Depression and Stress in Women With Recurrent Pregnancy Loss
In this group of 301 well characterized patients with RPL, we found that the odds of moderate/severe depression was more than five times higher than in a group of 1813 women trying to conceive naturally. We also found a significantly higher prevalence of self-reported stress among RPL patients than the comparison group. We consider a depression prevalence of 8.6% and a high stress level in 42.1% of newly referred patients with RPL as clinically relevant. The prevalence of moderate/severe depression in the comparison group is comparable to the prevalence in the general Danish population as previously described (Olsen et al., 2003). In both groups, we confirmed the already described correlation between stress and depression (Olsen et al., 2004).
We found a lower prevalence of depression among our patients than that reported in other studies (Craig et al., 2002; Mevorach-Zussman et al., 2012; Sugiura-Ogasawara et al., 2013).
The RPL Unit at Copenhagen University Hospital, Rigshospitalet is the only dedicated RPL Unit in Denmark and we investigate and treat patients from the entire country. It has been speculated that women with RPL who are psychologically distraught, are more often referred to a specialist centre (Craig et al., 2002). As the Danish RPL Unit is a national unit, some patients have to undergo investigations and treatment far from their homes. Furthermore, obtaining a referral to the Unit may require tenacity. This may select for patients who are not mentally distressed.
The RPL patients in our study were offered feedback on their stress and depression score and therefore, patients with stress or depression may have been more motivated to enter the study, though treatment or counselling was not offered. On the other hand, severely stressed or depressed patients may not have had the energy to complete the questionnaire.
The women entering the Soon Parents Study are self-referred, and women with a heightened awareness of psychological problems may be more motivated to participate, however at enrolment they did not know they would be asked about stress and depression. In addition, participants in the Soon Parents study did not receive feedback on their questionnaire and did not gain from participating. We noted that a relatively large number of their last pregnancies ended as either a stillbirth or a miscarriage, both of which may lead to psychological distress. The women in the Soon Parents Study were younger than the Danish average age at first pregnancy, and the mean number of months they had tried to conceive was relatively high (mean 5.4 months). Unfortunately, we did not have information on country of origin in the comparison group, but as the questionnaire is only available in Danish, we assume that the majority have an ethnically Danish background or have at least lived in Denmark for a substantial period of time. This is supported by the significantly higher proportion of non-native Danish women in the RPL non-participating group.
It is a key strength in this cross-sectional study that we are able to directly compare prevalence of stress and depression as both groups used the same psychometric scales. We cannot rule out that some of the women in the Soon Parents Study may suffer from RPL themselves, as this information was not available to us. If anything, this would lead to an underestimation of the difference between women with RPL and other women attempting to have a child.
As the RPL patients are selected a priori by having had at least three pregnancy losses in their history, it is not surprising that they are older than the women in the comparison group, of which more than half had not previously been pregnant. This selection can also reasonably account for higher household income and higher educational levels. The women in the two groups may differ on variables that we have not adjusted for, because they are unknown to us, but they are alike in the desire to have a child. It is our opinion that the comparison between the two groups is valid and relevant.
Based on the here presented high prevalence of stress and depression among women with RPL it would be interesting and relevant also to study stress and depression among these women's partners, as would face-to-face interviews based on the online questionnaires.
The standard of care for patients with RPL is 'tender loving care', an approach which usually entails frequent ultrasound examinations in early pregnancy and psychological support, although empirical evidence for the treatment is sparse (Rai et al., 2011). Nevertheless, evaluation of mental distress at referral is not customary in RPL clinics, as far as we know. Our results indicate that some women with RPL may have a need for psychological counselling, also when not pregnant.
Discussion
In this group of 301 well characterized patients with RPL, we found that the odds of moderate/severe depression was more than five times higher than in a group of 1813 women trying to conceive naturally. We also found a significantly higher prevalence of self-reported stress among RPL patients than the comparison group. We consider a depression prevalence of 8.6% and a high stress level in 42.1% of newly referred patients with RPL as clinically relevant. The prevalence of moderate/severe depression in the comparison group is comparable to the prevalence in the general Danish population as previously described (Olsen et al., 2003). In both groups, we confirmed the already described correlation between stress and depression (Olsen et al., 2004).
We found a lower prevalence of depression among our patients than that reported in other studies (Craig et al., 2002; Mevorach-Zussman et al., 2012; Sugiura-Ogasawara et al., 2013).
The RPL Unit at Copenhagen University Hospital, Rigshospitalet is the only dedicated RPL Unit in Denmark and we investigate and treat patients from the entire country. It has been speculated that women with RPL who are psychologically distraught, are more often referred to a specialist centre (Craig et al., 2002). As the Danish RPL Unit is a national unit, some patients have to undergo investigations and treatment far from their homes. Furthermore, obtaining a referral to the Unit may require tenacity. This may select for patients who are not mentally distressed.
The RPL patients in our study were offered feedback on their stress and depression score and therefore, patients with stress or depression may have been more motivated to enter the study, though treatment or counselling was not offered. On the other hand, severely stressed or depressed patients may not have had the energy to complete the questionnaire.
The women entering the Soon Parents Study are self-referred, and women with a heightened awareness of psychological problems may be more motivated to participate, however at enrolment they did not know they would be asked about stress and depression. In addition, participants in the Soon Parents study did not receive feedback on their questionnaire and did not gain from participating. We noted that a relatively large number of their last pregnancies ended as either a stillbirth or a miscarriage, both of which may lead to psychological distress. The women in the Soon Parents Study were younger than the Danish average age at first pregnancy, and the mean number of months they had tried to conceive was relatively high (mean 5.4 months). Unfortunately, we did not have information on country of origin in the comparison group, but as the questionnaire is only available in Danish, we assume that the majority have an ethnically Danish background or have at least lived in Denmark for a substantial period of time. This is supported by the significantly higher proportion of non-native Danish women in the RPL non-participating group.
It is a key strength in this cross-sectional study that we are able to directly compare prevalence of stress and depression as both groups used the same psychometric scales. We cannot rule out that some of the women in the Soon Parents Study may suffer from RPL themselves, as this information was not available to us. If anything, this would lead to an underestimation of the difference between women with RPL and other women attempting to have a child.
As the RPL patients are selected a priori by having had at least three pregnancy losses in their history, it is not surprising that they are older than the women in the comparison group, of which more than half had not previously been pregnant. This selection can also reasonably account for higher household income and higher educational levels. The women in the two groups may differ on variables that we have not adjusted for, because they are unknown to us, but they are alike in the desire to have a child. It is our opinion that the comparison between the two groups is valid and relevant.
Based on the here presented high prevalence of stress and depression among women with RPL it would be interesting and relevant also to study stress and depression among these women's partners, as would face-to-face interviews based on the online questionnaires.
The standard of care for patients with RPL is 'tender loving care', an approach which usually entails frequent ultrasound examinations in early pregnancy and psychological support, although empirical evidence for the treatment is sparse (Rai et al., 2011). Nevertheless, evaluation of mental distress at referral is not customary in RPL clinics, as far as we know. Our results indicate that some women with RPL may have a need for psychological counselling, also when not pregnant.
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