Most women have some nausea or vomiting, or “morning sickness”, during the first trimester of pregnancy.  Some women, however, have a more severe and persistent pattern of nausea and vomiting called hyperemesis gravidarum (HG).  A new study demonstrates, not so surprisingly, that depression is more common in women suffering from HG.

In this study, 200 consecutive women admitted for HG were compared to a control group of 200 women without HG. Depressive symptoms were measured using the Beck Depression inventory-II (BDI-II).  Median depression scores were much higher among women with HG as compared to women without (15 versus 5, respectively). In the HG group, 35.1% of the subjects had mild, 26.0% had moderate, and 17.8% had severe depression, while only 5% of the women in the control group had mild depression and 95% had no depression.

These results are not too surprising.  HG is a severe and disabling illness which may complicate an otherwise healthy pregnancy.  This report raises other questions.  What is the best way to manage the depressive symptoms that emerge in this setting?  Does treatment of the physical symptoms resolve the psychological symptoms?  Or does HG result in a more prolonged form of depression which persists beyond the physical resolution of the symptoms.

Another study puts a slightly different spin on the subject, posing a chicken and egg type of question.  Does HG cause depression and anxiety, or are women with mood and anxiety disorders more vulnerable to HG?

This study included 52 women with HG and a control group of 90 pregnant women without HG. Mood and anxiety disorders were ascertained using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders DSM-IV). Personality disorders were assessed with the Structured Clinical Interview for DSM (SCID-II).

In the group of women with HG, 15.4% met criteria for a mood disorder and 36.5% met criteria for an anxiety disorder.  In addition, 19 (36.5%) of the subjects with HG had at least one personality disorder. The prevalence of major depression, generalized anxiety disorder, avoidant personality disorder and obsessive-compulsive personality disorder was significantly higher in women with HG as compared to the control subjects.

Among the women with HG, most experienced the onset of the mood or anxiety disorder prior to pregnancy.  This is a preliminary study which is relatively small in size, but the results of the study suggest that mood and anxiety disorders, and certain types of personality disorders, are more frequently observed among women with HG.  Since for most women in this study, the psychiatric disorders predated the onset of HG, we may hypothesize that women with mood and anxiety disorders may be more vulnerable to HG.

Dietary changes and lifestyle modifications are often recommended to women with HG.  When medications are needed, anti-emetic agents, such as ondansetron are used. However, these two studies suggest that we may not be targeting the underlying disorder.  Would modalities that target anxiety and depression – such as cognitive-behavioral therapy, acupuncture, or anti-anxiety medications – be more effective for the management of HG.  A better understanding of the link between HG and mood and anxiety disorders may thus help us to refine our treatments.

Ruta Nonacs,MDPhD

Hizli D, Kamalak Z, Kosus A, Kosus N, Akkurt G. Hyperemesis gravidarum and depression in pregnancy: is there an association? Journal of Psychosomatic Obstetric & Gynecology. 2012 Dec;33(4):171-175.

Uguz F, Gezginc K, Kayhan F, Cicek E, Kantarci AH. Is hyperemesis gravidarum associated with mood, anxiety and personality disorders: a case-control study. General Hospital Psychiatry. 2012;34(4):398–402.