been reported in some, but not all, studies to be associated with an increased risk of preterm birth (PTB), low birth weight (LBW), and intrauterine growth restriction (IUGR). OBJECTIVE: To estimate the risk of PTB, LBW, and IUGR associated with antenatal depression. DATA SOURCES AND STUDY SELECTION: We searched for English-language and non-English-language articles via the MEDLINE, PsycINFO, CINAHL, Social Work Abstracts, Social Services Abstracts, and Dissertation Abstracts International databases (January 1980 through December 2009). We aimed to include prospective studies reporting data on antenatal depression and at least 1 adverse birth outcome: PTB (<37 weeks' gestation), LBW (<2500 g), or IUGR (<10th percentile for gestational age). Of 862 reviewed studies, 29 US-published and non-US-published studies met the selection criteria. DATA EXTRACTION: Information was extracted on study characteristics, antenatal depression measurement, and other biopsychosocial risk factors and was reviewed twice to minimize error. DATA SYNTHESIS: Pooled relative risks (RRs) for the effect of antenatal depression on each birth outcome were calculated using random-effects methods. In studies of PTB, LBW, and IUGR that used a categorical depression measure, pooled effect sizes were significantly larger (pooled RR [95% confidence interval] = 1.39 [1.19-1.61], 1.49 [1.25-1.77], and 1.45 [1.05-2.02], respectively) compared with studies that used a continuous depression measure (1.03 [1.00-1.06], 1.04 [0.99-1.09], and 1.02 [1.00-1.04], respectively). The estimates of risk for categorically defined antenatal depression and PTB and LBW remained significant when the trim-and-fill procedure was used to correct for publication bias. The risk of LBW associated with antenatal depression was significantly larger in developing countries (RR = 2.05; 95% confidence interval, 1.43-2.93) compared with the United States (RR = 1.10; 95% confidence interval, 1.01-1.21) or European social democracies (RR = 1.16; 95% confidence interval, 0.92-1.47). Categorically defined antenatal depression tended to be associated with an increased risk of PTB among women of lower socioeconomic status in the United States. CONCLUSIONS: Women with depression during pregnancy are at increased risk for PTB and LBW, although the magnitude of the effect varies as a function of depression measurement, country location, and US socioeconomic status. An important implication of these findings is that antenatal depression should be identified through universal screening and treated.

Fecal incontinence in primary care: prevalence, diagnosis, and health care utilization.

OBJECTIVE: We sought to estimate the frequency of self-reported fecal incontinence (FI), identify what proportion of these patients have a diagnosis of FI in their medical record, and compare health care costs and utilization in patients with different severities of FI to those without FI. STUDY DESIGN: Patients in a health maintenance organization were eligible and 1707 completed a survey. Patients with self-reported FI were assessed for a diagnosis of FI in their medical record for the last 5 years. Health care costs and utilization were obtained from claims data. RESULTS: FI was reported by 36.2% of primary care patients, but only 2.7% of patients with FI had a medical diagnosis. FI adversely affected quality of life and severe FI was associated with 55% higher health care costs (including 77% higher gastrointestinal-related health care costs) compared to continent patients. CONCLUSION: Increased screening of FI is needed.

Psychosocial stress during pregnancy.

OBJECTIVE: We sought to identify factors associated with high antenatal psychosocial stress and describe the course of psychosocial stress during pregnancy. STUDY DESIGN: We performed a cross-sectional analysis of data from an ongoing registry. Study participants were 1522 women receiving prenatal care at a university obstetric clinic from January 2004 through March 2008. Multiple logistic regression identified factors associated with high stress as measured by the Prenatal Psychosocial Profile stress scale. RESULTS: The majority of participants reported antenatal psychosocial stress (78% low-moderate, 6% high). Depression (odds ratios [OR], 9.6; 95% confidence interval [CI], 5.5-17.0), panic disorder (OR, 6.8; 95% CI, 2.9-16.2), drug use (OR, 3.8; 95% CI, 1.2-12.5), domestic violence (OR, 3.3; 95% CI, 1.4-8.3), and having > or =2 medical comorbidities (OR, 3.1; 95% CI, 1.8-5.5) were significantly associated with high psychosocial stress. For women who screened twice during pregnancy, mean stress scores declined during pregnancy (14.8 +/- 3.9 vs 14.2 +/- 3.8; P < .001). CONCLUSION: Antenatal psychosocial stress is common, and high levels are associated with maternal factors known to contribute to poor pregnancy outcomes.

Major depression and urinary incontinence in women: temporal associations in an epidemiologic sample.

OBJECTIVE: To determine whether: (1) major depression is associated with increased risk for onset of urinary incontinence, and (2) urinary incontinence is associated with increased risk for onset of depression. STUDY DESIGN: Longitudinal cohort study of female Health and Retirement Study participants completing baseline interviews at Wave 3 (1996-1997) and follow-up interviews at Waves 4-6 (1998-2003). RESULTS: In a cohort of 5820 women with a mean age 59.3 (+/- 0.5) years, 6-year cumulative incidences of depression and incontinence were 11% and 21%, respectively. Major depression was associated with increased odds of incident incontinence (adjusted odds ratio, 1.46; 95% confidence interval, 1.08-1.97) during follow-up compared with those without major depression at baseline. Conversely, incontinence was not associated with increased odds of incident depression (adjusted odds ratio, 1.03; 95% confidence interval, 0.75-1.42) compared with those without incontinence at baseline. CONCLUSION: Major depression predicted onset of urinary incontinence in a population-based sample of at-risk, community-dwelling women. Incontinence did not predict onset of depression.

Women's perceptions about the etiology of urinary incontinence.

OBJECTIVE: Incontinent women have low rates of care seeking and treatment, some of which may be explained by their beliefs about the causes of their own urine loss. As little is known about these beliefs, our aim was to qualitatively assess what women perceive as the etiology of their urinary incontinence (UI). METHODS: In a written survey on urinary symptoms administered to female HMO enrollees aged 30-90 years, incontinent women were asked the open-ended question: "Why do you think you lose urine?" Qualitative analyses of the responses identified themes, which were quantified and organized into major categories. Subjects were assigned multiple themes/categories as indicated. Relationships between major categories and subject/incontinence characteristics were explored. RESULTS: Of the 1458 women with incontinence who completed the survey, 1192 (82%) responded to the open-ended question. Qualitative analyses identified 23 themes, with 5 themes cited by >or=10% of subjects: pelvic floor/bladder muscles (31%), pregnancy/childbirth (18%), age (14%), exertional triggers (12%), and waiting too long to void (10%). The 23 themes were organized into 5 major categories: pelvic floor/bladder related (53%), uncontrollable factors (23%), part of being female (21%), personal/lifestyle attributes (21%), and don't know (12%). Subjects expressed a range of 1-4 themes/categories. Major categories differed by age, and significant associations were seen between major categories and incontinence severity. CONCLUSIONS: Women attribute their UI to a number of causes, which can be condensed into workable themes and categories. By understanding women's beliefs about the etiology of incontinence, clinicians may improve their ability to educate, counsel, and treat women with incontinence.

Can mentors prevent and reduce burnout in new chairs of departments of obstetrics and gynecology: results from a prospective, randomized pilot study.

OBJECTIVE: This study assessed burnout in new chairs of obstetrics and gynecology and whether mentoring by experienced chairs would prevent or reduce burnout. STUDY DESIGN: We performed a year-long prospective, randomized trial. Questionnaires were sent to new chairs to obtain demographic information and to identify need for mentoring and level of burnout. Fourteen chairs in the intervention group selected a mentor; 13 chairs served as controls. After 1 year, questionnaires were completed to determine stress and burnout and the impact of mentoring. RESULTS: Financial issues were the major stressors. New chairs identified human resources, finances, and relationships with school leaders as areas of greatest need for mentoring. Few chairs exhibited burnout. No differences were observed in burnout at the start of the study or after 1 year in the study groups. Mentors and new chairs found the mentoring relationship difficult to establish and maintain. CONCLUSION: Long-distance mentoring by experienced chairs did not alter burnout in new chairs of obstetrics and gynecology. Local mentors appear to be more effective.

Depressive symptoms, bone loss, and fractures in postmenopausal women.

BACKGROUND: Osteoporosis and depression may be associated through common physiologic systems or risk factors. OBJECTIVE: To assess the associations between depressive symptoms (Burnam's scale) or antidepressant use and bone outcomes. DESIGN: Prospective cohort study. PARTICIPANTS: A total of 93,676 postmenopausal women (50 to 79 years old) enrolled in the Women's Health Initiative Observational Study. MEASUREMENTS: Self-reported fractures (n = 14,982) (hip [adjudicated], spine, wrist, and "other"). Analyses included 82,410 women with complete information followed on average for 7.4 years. Bone mineral density (BMD) of the hip (n = 4539), spine (n = 4417), and whole body (n = 4502) was measured at baseline and 3 years in women enrolled at 3 densitometry study sites. RESULTS: Overall, there were no statistically significant associations between depressive symptoms or antidepressant therapy and 3-year change in BMD. In a subset of women not using antidepressants, there was a significant difference in whole-body BMD change between women with and without depressive symptoms (P = .05). Depressive symptoms (hazard ratio [HR] 1.08; 95% CI = 1.02 to 1.14) and antidepressant therapy (HR = 1.22; CI = 1.15 to 1.30) independently increased risk of any fracture, the majority of which occurred at "other" anatomic sites. Antidepressant therapy increased the risk of spine fracture (HR = 1.36; CI = 1.14 to 1.63). No associations were observed between depressive symptoms or antidepressant therapy and hip or wrist fracture. CONCLUSION: In this study of postmenopausal women, average age 64, we observed minimal association between depressive symptoms and 3-year changes in either BMD or fracture risk. Antidepressant use was not associated with changes in BMD, but was associated with increased risk of fractures at the spine and "other " anatomic sites.

Implementing a clinical and research registry in obstetrics: overcoming the barriers.

OBJECTIVE: This study aimed to describe the obstacles and solutions in developing and implementing a prospective obstetric database registry that collects biopsychosocial data on women during pregnancy and postpartum. The clinical goals of the registry were to improve both diagnosis of mental health and substance use problems and access to mental health care during pregnancy. The research goals were to examine the impact of psychiatric illness and substance use on birth outcomes. STUDY SETTING AND REGISTRY DESIGN: A questionnaire that contained validated instruments for mental health, substance use and psychosocial stressors was developed and administered to all pregnant women in an academic medical center obstetric clinic. Results were incorporated with reminder and decision support systems to ensure active follow-up of patients with mental health needs. Automated medical record information was collected for future analysis of outcomes. PROGRAM IMPLEMENTATION: Barriers to program implementation were overcome by a multifaceted intervention that included educational outreach to patients, providers and staff; integration of the registry into preexisting clinical protocols; reminder systems at workstations; provision of mental health decision support through perinatal social work and psychiatric consultation; and utilization of a "stepped-care" model to delivering mental health services. CONCLUSION: A mental health registry that merges clinical and research needs can be successfully integrated into the obstetric clinic setting.

Health care discussions and treatment for urinary incontinence in U.S. women.

OBJECTIVE: The objective of the study was to determine the proportions of women with urinary incontinence who had discussed their condition with a health care provider or received treatment and to identify factors associated with seeking health care. STUDY DESIGN: The study was a population-based, age-stratified postal survey of 6000 women aged 30 to 90 years enrolled in a large health maintenance organization in Washington state. RESULTS: The response rate was 64% (n = 3536) after applying exclusion criteria. Eighty percent (n = 1160) of women with urinary incontinence completed a detailed set of questions on care seeking and treatments. Fifty percent had discussed their incontinence with a health care provider, 21% reported receiving surgery or prescription medication, 10% reported performing Kegel exercises, and 48% reported wearing a pad to absorb urine daily or weekly. The following factors were significantly associated with odds of discussing urinary incontinence with a health care provider: age (50 to 69 years, adjusted odds ratio 1.5 [1.1 to 2.0]; 70 to 89 years, adjusted odds ratio 1.9 [1.4, 2.7]); duration of urinary incontinence (2 to 5 years, adjusted odds ratio 1.9 [1.3 to 2.8]; more than 5 years, adjusted odds ratio 2.8 [2.0,4.1]); severe urinary incontinence (adjusted odds ratio 1.7 [1.2 to 2.6]); and greater effect on daily activities (adjusted odds ratio 2.7 [1.9,3.8]). CONCLUSION: Among women with urinary incontinence, one half have discussed their incontinence with a health care provider and one third have received any form of treatment.

Fecal incontinence in US women: a population-based study.

OBJECTIVE: The purpose of this study was to determine the prevalence of fecal incontinence (FI) and associated risk factors in a broad age range of community-dwelling women. STUDY DESIGN: This was a population-based, age-stratified postal survey of 6000 women aged 30 to 90 years enrolled in a large HMO in Washington State. Sample was linked to longitudinal automated medical data. FI was defined as loss of liquid or solid stool at least monthly. RESULTS: The response rate was 64%. The prevalence of FI was 7.2%; prevalence increased notably with age. Women with FI reported significant lifestyle alteration and functional disability. Older age (adjusted odds ratio [OR] 2.11-2.22), major depression (OR 2.73), urinary incontinence (OR 2.32), medical comorbidity (OR 1.76-2.58), and operative vaginal delivery (OR 1.52) were significantly associated with increased odds of FI. CONCLUSION: In this large report of US community-dwelling women, FI was a prevalent condition. Age, major depression, urinary incontinence, medical illness, and operative vaginal delivery were strongly associated with likelihood of FI.

Incontinence severity and major depression in incontinent women.

OBJECTIVE: Research has shown an association between urinary incontinence and depression. Studies that use community-based samples and major depressive disorder diagnostic criteria are needed. The objective of this study was to estimate the prevalence of and factors associated with major depression in women with urinary incontinence. METHODS: We conducted an age-stratified postal survey of 6,000 women aged 30-90 years. Subjects were randomly selected from enrollees in a large health maintenance organization in Washington state. Main outcome measures were prevalence of current major depression and adjusted odds ratios for factors associated with major depression in women with urinary incontinence. RESULTS: The response rate was 64% (n = 3,536) after applying exclusion criteria. The prevalence of urinary incontinence was 42% (n = 1,458). The prevalence of major depression was 3.7% (n = 129), with 2.2% in those without incontinence versus 6.1% in those with incontinence. Among women with incontinence, major depression prevalence rates differed by incontinence severity (2.1% in mild, 5.7% in moderate, and 8.3% in severe) and incontinence type (4.7% in stress, 6.6% in urge/mixed). Obesity (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.3-4.0), current smoking (OR 2.7, 95% CI 1.5-4.9), lower educational attainment (OR 2.0, 95% CI 1.2-3.3), moderate incontinence (OR 2.7, 95% CI 1.1-6.6), and severe incontinence (OR 3.8, 95% CI 1.6-9.1) were each associated with increased odds of major depression in women with urinary incontinence, controlling for age and medical comorbidity. Compared with women with incontinence alone, women with comorbid incontinence and major depression had significantly greater decrements in quality of life and functional status and increased incontinence symptom burden. CONCLUSION: Women with moderate-to-severe urinary incontinence should be screened for comorbid major depression and offered treatment if depression is present. LEVEL OF EVIDENCE: II-2.