Routine antenatal maternal screening for current mental health: evaluation of a change in the use of the Edinburgh Depression Scale in clinical practice

A hospital antenatal clinic conducting routine psychosocial screening changed the Edinburgh Depression Scale (EDS) referral criterion for determining which women needed to be referred to a multidisciplinary meeting health professional ("Safe Start meeting"). The criterion was changed from a score of 10 or more to 13 or more, when no other psychosocial risks were present. Women scoring 10-12 on the EDS, with no other psychosocial risks, were now informed they should contact the Social Work Department if they had issues they wanted to discuss with a health professional. The study evaluated the impact of this change in EDS clinical practice. Records were audited over a 20-month period. In addition, 20 women scoring in this EDS marginal range (10-12), with no other psychosocial risks, participated in a telephone interview to ascertain if they should have been referred to the Safe Start meeting. Of 174 eligible women who scored in the marginal EDS range, none had contacted the Social Work Department. In addition, none of the 20 women interviewed indicated that they would have wanted to talk further with a health professional. This change in clinical practice reduced monthly referrals to the Safe Start meeting by about 20%. There was a linear relationship between the increasing EDS category scores and the likelihood of psychosocial risks being endorsed. Increasing the automatic referral EDS cutoff score from 10 or more to 13 or more does not appear to result in women "in need" being missed. The reduction in referrals allowed more time in the Safe Start meeting to be devoted to women with greater needs.

Barefoot therapists: barriers and facilitators to delivering maternal mental health care through peer volunteers in Pakistan: a qualitative study

BACKGROUND

Perinatal depression is a public health problem in low and middle income countries. Although effective psychosocial interventions exist, a major limitation to their scale up is the scarcity of mental health professionals. The aim of this study was to explore the facilitators and barriers to the acceptability of peer volunteers (PVs)-volunteer lay women from the community with shared socio-demographic and life experiences with the target population-as delivery agents of a psychosocial intervention for perinatal depression in a rural area of Pakistan.

METHODS

This qualitative study was embedded in the pilot phase of a larger peer-delivered mental health programme. Forty nine participants were included: depressed mothers (n = 21), PVs (n = 8), primary health care staff (n = 5), husbands (n = 5) and mothers-in-law (n = 10). Data were collected through in-depth interviews and focus groups and analysed using the Framework Analysis approach.

RESULTS

The PVs were accepted as delivery agents by all key stakeholders. Facilitators included the PVs' personal attributes such as being local, trustworthy, empathetic, and having similar experiences of motherhood. The perceived usefulness and cultural appropriateness of the intervention and linkages with the primary health care (PHC) system was vital to their legitimacy and credibility. The PVs' motivation was important, and factors influencing this were: appropriate selection; effective training and supervision; community endorsement of their role, and appropriate incentivisation. Barriers included women's lack of autonomy, certain cultural beliefs, stigma associated with depression, lack of some mothers' engagement and resistance from some families.

CONCLUSION

PVs are a potential human resource for the delivery of a psychosocial intervention for perinatal depression in this rural area of Pakistan. The use of such delivery agents could be considered for other under-resourced settings globally.

Lifetime costs of perinatal anxiety and depression

BACKGROUND

Anxiety and depression are common among women during pregnancy and the year after birth. The consequences, both for the women themselves and for their children, can be considerable and last for many years. This study focuses on the economic consequences, aiming to estimate the total costs and health-related quality of life losses over the lifetime of mothers and their children.

METHOD

A pathway or decision modelling approach was employed, based on data from previous studies. Systematic and pragmatic literature reviews were conducted to identify evidence of impacts of perinatal anxiety and depression on mothers and their children.

RESULTS

The present value of total lifetime costs of perinatal depression (anxiety) was £75,728 (£34,811) per woman with condition. If prevalence estimates were applied the respective cost of perinatal anxiety and depression combined was about £8500 per woman giving birth; for the United Kingdom, the aggregated costs were £6.6 billion. The majority of the costs related to adverse impacts on children and almost a fifth were borne by the public sector.

LIMITATIONS

The method was exploratory in nature, based on a diverse range of literature and encountered important data gaps.

CONCLUSIONS

Findings suggest the need to allocate more resources to support women with perinatal mental illness. More research is required to understand the type of interventions that can reduce long-term negative effects for both mothers and offspring.

The impact of domestic violence and depressive symptoms on preterm birth in South India

PURPOSE

India has the highest absolute number of maternal deaths, preterm birth cases, and under-5 mortality in the world, as well as high domestic violence (DV) rates. We sought to examine the impact of DV and its psychosocial correlates on pregnancy and birth outcomes.

METHODS

Women seeking antenatal care in Tamil Nadu, South India (N = 150) were assessed during pregnancy, and birth outcomes were abstracted from medical records after the babies were born.

RESULTS

We found that psychological abuse (OR 3.9; 95% CI 1.19-12.82) and mild or greater depressive symptoms (OR 3.3; 95% CI 0.99-11.17) were significantly associated with increased risk of preterm birth. Physical abuse was also associated with increased risk of preterm birth, but this was not statistically significant (OR 1.9; 95% CI 0.59-6.19). In each of the above adjusted models, low maternal education was associated with increased risk of preterm birth, in the analysis with depressive symptoms OR 0.18, CI 0.04-0.86 and in the analyses with psychological abuse OR 0.19, CI 0.04-0.91.

CONCLUSIONS

These findings suggest that future research should focus on understanding the psychosocial antecedents to preterm birth, to better target interventions and improve maternal child health in limited resource settings.

Women׳s help-seeking behaviours for depressive symptoms during the perinatal period: Socio-demographic and clinical correlates and perceived barriers to seeking professional help

OBJECTIVE

This study aims to characterize the help-seeking behaviours of women who were screened positive for perinatal depression, to investigate its sociodemographic and clinical correlates, and to characterize the perceived barriers that prevent women from seeking professional help.

DESIGN

Cross-sectional internet survey.

SETTING

Participants were recruited through advertisements published in pamphlets and posted on social media websites (e.g., Facebook) and websites and forums that focused on pregnancy and childbirth.

PARTICIPANTS

656 women (currently pregnant or who had a baby during the last 12 months) completed the survey.

MEASUREMENTS

Participants were assessed with the Edinburgh Postpartum Depression Scale, and were questioned about sociodemographic and clinical data, help-seeking behaviours and perceived barriers to help-seeking.

FINDINGS

Different pathways of help-seeking were found, with only 13.6% of women with a perinatal depression seeking help for their emotional problems. Married women, currently pregnant women, and women without history of psychological problems had a higher likelihood of not engaging in any type of help-seeking behaviour. The majority of women who had not sought professional assistance identified several barriers to help-seeking, particularly knowledge barriers.

KEY CONCLUSIONS

Strategies to increase women׳s help-seeking behaviours should be implemented, namely improving mental health literacy, introducing screening procedures for mental health problems in pre/postnatal health care settings, and offering women innovative opportunities (e.g., web-based tools) that allow them to overcome the practical barriers to help-seeking.

Maternal mental health: The missing "m" in the global maternal and child health agenda

While the physical health of women and children is emphasized, the mental aspects of their health are often ignored by maternal and child health programs, especially in low- and middle-income countries. We review the evidence of the magnitude, impact, and interventions for common maternal mental health problems with a focus on depression, the condition with the greatest public health impact. The mean prevalence of maternal depression ranges between 15.6% in the prenatal and 19.8% in the postnatal period. It is associated with preterm birth, low birth weight, and poor infant growth and cognitive development. There is emerging evidence for the effectiveness of interventions, especially those that can be delivered by non-specialists, including community health workers, in low-income settings. Strategies for integrating maternal mental health in the maternal and child health agenda are suggested.

Perinatal depression and associated factors among reproductive aged group women at Goba and Robe Town of Bale Zone, Oromia Region, South East Ethiopia

Background

In sub Saharan Africa little progress has been made towards achieving the Millennium Development Goals. Lack of achievement of MDGs is reflected in only minor changes in maternal mortality and child health – this is especially true in Ethiopia. Perinatal depression is common in developing countries where one in three women has a significant mental health problem during pregnancy and after childbirth. Perinatal depression is associated with inadequate prenatal care and poor maternal weight gain, low infant birth weight, and infant growth restriction. This study determined the prevalence of perinatal depression and its associated factors among reproductive age group women at Goba and Robe town of Bale zone; Oromia Region, South East Ethiopia. A cross sectional study with Simple Random sampling was employed to include 340 eligible subjects. The WHO self reporting questionnaire with 20 items with a cut off point 6 and above was used to separate non-cases/cases of perinatal depression. Data were collected by trained data collectors. Descriptive analysis was done using SPSS Version 16. Multivariate logistic regression was used to identify independent predictors of perinatal depression at 95% CI and P value of ≤ 0.05.

Results

Prevalence of perinatal depression was about 107(31.5%). About 20(5.9%), 86(25.3%) were current smokers and alcohol consumers respectively. Two hundred seventy seven (71.2%) of the respondents reported husband support during their pregnancy and after birth and 195(59.3%) were reported support from the husband’s family/relatives. Maternal perceived difficulty of child care, family History of mental illness, family visit during the perinatal period, history of child death and husband smoking status were found as independent predictors of perinatal depression.

Conclusion

This study found that 1 in 3 women in this region of Ethiopia have depression. Depression screening is not currently routine care, but should be given due attention due to the high prevalence of depression in these populations. Public health agencies could organize special training events for Health care workers, including Health Extension workers on Mental Health and has to provide screening service to strengthen mental health in the pregnant and postpartum family.

Prevalence and incidence of perinatal depression and depressive symptoms among Mexican women

BACKGROUND

The aim of this study was to assess point and period prevalence and incidence of perinatal depression in Mexican women.

METHODS

The Structured Clinical Interview for DSM-IV and the Patient Health Questionnaire (PHQ-9) were administered at three points in time to 210 women: during the third trimester of pregnancy, at six weeks and at six months after delivery.

RESULTS

Prevalence of prenatal depression was 9.0%, and 13.8% at six weeks and 13.3% at six months postpartum. Incidence of postpartum depression (PPD) was 10.0% at six weeks and 8.2% at six months. Prevalence of prenatal depressive symptoms was 16.6%; and 17.1% at six weeks and 20.0% at six months postpartum. Incidence of postpartum depressive symptoms (PPDS) was 11.4% at six weeks and 9.0% at six months. At six months postpartum, women with depression were younger (OR=2.45, p=0.02), had fewer years׳ schooling (OR=5.61, p=0.00), were unpartnered (OR=3.03, p=0.01), unemployed (OR=3.48, p=0.00) and poorer (OR=4.00, p=0.00) than women without depression.

LIMITATIONS

25% of the initial sample was not retained to complete the three assessments. Non completers were younger, less educated and reported more depressive symptoms. This may have resulted in an underestimation of prevalence.

CONCLUSIONS

This is the first longitudinal study in Latin America to assess perinatal depression at three different points in times, reporting point and period prevalence and incidence of clinical depression and depressive symptoms. Most LA countries have yet to recognize the importance of providing mental health care for expectant and postpartum mothers to reduce disability in mothers and infants.

A systematic review of perinatal depression interventions for adolescent mothers

Poor, adolescent, racial/ethnic minority women are at great risk for developing perinatal depression. However, little research has been conducted evaluating interventions for this population. We conducted a systematic review of preventive and treatment interventions for perinatal depression tested with adolescents, with a focus on low income, minority populations. Nine research-based articles (including one that reported on two studies) were reviewed systematically, and quality ratings were assigned based on a validated measure assessing randomization, double-blinding, and reporting of participant withdrawals. Two treatment studies were identified, both of which were successful in reducing depression. Eight prevention studies were located, of which four were more efficacious than control conditions in preventing depression. Studies sampled mostly minority, low socioeconomic status adolescents. No consistent characteristics across efficacious interventions could be identified. This review underscores the need for researchers to further investigate and build an evidence base.

Frequency of perinatal depression in Serbia and associated risk factors

OBJECTIVE

To screen 212 women for depression symptoms during pregnancy and postpartum in Serbia.

METHODS

Questionnaires that covered key demographic and obstetric information and Edinburgh Postnatal Depression Scale (EPDS) were administered at the third trimester of pregnancy and at 8 weeks postpartum.

RESULTS

In all, 21% of the sample was screened as depression positive during pregnancy. Subsequently, efforts were made to follow up 195 women through postpartum. Of the 195 women, 11% were screened positive during postpartum. Risk factors were low education level, low satisfaction with financial situation, high-risk pregnancy and depression during pregnancy. Logistic regression with backward elimination showed that women who had high-risk pregnancy have threefold increased risk of postpartum depression, and women who had antenatal depressive symptoms have 10-fold increased risk of postpartum depression.

CONCLUSION

In countries where screening tool for depression is not applied routinely in obstetrics settings, clinicians should be aware of risk factors, frequency and level of depressive symptoms during pregnancy and postpartum.

Culturally relevant treatment services for perinatal depression in socio-economically disadvantaged women: the design of the MOMCare study

BACKGROUND

Depression during pregnancy has been demonstrated to be predictive of low birthweight, prematurity, and postpartum depression. These adverse outcomes potentially have lasting effects on maternal and child well-being. Socio-economically disadvantaged women are twice as likely as middle-class women to meet diagnostic criteria for antenatal major depression (MDD), but have proven difficult to engage and retain in treatment. Collaborative care treatment models for depression have not been evaluated for racially/ethnically diverse, pregnant women on Medicaid receiving care in a public health system. This paper describes the design, methodology, culturally relevant enhancements, and implementation of a randomized controlled trial of depression care management compared to public health Maternity Support Services (MSS).

METHODS

Pregnant, public health patients, >18 years with a likely diagnosis of MDD or dysthymia, measured respectively by the Patient Health Questionnaire-9 (PHQ-9) or the Mini-International Neuropsychiatric Interview (MINI), were randomized to the intervention or to public health MSS. The primary outcome was reduction in depression severity from baseline during pregnancy to 18-months post-baseline (one-year postpartum).

BASELINE RESULTS

168 women with likely MDD (96.4%) and/or dysthymia (24.4%) were randomized. Average age was 27.6 years and gestational age was 22.4 weeks; 58.3% racial/ethnic minority; 71.4% unmarried; 22% no high school degree/GED; 65.3% unemployed; 42.1% making <$10,000 annually; 80.4% having recurrent depression; 64.6% PTSD, and 72% unplanned pregnancy.

CONCLUSIONS

A collaborative care team, including a psychiatrist, psychologist, project manager, and 3 social workers, met weekly, collaborated with the patients' obstetrics providers, and monitored depression severity using an electronic tracking system. Potential sustainability of the intervention within a public health system requires further study.

Association of premenstrual/menstrual symptoms with perinatal depression and a polymorphic repeat in the polyglutamine tract of the retinoic acid induced 1 gene

BACKGROUND

Depression during pregnancy or after childbirth is the most frequent perinatal illness affecting women. We investigated the length distribution of a trinucleotide repeat in RAI1, which has not been studied in perinatal depression or in the Chinese population.

METHODS

Cases (n=139) with confirmed diagnosis of clinical (major) depression related to pregnancy/postpartum were recruited from the outpatient clinic. Controls were patients who came to the obstetrics clinics and scored <7 on the Edinburgh Postnatal Depression Scale (EPDS) (n=540). Saliva samples for DNA analysis, demographic information and self-reported frequency of occurrence of various premenstrual/menstrual symptoms were collected from all participants. Genomic DNA was extracted from saliva and relevant region sequenced to determine the number of CAG/CAA repeats that encodes the polyglutamine tract in the N terminal of the protein. Difference between groups was assessed by chi-square analysis for categorical variables and analysis of variance for quantitative scores.

RESULTS

Compared to control subjects, patients with perinatal depression reported more frequent mood changes, cramps, nausea, vomiting, diarrhoea, and headache during premenstrual/menstrual periods (p=0.000). For the RAI1 gene CAG/CAA repeat, there was a statistically significant difference in the genotypic distribution between cases and controls (p=0.031). There was also a statistically significant association between the 14-repeat allele and perinatal depression (p=0.016).

LIMITATIONS

Family history, previous mental illness, and physical and psychological symptoms during the premenstrual/menstrual periods were self-reported. EPDS screening was done only once for controls.

CONCLUSIONS

The RAI1 gene polyglutamine repeat has a different distribution in our population. The 14-repeat allele is associated with perinatal depression and more frequent experience of physical and psychological symptoms during menstrual period.

Perinatal depression--the fourth inflammatory morbidity of pregnancy?: Theory and literature review

Perinatal depression is one of the leading causes of maternal morbidity and mortality. The biological etiology of this disorder remains in question, despite considerable research into the contributions of hormonal imbalance, the role of monoamines, and dysregulation of the HPA axis. Because inflammation is known to be associated with major depression in men and non-perinatal women as well as with other important morbidities of pregnancy (such as preeclampsia, preterm birth, and gestational diabetes), and because these morbidities may correlate with perinatal depression, inflammation may be a common physiological pathway that can also help explain perinatal depression. In this paper, we review the theoretical background of inflammation in perinatal depression and then review the literature concerning immune and inflammatory factors in the etiology and course of perinatal depression. We close with recommendations for future studies in this still relatively unexplored area. Identification and understanding of a common pathophysiology between other pregnancy morbidities and perinatal depression would link physical and mental well-being, likely leading to better treatment and prevention.

A pilot study evaluating genetic and environmental factors for postpartum depression

OBJECTIVE

To assess the influence of genetic and environmental risk factors upon postpartum depression.

DESIGN

Case-control, prospective study.

SETTING

The University of California at San Francisco Obstetric and Gynecology Clinic.

PARTICIPANTS

Mothers screened for postpartum depression six weeks after delivery with the Edinburgh Postnatal Depression Scale and recruited as cases and controls.

MEASUREMENTS

Eligible subjects completed a series of assessments and a structured clinical interview to confirm diagnosis of depression. Deoxyribonucleic acid was obtained for genotyping of 81 single nucleotide polymorphisms in 12 genes hypothesized to be postpartum depression-related.

RESULTS

Twenty-four cases and 24 controls were eligible for analysis. Three single necleotide polymorphisms in the serotonin 2A receptor (HTR2A) gene were associated with postpartum depression. The strongest association at a functional promoter polymorphism (rs6311), a functional promoter single nucleotide polymorphisms (p=0.002, odds ratio 0.25, 95% confidence interval:0.10-0.63), was a finding robust to population stratification. Gene-wide association was significant for HTR2A (permuted p=0.008), but not when corrected for all 12 genes. Analysis of demographic and psychosocial risk factors identified distressed relationship, unplanned pregnancy, and a previous history of depression as significant predictive variables (p≤0.05).

CONCLUSIONS

This pilot data suggests deoxyribonucleic acid variations in HTR2A may be associated with postpartum depression. Psychosocial variables were also identified as risk factors. The relative influence of these variables on the manifestation of postpartum depression is yet to be determined.

The relationship between perinatal psychiatric disorders and contraception use among postpartum women

BACKGROUND

The relationship between perinatal psychiatric disorders and the use of effective contraceptive methods among postpartum women served by primary care clinics has not been established.

STUDY DESIGN

This was a prospective cohort study with 831 pregnant women recruited from 10 primary care clinics of the public sector in São Paulo followed up to 18 months after delivery.

RESULTS

Among 701 postpartum women, 644 women (91.8%) had resumed sexual activity. Two hundred fifty-three women (39.2%) were classified as using a less effective contraception method (LECM). The presence of perinatal psychiatric disorder (in pregnancy and/or postpartum) was not associated with LECM. Resumption of sexual life 3 months or beyond after delivery was associated with LECM (odds ratio=1.28, 95% confidence interval: 1.02-1.56).

DISCUSSION

Although the use of an LECM after delivery is common, contraception choice is not associated with perinatal depressive/anxiety symptoms. However, women who delay the resumption of sexual activity after delivery should be counseled on the use of available contraceptive methods.