PPD Rates Increase Among All Racial Groups, but Asian/Pacific Islander and Black Patients See Highest Increases

Postpartum depression (PPD) can pose risks to both maternal and child health. Understanding the trends can be significant to evaluating prevalence, identifying risk, and initiating intervention methods. Authors of study results published in JAMA Network Open aimed to explain trends in PPD prevalence by race, ethnicity, and prepregnancy body mass index (BMI).

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Data from electronic health records (EHRs) at Kaiser Permanente Southern California (KPSC) were used to conduct this serial cross-sectional study. KPSC is a large integrated health care delivery system that services over 4.8 million members across 15 medical centers and 236 medical offices. The study authors identified all life and stillbirths at 20 or more weeks of gestation between January 1, 2010, and December 31, 2021.

The outcome of the study was PPD prevalence, which was defined as the presence of a depressive disorder diagnosis according to the International Classification of Diseases, Ninth and Tenth Revision diagnostic codes provided by a mental health specialist and/or by use of antidepressants prescribed for PPD within 12 months following childbirth. PPD diagnosis at KPSC follows a 2-step process. Depression status was routinely assessed during well-child visits for postpartum individuals, and those who showed signs and symptoms were asked to undergo further evaluation using standardized questionnaires (eg, Edinburgh Postnatal Depression Scale [EPDS]). Individuals who score a 10 or higher on the EPDS are referred for a clinical interview with mental health professionals, who conduct additional comprehensive assessments and provide follow-up care, diagnosis, and treatment.

Additionally, BMI was categorized into 5 groups: underweight (<18.5), normal weight (18.5-24.9), overweight (25.0-29.9), obese class I (30-34.9), and obese class II/III (≥35.0). Self-reported race and ethnicity data were pulled from EHRs and categorized as non-Hispanic White, non-Hispanic Black, Hispanic, Asian and Pacific Islander, and Other and multiple groups. Race and ethnicity were assessed in this study to provide race- and ethnicity-specific rates for PPD and to identify potential disparities in mental health conditions.

A total of 442,308 individuals were enrolled in the study. The median maternal age at delivery was about 31.0 years, and the cohort was considered racially and ethnically diverse, with 62,860 individuals (14.2%) identifying as Asian/Pacific Islander, 231,837 (52.4%) as Hispanic, 33,207 (7.5%) as non-Hispanic Black, 108,201 (24.5%) as non-Hispanic White, 5903 (1.3%) as multiple or other, and 300 (0.1%) unknown.

Further, approximately 13.9% (n = 61,556) of individuals had a PPD diagnosis and/or received a prescription for antidepressants within 12 months of childbirth between 2010 and 2021. PPD was more frequently diagnosed in those who were older, with about 35.1% (n = 21,577) of individuals aged 30 to 34 years and 27.3% (n = 16,781) aged 35 years or older being diagnosed compared with 33.3% (n = 126,887) and 23.1% (n = 88,099), respectively, in the non-PPD group. Additionally, PPD diagnosis trends were observed at 42, 90, and 180 days, and when the follow-up was limited to 42 days following delivery, the relative increase in PPD trend over time was about 3.17-fold (95% CI, 2.92-3.45). When the follow-up was limited to 90 days after delivery, the relative increase in PPD trend over time was about 2.80-fold (95% CI, 2.64-2.97).

The investigators also observed that those with a PPD diagnosis were likely to be non-Hispanic White (18,061 [29.3%] vs 90,140 individuals [23.7%]) and non-Hispanic Black (5240 [8.5%] vs 27,967 individuals [7.3%]). Patients diagnosed with PPD were also more likely to be multiparous (35,981 [58.5%] vs 212,369 individuals [55.8%]), to have smoked (2349 [3.8%] vs 8556 individuals [2.2%]) or used alcohol (11,042 [17.9%] vs 47,916 individuals [12.6%]) during pregnancy, and have overweight (16,200 [26.3%] vs 94,008 individuals [24.7%]) or obesity. Those considered class I obese (10,287 [16.7%] vs 51,492 individuals [13.5%]) had a higher prevalence of PPD compared with those in class II/III (9455 [15.4%] vs 39,508 individuals [10.4%]).

Additionally, the investigators saw an increase in overall PPD rates from 2010 (9.4%) to 2021 (19.0%), with the largest relative increases observed in 2013 (22% increase from 2012), 2018 (30% increase from 2017), and 2019 (20% increase from 2018). Although PPD rates increased for all races and ethnicities, the largest increases were present among Asian and Pacific Islander participants (280% increase) and non-Hispanic Black participants (140% increase).

Limitations of the study include the underestimation of PPD’s true prevalence, the lack of consideration for variations among access to care or health care utilization patterns, and the possibility of information not being submitted to the KPSC system. Additionally, the authors noted that the results lack generalizability because the results are limited to populations receiving care within integrated health care systems, such as KPSC.

REFERENCE

Khadka N, Fassett MJ, Oyelese Y, et al. Trends in Postpartum Depression by Race, Ethnicity, and Prepregnancy Body Mass Index. JAMA Netw Open. 2024;7(11):e2446486. doi:10.1001/jamanetworkopen.2024.46486