Objective
The objective of the study was to estimate prevalence of depression and serious psychological distress (SPD) and mental health service receipt among reproductive-age women.
Study Design
We used 2006-2007 nationally representative data to estimate the prevalence of depression and SPD among nonpregnant women aged 18 to 44 years. Using logistic regression, we individually examined predictors of depression and SPD and characteristics associated with clinical diagnosis and current treatment.
Results
More than 14% of women had current depression and 2.7% had current SPD. Risk factors for major depression and SPD included older age, less education, being unmarried, inability to work/unemployed, and low income. Among depressed women, 18-24 year-olds, nonwhite women, those with children, the employed, and urban women had lower odds of clinical diagnosis. Among women with SPD, Hispanic, employed, and those without health insurance had lower odds of receiving treatment.
Conclusion
Mental health conditions are prevalent among women of reproductive age and a substantial proportion goes untreated.
Depression and severe mental illness can be debilitating conditions for all women and, for reproductive-age women, may also negatively affect fertility, pregnancy, infant health and development, maternal functioning, and child rearing. Perinatal depression is one of the most common morbidities among pregnant and postpartum women, and often depression precedes the pregnancy. Up to 30% of women of reproductive age may experience a psychiatric disorder in a year and the 12-month prevalence of depression in this group is estimated to be between 8% and 16%, depending on specific age and diagnostic test. However, risk factors for depression and other severe mental health conditions among a nationally representative sample of nonpregnant women of reproductive age remain unknown. In addition, access to health care and risk factors associated with using mental health services among reproductive-age women with mental health conditions have not been reported.
Because a large proportion of women of reproductive age routinely interact with obstetrician-gynecologists, these providers are in a unique position to identify women with mental health conditions. Diagnosing and treating mental health conditions among women of reproductive age may lead to better preconception health and reduce future adverse outcomes for both the woman and her child(ren). Estimating the burden of poor mental health and understanding issues that may affect access to care for women of reproductive age may help guide early detection and treatment strategies.
In this report, we estimate the prevalence of depression and serious psychological distress (SPD), a nonspecific measure of only the most severe mental illness (eg, severe mood disorders and anxiety), among US women of reproductive age, assess the demographic characteristics associated with these conditions, and examine access to mental health care.
Materials and Methods
Data are from the 2006 and 2007 Behavioral Risk Factor Surveillance System (BRFSS), a state-based random digit-dialed sample of the noninstitutionalized US population aged 18 years and older. The BRFSS is operated by state health departments in collaboration with the US Centers for Disease Control and Prevention (CDC).
Through an independent probability sample of households with telephones in the United States, trained interviewers asked adults in the District of Columbia, Puerto Rico, US Virgin Islands, and the 50 states standardized questions from core and supplemental modules. Of all US households selected for participation in both years, 51% completed an interview, with nonresponse due to households not having telephones, unsuccessful attempts at contact, or, when successfully contacted, refusal to participate. Of the households that were successfully contacted, 75% in 2006 and 72% in 2007 completed an interview. Studies that use deidentified, publicly available data do not require CDC institutional review board approval. Information on BRFSS can be found at http://www.cdc.gov/brfss .
In 2006, 38 states and the District of Columbia included a module on anxiety and depression that contained a validated 8-item depression scale adapted from the 9-item Patient Health Questionnaire (PHQ-9), a screener for a diagnosis of depression according to the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition , with a sensitivity of 73% and specificity of 94% for major depression. The 2006 BRFSS depression module also included 2 separate questions about whether the woman had ever been told by a health care provider that she had a depressive or anxiety disorder.
Current major and minor depression were categorized based on the PHQ-8, which is similar to the PHQ-9 but omits 1 question that assesses suicidal or self-injurious ideation because interviewer intervention is not feasible. The 8 questions assessed number of days in the last 2 weeks the following were experienced: little interest or pleasure in doing things; felt down, depressed, or hopeless; trouble falling asleep; felt tired or had little energy; had a poor appetite or ate too much; felt bad about yourself or that you were a failure; trouble concentrating on things; and moved or spoken so slowly that other people could have noticed, or the opposite (being so fidgety or restless that you were moving around a lot more than usual).
Similar to PHQ-9 methodology, we defined major depression as reporting 7 or more days of having little interest or pleasure in doing things or feeling down, depressed, or hopeless, and reporting 7 or more days to 5 or more questions overall. Minor depression was defined as reporting 7 or more days of having little interest or pleasure in doing things or felt down, depressed, or hopeless and reporting 7 or more days to 2-4 questions overall. All other women were categorized as not depressed. Using an alternate scoring method, the PHQ-8 has similar sensitivity and specificity to the PHQ-9.
In 2007, 26 states used a module on mental illness and stigma, which included the Kessler-6 (K-6) screening scale for SPD and a question about whether the woman was currently taking medicine or receiving treatment from a health professional for any type of mental health condition or emotional problem. Created to estimate the prevalence of all severe mental illness, the K-6 captures a wide range of heterogeneous severe mental disorders. The K-6 has sensitivity of 36% and specificity of 96% and total classification accuracy of 92%.
We categorized current SPD as yes/no, based on answers to the K-6 screening scale, which assessed frequency of the following feelings in the preceding 30 days: nervous, hopeless, restless or fidgety, so depressed that nothing could cheer you up, everything was an effort, and worthless. Possible answers to these questions and associated points included “all of the time” = 4, “most of the time” = 3, “some of the time” = 2, “a little of the time” = 1, and “none of the time” = 0. Points were totaled across the 6 questions to give an overall SPD score. Consistent with K-6 methodology, we considered women with scores of 13 or greater to have current SPD.
We limited all analyses for this report to nonpregnant women of reproductive age (18-44 years-old; n = 42,444 in 2006 and n = 39,121 in 2007) because associations with depression may differ by pregnancy status, and too few pregnant women were surveyed in BRFSS to provide precise estimates. We excluded missing data on depression (n = 3569, 8.4% of eligible women) and on SPD (n = 2774, 7.1% of eligible women) from all the analyses for a total of 38,875 in 2006 and 36,347 in 2007. All analyses were conducted in SUDAAN to account for the complex survey design and were weighted to produce unbiased prevalence and adjusted odds ratio (AOR) estimates.
We estimated the prevalence of major and minor depression in 2006 and SPD in 2007 overall and by demographic characteristics (age, race, and ethnicity; educational, marital and employment status; number of children under 18 years-old residing in the household; household income; and place of residence [urban or rural based on metropolitan statistical area size]). Race and ethnicity was categorized as non-Hispanic white; non-Hispanic black; Hispanic of any race; and other, which included Asian, American Indian, or Alaska Native, and all others, including multiple races. Women with missing data on at least 1 covariate were excluded from multivariable analyses (n = 3718 [8.8%] for 2006 and n = 3444 [8.8%] for 2007).
We conducted χ 2 tests to assess differential distribution of major and minor depression and SPD by demographic characteristics. We used a multivariable multinomial logistic regression model to estimate AOR for major and minor depression by demographic characteristics. Similarly for SPD, we created a multivariable logistic regression model to assess independent associations between current SPD and demographic characteristics. We also examined the prevalence of self-reported overall health, days in the previous month when poor mental or physical health prevented usual activities, and health care access by depression and SPD.
Among women with current major or minor depression combined, we examined the prevalence of self-report of ever receiving a clinical diagnosis of a depressive disorder, overall and by demographic characteristics. Similarly, among women with SPD, we examined prevalence of self-report of current medication use or clinical treatment for a mental health condition or emotional problem, overall and by demographic characteristics. We assessed demographic associations with diagnosis (for depression) and treatment (for SPD) through χ 2 tests and in separate multivariable logistic regression models.
Results
In 2006, more than 14% of women of reproductive age had current major (5.4%) or minor (9.3%) depression ( Figure ). More than a quarter of women of reproductive age (26%) had ever been clinically diagnosed with a depressive disorder (11%), an anxiety disorder (5.2%), or both conditions (9.8%). Almost 30% of women had current depression or had ever received a clinical diagnosis of a depressive and/or anxiety disorder. In 2007, 2.7% of women of reproductive age had current SPD and 13% of all women were currently being treated for a mental or emotional problem.
In univariate analyses, depression and SPD were both independently associated with education, marital status, employment, income, and place of residence ( Table 1 ). Depression was also associated with age and race/ethnicity. The highest prevalence of major and minor depression and SPD were among women who were currently unable to work (major: 38%, minor: 20%, SPD: 24%) or unemployed (major: 13%, minor: 16%, SPD: 5%), those with an annual household income below $15,000 (major: 16%, minor: 14%, SPD: 9%), those with less than a high school education (major: 12%, minor: 14%, SPD: 5.5%), and women who were divorced, separated, or widowed (major: 12%, minor: 11%, SPD: 7%).
| Depression a | SPD b | |||||
|---|---|---|---|---|---|---|
| Major depression | Minor depression | |||||
| Variable | Percent (95% CI) | AOR (95% CI) | Percent (95% CI) | AOR (95% CI) | Percent (95% CI) | AOR (95% CI) |
| Total | 5.4 (5.0–5.8) | N/A | 9.3 (8.6–9.9) | N/A | 2.7 (2.4–3.0) | N/A |
| Age, y c | ||||||
| 18-24 | 5.0 (4.0–6.1) | 1.0 | 12.5 (10.8–14.6) | 1.0 | 2.0 (1.4–2.9) | 1.0 |
| 25-29 | 5.0 (4.1–6.0) | 1.3 (0.9–1.9) | 8.6 (7.4–10.0) | 0.7 (0.5–0.9) | 2.6 (1.9–3.4) | 1.7 (0.9–3.3) |
| 30-34 | 5.2 (4.3–6.1) | 1.5 (1.0–2.3) | 8.3 (7.1–9.6) | 0.8 (0.6–1.0) | 2.4 (1.9–3.1) | 2.1 (1.1–3.7) |
| 35-39 | 5.7 (4.7–6.8) | 1.6 (1.1–2.4) | 8.3 (7.2–9.5) | 0.8 (0.6–1.1) | 2.8 (2.3–3.4) | 2.2 (1.2–3.9) |
| 40-44 | 6.1 (5.3–7.1) | 1.6 (1.1–2.3) | 7.7 (6.8–8.7) | 0.7 (0.5–0.9) | 3.3 (2.7–4.1) | 2.3 (1.3–4.1) |
| Race/ethnicity c | ||||||
| Black | 6.0 (5.0–7.3) | 0.7 (0.5–0.9) | 11.9 (10.3–13.7) | 1.1 (0.9–1.4) | 3.3 (2.5–4.3) | 0.8 (0.5–1.1) |
| Hispanic | 5.0 (3.8–6.5) | 0.5 (0.3–0.8) | 11.1 (9.2–13.4) | 1.0 (0.7–1.3) | 3.2 (2.3–4.6) | 1.0 (0.6–1.5) |
| Other | 6.8 (5.3–8.8) | 1.1 (0.7–1.5) | 9.6 (7.6–11.9) | 1.1 (0.8–1.5) | 2.4 (1.7–3.5) | 0.9 (0.5–1.4) |
| White | 5.2 (4.8–5.8) | 1.0 | 8.2 (7.5–8.9) | 1.0 | 2.4 (2.1–2.8) | 1.0 |
| Education c , d | ||||||
| Less than high school | 11.8 (9.7–14.1) | 2.7 (1.9–3.8) | 14.3 (11.8–17.2) | 2.2 (1.6–3.1) | 5.5 (4.2–7.2) | 3.1 (1.8–5.4) |
| High school | 6.8 (6.0–7.7) | 1.8 (1.3–2.3) | 11.5 (10.1–13.0) | 1.8 (1.4–2.3) | 4.2 (3.5–5.1) | 3.3 (2.1–5.2) |
| Some college | 5.2 (4.4–6.1) | 1.6 (1.2–2.2) | 9.9 (8.8–11.2) | 1.7 (1.3–2.2) | 2.6 (2.1–3.3) | 2.2 (1.4–3.5) |
| College | 2.4 (1.9–2.9) | 1.0 | 5.3 (4.6–6.2) | 1.0 | 0.7 (0.5–1.0) | 1.0 |
| Marital status c , d | ||||||
| Never married | 6.1 (5.1–7.1) | 1.5 (1.1–2.0) | 11.1 (9.7–12.6) | 1.4 (1.0–1.8) | 3.2 (2.5–4.1) | 1.4 (0.9–2.2) |
| Divorced, separated, or widowed | 12.0 (10.3–13.9) | 1.8 (1.4–2.4) | 11.2 (9.7–13.0) | 1.3 (1.0–1.7) | 6.9 (5.7–8.3) | 1.8 (1.3–2.5) |
| Unmarried | 6.5 (4.8–8.8) | 1.5 (1.0–2.3) | 12.8 (9.4–17.1) | 1.5 (1.0–2.4) | 4.4 (2.9–6.7) | 2.2 (1.3–3.6) |
| Couple married | 3.6 (3.2–4.1) | 1.0 | 7.6 (6.9–8.3) | 1.0 | 1.5 (1.3–1.8) | 1.0 |
| Number of children <18 y in household | ||||||
| 0 | 5.7 (4.9–6.6) | 1.0 | 8.8 (7.7–10.1) | 1.0 | 3.2 (2.6–4.0) | 1.0 |
| 1 | 5.0 (4.2–5.8) | 0.9 (0.7–1.2) | 10.6 (9.2–12.1) | 1.2 (0.9–1.5) | 2.4 (1.9–2.9) | 0.7 (0.5–1.0) |
| ≥2 | 5.4 (4.8–6.1) | 1.0 (0.8–1.4) | 8.9 (8.0–9.8) | 1.0 (0.8–1.3) | 2.5 (2.1–3.0) | 0.8 (0.6–1.2) |
| Employment c , d | ||||||
| Employed for wages | 3.6 (3.2–4.1) | 1.0 | 8.6 (7.9–9.4) | 1.0 | 1.7 (1.4–2.1) | 1.0 |
| Homemaker | 4.3 (3.3–5.5) | 1.2 (0.8–1.7) | 9.0 (7.2–11.2) | 1.0 (0.7–1.4) | 1.5 (1.1–2.0) | 0.8 (0.5–1.2) |
| Unemployed | 12.8 (10.4–15.6) | 2.9 (2.1–3.9) | 15.8 (12.7–19.4) | 1.5 (1.1–2.2) | 4.9 (3.7–6.5) | 1.9 (1.3–2.8) |
| Unable to work | 38.0 (33.4–42.9) | 10.7 (8.0–14.3) | 19.6 (15.6–24.3) | 3.3 (2.3–4.6) | 24.1 (19.7–29.1) | 7.9 (5.3–11.9) |
| Student or retired | 5.1 (3.4–7.6) | 1.3 (0.8–2.2) | 7.0 (5.5–8.8) | 0.6 (0.4–0.8) | 2.3 (1.5–3.5) | 1.6 (0.9–2.8) |
| Income, $ c , d | ||||||
| <15,000 | 15.7 (12.5–19.6) | 4.1 (2.6–6.4) | 13.6 (10.7–17.0) | 1.4 (1.0–2.1) | 8.8 (6.6–11.7) | 3.3 (1.7–6.3) |
| 15,000-24,999 | 10.4 (9.1–11.9) | 3.7 (2.5–5.4) | 12.6 (11.1–14.3) | 1.5 (1.1–1.9) | 5.8 (4.8–6.9) | 3.3 (2.0–5.4) |
| 25,000-49,999 | 5.0 (4.2–5.8) | 2.2 (1.6–2.9) | 10.3 (8.9–11.9) | 1.4 (1.0–1.8) | 2.3 (1.8–2.9) | 2.0 (1.3–3.1) |
| ≥50,000 | 2.0 (1.6–2.5) | 1.0 | 6.3 (5.5–7.2) | 1.0 | 0.8 (0.6–1.1) | 1.0 |
| Place of residence c , d | ||||||
| Urban | 5.1 (4.7–5.7) | 1.0 | 9.2 (8.4–9.9) | 1.0 | 2.4 (2.1–2.7) | 1.0 |
| Rural | 6.5 (5.7–7.3) | 1.0 (0.8–1.2) | 9.8 (8.9–10.8) | 1.0 (0.8–1.1) | 3.8 (3.2–4.6) | 1.2 (0.9–1.6) |
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