Managing Posttraumatic Stress Disorder and Major Depression in Women Veterans During the Perinatal Period

Case 1

A 30-year old female army veteran of the Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) era with diagnoses of PTSD and major depression presents 8 weeks pregnant. She is experiencing a moderate degree of posttraumatic and depressive symptoms. She declines considerations of psychotropic medications, owing to safety concerns, and is unable to commit to evidence-based therapies because of schedule conflict and childcare issues. She is receiving prenatal care, maintaining good nutrition and sleep hygiene, and is making an effort to be physically active. Two months after giving birth to a healthy baby, she is experiencing an exacerbation of her anxiety and depressive symptoms. She is not breastfeeding and would like to consider psychotropic medication to manage her psychiatric symptoms.

Case 2

A 25-year-old female army veteran of OEF/OIF/OND with major depression seeks consultation prior to conception. She and her husband have two children and are considering a third child. She has past histories of postpartum depression in both pregnancies. After careful evaluation of current symptoms and treatment response, past histories of postpartum depression, and potential risks associated with medication use during pregnancy, the decision was made to continue the psychotropic medication along with cognitive behavioral therapy.

The above two cases with prominent perinatal issues represent increasingly common scenarios in mental health clinics across Veterans Administration (VA) medical centers. Women constitute 8% of the veteran population and are projected to reach 11% by the year 2020. ¹ Research suggests that women ages 18–44 are among the fastest-growing demographic of new VA users. The number of women veterans using Veterans Health Administration (VHA) services more than doubled in the past decade to the current estimate of over 390,000 women veteran users in the fiscal year (FY) 2013. ² Of these, nearly 90% were seen in primary care (including women's health clinics), and 37% were seen in mental health clinics. Data show that younger women veterans are more likely than older women veterans to seek mental health services. Common postdeployment mental health issues reported by women veterans are posttraumatic stress disorder (PTSD) and major depression.

This growing population of women of childbearing age has led to an expansion of care and programs addressing reproductive health. Clinical needs specific to women veterans of childbearing age include access to contraception, pregnancy care, and postpartum care. There has been significant progress in the past decade in women veterans' healthcare services across VA medical centers, with expansion of gender- specific services. Given the rates of mental health conditions in women, there is a continued need to understand the impact of key reproductive life events, such as pregnancy and postpartum conditions.

Pregnancy and postpartum psychiatric conditions in the general population have been associated with negative consequences to the health of the mother and her offspring. ³ However, there is a knowledge gap in the impact of psychiatric morbidity on pregnancy and postpartum health in women veterans. The fundamental question that needs to be answered is whether mental health conditions during pregnancy and the postpartum period have different outcomes in women veterans in comparison to women in general. If so, how and why they are different? This article is a step toward critically examining these questions and identifying factors unique to women veterans from women in the general population.

What is known about pregnancy and major psychiatric conditions in nonveteran sample?

In the absence of specific data available for women veterans, an understanding of perinatal issues available in the nonveteran sample may help in the thinking process. Biologically, women experience distinct periods across their life span, during which physiological changes in sex steroids are needed to maintain their reproductive function and, of which, pregnancy and the postpartum period are important components of reproductive health. ⁴ The biological state of pregnancy is characterized by excessive physiological levels of estrogen and progesterone, followed by an abrupt “withdrawal” of these hormones with delivery. ⁵ Such a rapid shift in the physiological levels of reproductive hormones contributes to emotional dysregulation and has been postulated as contributory for manifestation or exacerbation of psychiatric conditions during pregnancy and the postpartum period. ⁶

In general, women are disproportionately affected by major depression and PTSD in comparison to men. ⁷ Major depression during pregnancy and the postpartum period is associated with a myriad of negative consequences to both the mother and her child. ^3,8 For example, obstetric conditions, such as preeclampsia, gestational diabetes, and low birth weight (LBW), are significantly higher for women with major psychiatric illnesses during pregnancy. ^{9 –11} Children born to mothers who were depressed or anxious during pregnancy or the postpartum period frequently encounter long-term psychological and behavioral problems. ¹² Both preclinical and clinical studies have shown that major psychiatric illnesses during pregnancy affect psychoneuroendrocrine systems in utero that directly influence fetal growth and maturation. ¹³ These changes have downstream negative effects into early childhood, affecting temperament, behavior, and neuropsychological development. Effects of PTSD on pregnancy are vastly unknown. There is some evidence that anxiety disorders (which included PTSD under the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) classification) are often highly comorbid with major depression. ¹⁴ Future studies are needed to understand the impact of PTSD and other trauma- and stressors-related disorders on pregnancy outcomes.

There has been some suggestion that pregnancy may pose significant risk for relapse in major psychiatric conditions. A 2006 prospective cohort study by Cohen et al. found that women with prior histories of recurrent major depressive episodes who discontinued their antidepressant treatment during or just prior to pregnancy had a significantly greater risk of relapse during their pregnancy compared to women who remained on medication. ¹⁵ In contrast, a more recent study found that the risk of relapse was similar regardless of whether women with recurrent depressive episodes took antidepressant medication during pregnancy. ¹⁶

Perhaps the major clinical dilemma and source of controversy is in the treatment realm—specifically, with the use of psychotropic medications during pregnancy. ^17,18 Several observational studies describe outcomes that bring into question the safety and potential teratogenic effects of commonly prescribed medications, such as selective serotonin reuptake inhibitors (SSRIs), during pregnancy. ¹⁹ The major criticism of observational studies is that they do not adequately address the potential confounders (known or unknown); however, implementation of well-controlled randomized clinical studies for pregnant women remains ethically challenging to implement under current restrictions, which is a significant reason for the paucity of research in perinatal mental health. A recent meta-analysis showed negative delivery outcomes with commonly prescribed SSRIs to be significantly low. ²⁰ Nonetheless, these perceived safety issues frequently cause fear and anxiety among patients (as seen in the Case 1 example) and influence prescribing practices by their treating providers. ²¹ Despite an overall increase in prescribing antidepressant medication during pregnancy in the past decade, a recent study reported a downward shift in rates of SSRI prescriptions during pregnancy in the periods 2002–2006 to 2007–2010. ²²

What is lacking in the understanding of pregnancy and major psychiatric conditions for women veterans?

Numerous issues are uniquely different for women veterans in comparison to women in the general population. Combat-related stressors are prevalent for women veterans. ²³ Compared to previous wars and military conflicts, the OEF/OIF/OND conflict is unique for its multiple and longer deployments with shorter intervals between missions. ²⁴ This type of deployment schedule has been associated with a greater risk of mental health problems for both men and women. ²⁵ Although research indicates that women generally experience lower rates of combat exposure than do men, findings also suggest that women's levels of combat exposure are substantial. ²⁶ A study examining a national sample of OEF/OIF military personnel found that women's experiences of combat exposure, exposure to aftermath of battle, perceived threat, and difficult living/working environment were generally high. ²⁷ Forty-four percent of returning service members have reported difficulty coming home to postdeployment life, with a significant number experiencing symptoms of PTSD, depression, and substance abuse. ²⁴

Another significant stressor faced by military personnel is military sexual trauma (MST), a term used to describe sexual assault and threatening sexual harassment that occur while an individual is on active duty. Compared to male veterans, women veterans have high rates of MST. ^28,29 It is estimated that 1 in 4 women Veterans experience MST (US Department of Veterans Affairs, www.mentalhealth.va.gov/msthome.asp). The psychological consequences of MST are well established. Female veterans with a history of MST are nine times more likely to develop PTSD than are female veterans without a history of sexual assault. ²⁸ MST is also associated with other anxiety disorders, depression, and substance-use disorders, as well as physical symptoms, chronic health problems, and occupational and financial difficulties. ^{30 –32} In addition to MST, women veterans have high rates of prior life stressors. A recent review of studies suggested that roughly half of female veterans experience physical or sexual abuse prior to entering the military. ³³ A study by Sadler found that 49% of the women in their sample with premilitary physical or sexual violence reported that they joined the military to escape an abusive or difficult home life. ^34,35

Recent studies have suggested that there are significant gender differences in postdeployment mental health. ³⁶ Women veterans are more susceptible to deployment-related disruptions in family and social relationships and report less postdeployment social support. ³³ This factor further complicates postdeployment adjustment and may be contributory toward posttraumatic stress symptomatology. ²⁹ These women were more likely than men to be single parents or married to another military member, leading to the possibility of dual deployment. Military moms face issues with access to childcare during deployments and appropriate healthcare services. Compared to women with spouses who were not scheduled for deployment, the risk of screening positive for depression nearly doubled for women with a spouse deployed during their pregnancy or the postpartum period. ³⁷ In addition to deployment, military families experience other stressors, such as frequent relocations, international moves, and non-war-related separations. The psychological health of the parent(s) during stressful times, such as deployment, has a significant impact on children. Parental stress was identified as one of the most significant predictors of child psychosocial functioning. ³⁸

Lastly, there is mounting evidence that women veterans suffer frequently from psychiatric conditions during pregnancy. ³⁹ Pregnancy is a common event for women veterans; further, research suggests that women veterans who are pregnant are more likely to be diagnosed with major psychiatric condition(s) in comparison to women veterans who are not pregnant. A recent study showed that from 2001 to 2008, 32% of women veterans with an index pregnancy received one or more psychiatric diagnoses in comparison to only 21% of women veterans without an index pregnancy. ⁴⁰ Another recent study of the OEF/OIF era showed that military deployment was indeed a risk factor for development of maternal depression. ⁴¹ However, the degree to which these common mental health conditions during pregnancy affect the overall health of women veterans and their unborn children is not known. Figure 1 summarizes various factors that may contribute to optimal perinatal mental health.

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FIG. 1.

Factors to consider for optimal perinatal health.