Unique Kaiser Permanente analysis delves into detailed identity data to understand differing mental health risk in pregnancy
Black, Hispanic, and Asian patients of Kaiser Permanente Northern California (KPNC) were more likely to report prenatal depression symptoms than White patients, according to a new analysis published in JAMA Network Open.
The study also found that when compared with White patients, certain Asian and Hispanic subgroups were more likely to report moderate to severe depression symptoms but less likely to have a depression diagnosis during pregnancy. Also, Black patients were more likely to report depression symptoms.
“This study is unique because of the rich data involved and our ability to take a deeper dive into subgroups of race and ethnicity to learn how risk differs across depression diagnosis and symptom severity,” said lead author Kendria Kelly-Taylor, PhD, a research fellow with the Kaiser Permanente Division of Research. “These findings are among the first in pregnant women.”
The study looked at 258,452 KPNC patients who received prenatal care between 2013 and 2019 and whose self-reported race or ethnicity were identified by state birth records or their Kaiser Permanente electronic health record. The researchers compared differences in prenatal depression symptoms, diagnosis, and undiagnosed depression among subgroups of race and ethnicity. Typically, when exploring differences across racial and ethnic groups, larger categories are identified (White, Black, Asian, Hispanic) with little focus on smaller groups within these categories (for example, Asian subgroups such as Korean, Thai, and Japanese).
Overall, 15.5% of pregnant patients in the study were diagnosed with prenatal depression and 10.9% reported moderate to severe depressive symptoms, though the prevalence and risk differed substantially by race and ethnic subgroups. For example, Puerto Rican patients were 28% more likely than White patients to have a depression diagnosis, while Hmong patients were 77% less likely, and Asian Indian patients 72% less likely to be diagnosed.
Depression symptoms were self-reported and captured using a widely used depression screening questionnaire, generally given twice during pregnancy. The researchers found a higher risk of reported moderate to moderately severe symptoms across groups, compared with White patients. For instance, Black patients were 2 times more likely to report symptoms than White patients, Cambodian patients 68% more likely, and Hawaiian or Pacific Islander patients 63% more likely.
“Other studies have shown that depression can present differently across cultures, and this can be tied to many things such as stigma regarding mental health conditions,” Kelly-Taylor said. “This is a reminder of the importance of culturally relevant care, especially regarding pregnancy and mental health conditions. Although awareness has increased over the years, this study serves as a reminder that there is still much work to be done.”
Underdiagnosis needs further study
The researchers also investigated whether patients reported symptoms but did not receive a prenatal depression diagnosis during pregnancy, known as underdiagnosis. They found that most racial and ethnic groups had higher undiagnosed depression than White patients. The rates varied by subgroup; Hmong, American Indian, and Cambodian patients were twice as likely to be underdiagnosed than White patients.
“Previous research suggests that non-White populations may experience more severe depression symptoms, yet are less likely to engage in treatment, especially across the perinatal period,” said senior author Lyndsay Avalos, PhD, MPH, a DOR research scientist. “Our study suggests minoritized populations may be less likely to have a documented depression diagnosis, highlighting the need for research to understand why this happens and if it is a barrier to care.”
The research team has previously conducted focus groups with Black and Latina patients, some of whom said they worry they may face possible economic or legal consequences to having medical records showing depression diagnosis and treatment, including threats to immigration status or employment. Avalos said it is unclear whether these factors could be contributing to the differences shown in this study.
Co-author Kathryn Erickson-Ridout, MD, PhD a psychiatrist with The Permanente Medical Group and DOR adjunct investigator, said other research has shown some racial and ethnic groups experience family disapproval of a mental health diagnosis, fear discrimination, or don’t feel comfortable speaking with their doctor about their symptoms. “There is also literature suggesting that certain racial and ethnic groups may report symptoms on a screening questionnaire, but do not believe these represent a depressive disorder,” Erickson-Ridout said. “They may not perceive physical symptoms such as pain or fatigue as related to a mental health problem.”
Whatever the reasons for the gap in diagnosis, Avalos said, it is important for prenatal depression to be identified and treated. “Untreated prenatal depression among non-White individuals could further explain existing racial and ethnic disparities in adverse maternal and child health outcomes,” she said.
Pregnant patients are also screened for depression after birth, providing another opportunity for diagnosis of postpartum depression. This study looked for depression diagnosis only during pregnancy.
Additional co-authors were Sara Aghaee, MPH, Joshua Nugent, PhD, Ai Kubo, PhD, MPH, Elaine Kurtovich, MPH, Nina Oberman, MPH, and Charles P. Quesenberry, Jr., PhD, of the Division of Research; Ayesha C. Sujan, PhD, of Stanford University; and Mibhali M. Bhalala, MD, of The Permanente Medical Group.
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About the Kaiser Permanente Division of Research
The Kaiser Permanente Division of Research conducts, publishes, and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. KPDOR seeks to understand the determinants of illness and well-being and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 720-plus staff, including 73 research and staff scientists, are working on nearly 630 epidemiological and health services research projects. For more information, visit divisionofresearch.kp.org or follow us @KPDOR.
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