Seeking help for anxiety and depression after childbirth: results of the Maternal Health Study

Attachment and Mental Help-Seeking in the Perinatal Period: The Role of Stigma

This study aimed at (1) examining how women's attachment representations influence their intentions to seek formal help for their emotional problems, either directly or by affecting attitudes towards professional help-seeking (stigma and psychological openness), and (2) examining whether these effects are moderated by the presence of clinically significant psychopathological symptoms. A cross-sectional online survey including 226 women during the perinatal period was conducted. Results showed that, when clinically significant psychopathological symptoms were present, women's more insecure attachment representations were associated with lower intentions to seek professional help, and this influence occurred throughout a decrease in women's indifference to stigma associated with mental healthcare. These results support both the intra and interpersonal nature of the help-seeking process, and highlight the importance of implementing stigma reduction strategies (e.g., awareness campaigns, health professional's non-judgmental questioning of emotional difficulties), particularly in women with clinically significant psychopathological symptoms.

Subconstructs of the Edinburgh Postnatal Depression Scale in a multi-ethnic inner-city population in the U.S

The ten-item Edinburgh Postnatal Depression Scale (EPDS) is one of the most widely used self-report measures of postpartum depression. Although originally described as a one-dimensional measure, the recognition that depressive symptoms may be differentially experienced across cultural and racial/ethnic groups has led to studies examining structural equivalence of the EPDS in different populations. Variation of the factor structure remains understudied across racial/ethnic groups of US women. We examined the factor structure of the EPDS assessed 6 months postpartum in 515 women (29% black, 53% Hispanic, 18% white) enrolled in an urban Boston longitudinal birth cohort. Exploratory factor analysis (EFA) identified that a three-factor model, including depression, anxiety, and anhedonia subscales, was the most optimal fit in our sample as a whole and across race/ethnicity. Confirmatory factor analysis (CFA) was used to examine the fit of both the two- and three-factor models reported in prior research. CFA confirmed the best fit for a three-factor model, with minimal differences across race/ethnicity. "Things get on top of me" loaded on the anxiety factor among Hispanics, but loaded on the depression factor in whites and African Americans. These findings suggest that EPDS factor structure may need to be adjusted for diverse samples and warrants further study.

Using the EPDS to Identify Anxiety in Mothers of Infants on the Neonatal Intensive Care Unit

Despite the prevalence of postpartum depression and anxiety, current screening recommendations are limited to depression symptoms. Screening using the Edinburgh Postnatal Depression Scale-Anxiety subscale (EPDS-A) may enhance ability to detect distress in postpartum women. We aimed to replicate the EPDS-A in 200 mothers with infants hospitalized in the neonatal intensive care unit (NICU) and examine its incremental utility in identifying emotional distress. Presence of the EPDS-A was identified using exploratory factor analysis. Women experiencing elevated anxiety were identified using a previously established cutoff score. Results replicated the EPDS-A for the first time in mothers with infants hospitalized in the NICU. In all, 21.9% of these women had elevated anxiety symptoms and nearly one quarter of them would have been missed in routine depression screening. Use of the EPDS-A, in addition to the total EPDS score, is a promising approach to identifying anxious women in need of further evaluation, treatment, or support.

Maternal psychological distress after preterm birth: Disruptive or adaptive?

BACKGROUND

Maternal postpartum distress is often construed as a marker of vulnerability to poor parenting. Less is known, however, about the impact of postpartum distress on parenting an infant born prematurely. The present study investigated whether high distress levels, which are particularly prevalent in mothers of preterm born infants, necessarily affect a mother's quality of parenting.

METHOD

Latent Class Analysis was used to group mothers (N=197) of term, moderately, and very preterm born infants, based on their levels of distress (depression, anxiety, and PTSD symptoms) at one month postpartum, and their quality of parenting at one and six months postpartum. Parenting quality was assessed on the basis of maternal interactive behaviors (sensitivity, intrusiveness, and withdrawal) using observations, and maternal attachment representations (balanced, disengaged, or distorted) using interviews.

RESULTS

A 5-Class model yielded the best fit to the data. The first Class (47%) of mothers was characterized by low distress levels and high-quality parenting, the second Class (20%) by low distress levels and low-quality parenting, the third Class (22%) by high distress levels and medium-quality parenting, the fourth Class (9%) by high distress levels and high-quality parenting, and finally the fifth Class (2%) by extremely high levels of distress and low-quality parenting.

CONCLUSIONS

While heightened distress levels seem inherent to preterm birth, there appears to be substantial heterogeneity in mothers' emotional responsivity. This study indicates that relatively high levels of distress after preterm birth do not necessarily place these mothers at increased risk with regard to poor parenting. Conversely, low distress levels do not necessarily indicate good-quality parenting. The results of the present study prompt a reconsideration of the association between postpartum distress and parenting quality, and challenge the notion that high levels of maternal distress always result in low-quality parenting practices.

Pregnant Women's Views on the Feasibility and Acceptability of Web-Based Mental Health E-Screening Versus Paper-Based Screening: A Randomized Controlled Trial

BACKGROUND

Major international guidelines recommend mental health screening during the perinatal period. However, substantial barriers to screening have been reported by pregnant and postpartum women and perinatal care providers. E-screening offers benefits that may address implementation challenges.

OBJECTIVE

The primary objective of this randomized controlled trial was to evaluate the feasibility and acceptability of Web-based mental health e-screening compared with paper-based screening among pregnant women. A secondary objective was to identify factors associated with women's preferences for e-screening and disclosure of mental health concerns.

METHODS

Pregnant women recruited from community and hospital-based antenatal clinics and hospital-based prenatal classes were computer-randomized to a fully automated Web-based e-screening intervention group or a paper-based control group. Women were eligible if they spoke or read English, were willing to be randomized to e-screening, and were willing to participate in a follow-up diagnostic interview. The intervention group completed the Antenatal Psychosocial Health Assessment and the Edinburgh Postnatal Depression Scale on a tablet computer, while controls completed them on paper. All women completed self-report baseline questions and were telephoned 1 week after randomization by a blinded research assistant for a MINI International Neuropsychiatric Interview. Renker and Tonkin's tool of feasibility and acceptability of computerized screening was used to assess the feasibility and acceptability of e-screening compared with paper-based screening. Intention-to-treat analysis was used. To identify factors associated with preference for e-screening and disclosure, variables associated with each outcome at P<.20 were simultaneously entered into final multivariable models to estimate adjusted odds ratios (AORs) and 95% CIs.

RESULTS

Of the 675 eligible women approached, 636 agreed to participate (participation rate 94.2%) and were randomized to the intervention (n=305) or control (n=331) groups. There were no significant baseline differences between groups. More women in the e-screening group strongly or somewhat agreed that they would like to use a tablet for answering questions on emotional health (57.9%, 175/302 vs 37.2%, 121/325) and would prefer using a tablet to paper (46.0%, 139/302 vs 29.2%, 95/325), compared with women in the paper-based screening group. There were no differences between groups in women's disclosure of emotional health concerns (94.1%, 284/302 vs 90.2%, 293/325). Women in the e-screening group consistently reported the features of e-screening more favorably than controls (more private or confidential, less impersonal, less time-consuming). In the multivariable models, being in the e-screening group was significantly associated with preferring e-screening (AOR 2.29, 95% CI 1.66-3.17), while no factors were significantly associated with disclosure.

CONCLUSIONS

The findings suggest that mental health e-screening is feasible and acceptable to pregnant women.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01899534; https://clinicaltrials.gov/ct2/show/NCT01899534 (Archived by WebCite at http://www.webcitation.org/6ntWg1yWb).

Preconception personality disorder and antenatal maternal mental health: A population-based cohort study

BACKGROUND

Prior anxiety and depression have been identified as risk factors for maternal perinatal mental health problems, but other preconception mental disorders have not been prospectively examined. This study investigated prospectively whether women with preconception personality disorder have increased rates of antenatal anxiety and/or depressive symptoms.

METHODS

244 women in a population cohort were assessed for personality disorder at age 24 using the Standardised Assessment of Personality. Five to twelve years later, women were screened with the Clinical Interview Schedule, Revised Anxiety Subscale and the Edinburgh Postnatal Depression Scale during the third trimester of 328 pregnancies.

RESULTS

Preconception personality disorder was associated with a three-fold increase in the odds of antenatal anxiety symptoms, which remained with adjustment for preconception background factors and preconception common mental disorder (adjusted OR 2.84, 95% CI 1.31-6.15). Preconception personality disorder was associated with doubled odds of antenatal depressive symptoms, however this was attenuated with adjustment for preconception background factors and preconception common mental disorder (adjusted OR 1.98, 95% CI 0.81-4.81).

LIMITATIONS

Our findings are restricted to pregnant women aged 29-35 years. Anxiety and depression may have been under-identified because they were assessed at a single antenatal time point. Residual confounding of the associations by preconception common mental disorder at other time points may have occurred.

CONCLUSIONS

Women with personality disorder are at heightened risk of anxiety symptoms in pregnancy, over and above risks associated with prior common mental disorder. This raises a possibility that pregnancy brings particular emotional challenges for women with personality disorders.

Antenatal psychosocial risk status and Australian women's use of primary care and specialist mental health services in the year after birth: a prospective study

BACKGROUND

Poor mental health in the perinatal period can impact negatively on women, their infants and families. Australian State and Territory governments are investing in routine psychosocial assessment and depression screening with referral to services and support, however, little is known about how well these services are used. The aim of this paper is to report on the health services used by women for their physical and mental health needs from pregnancy to 12 months after birth and to compare service use for women who have been identified in pregnancy as having moderate-high psychosocial risk with those with low psychosocial risk.

METHODS

One hundred and six women were recruited to a prospective longitudinal study with five points of data collection (2-4 weeks after prenatal booking, 36 weeks gestation, 6 weeks postpartum, 6 months postpartum and 12 months postpartum) was undertaken. Data were collected via face-to-face and telephone interviews, relating to psychosocial risk factors, mental health and service use. The prenatal psychosocial risk status of women (data available for 83 of 106 women) was determined using the Antenatal Risk Questionnaire (ANRQ) and was used to compare socio-demographic characteristics and service use of women with 'low' and 'moderate to high' risk of perinatal mental health problems.

RESULTS

The findings indicate high use of postnatal universal health services (child and family health nurses, general practitioners) by both groups of women, with limited use of specialist mental health services by women identified with moderate to high risk of mental health problems. While almost all respondents indicated that they would seek help for mental health concerns most had a preference to seek help from partners and family before accessing health professionals.

CONCLUSION

These preliminary data support local and international studies that highlight the poor uptake of specialist services for mental health problems in postnatal women, where this may be required. Further research comparing larger samples of women (with low and psychosocial high risk) are needed to explore the extent of any differences and the reasons why women do not access these specialist services.

Anxiety disorders in postpartum women: A systematic review and meta-analysis

BACKGROUND

Evidence suggests that postpartum anxiety is relatively common among postpartum women. Anxiety meeting diagnostic criteria for a disorder represents anxiety at its most severe, distressing, and persistent, and thus it is most important to identify, understand, and treat. This paper describes a comprehensive systematic review of anxiety disorders among postpartum women, along with meta-analysis of prevalence.

METHODS

Findings are based on a thorough search of the literature, strict inclusion of only studies which utilized the gold standard of diagnostic interviews for anxiety disorder determination, and critical appraisal and review of included studies. A random effects meta-analysis was used to determine prevalence.

RESULTS

Fifty-eight studies were included in the review: 13 addressed prevalence, 5 incidence, 14 onset, 16 course, 13 correlates and risk factors, 15 outcomes, and 2 treatments for postpartum anxiety disorders. An estimated 8.5% of postpartum mothers experience one or more anxiety disorders.

LIMITATIONS

Many limitations relate to the state of the current literature, including a small number of studies to answer specific research questions for each disorder, methodological limitations, and considerable heterogeneity across studies.

CONCLUSIONS

Anxiety disorders are common among postpartum women. The review summarizes the current status of research on postpartum anxiety disorders and underscores the need for increased research to more accurately determine prevalence, understand course, identify risk factors and outcomes, and determine effective treatments. Greater clinical attention to these disorders is warranted to ameliorate the negative consequences of postpartum anxiety disorders on women and families.

Mothering and anxiety: Social support and competence as mitigating factors for first-time mothers

This study investigated anxiety as a phenomenon distinct from depression and evaluated several variables that influence anxiety in first-time mothers. This explored the relationship between maternal sense of competence (both of mothering and efficacy) and perceived social support (from family, friends, and significant others) and first-time mothers' postpartum anxiety, when depression, socioeconomic status (SES), and marital status were controlled for. The population studied were 86 first-time mothers made up of women with children 24 months or younger in two populations of Kentucky and Michigan. The constructs of maternal sense of competence and perceived social support were found to be significant in explaining first-time mothers' anxiety. The study concluded that a combined association of perceived social support and maternal sense of competence were associated with a 34% (change in R-squared = .339) decrease of a first-time mothers' anxiety. However, not all types of social support, or maternal competence appeared to be equally important with regards to maternal anxiety: social support from friends and family and maternal sense of competence in regard to productivity appeared to be most significant. Lastly, some recommendations for health practitioners who work with mothers are provided.

Women's Preferences for Treatment of Perinatal Depression and Anxiety: A Discrete Choice Experiment

Perinatal depression and anxiety (PNDA) are an international healthcare priority, associated with significant short- and long-term problems for women, their children and families. Effective treatment is available but uptake is suboptimal: some women go untreated whilst others choose treatments without strong evidence of efficacy. Better understanding of women’s preferences for treatment is needed to facilitate uptake of effective treatment. To address this issue, a discrete choice experiment (DCE) was administered to 217 pregnant or postnatal women in Australia, who were recruited through an online research company and had similar sociodemographic characteristics to Australian data for perinatal women. The DCE investigated preferences regarding cost, treatment type, availability of childcare, modality and efficacy. Data were analysed using logit-based models accounting for preference and scale heterogeneity. Predicted probability analysis was used to explore relative attribute importance and policy change scenarios, including how these differed by women’s sociodemographic characteristics. Cost and treatment type had the greatest impact on choice, such that a policy of subsidising effective treatments was predicted to double their uptake compared with the base case. There were differences in predicted uptake associated with certain sociodemographic characteristics: for example, women with higher educational attainment were more likely to choose effective treatment. The findings suggest policy directions for decision makers whose goal is to reduce the burden of PNDA on women, their children and families.

Computer- or web-based interventions for perinatal mental health: A systematic review

BACKGROUND

Treating prenatal mental health issues is of great importance, but access to treatment is often poor. One way of accessing treatment is through computer- or web-based interventions. Reviews have shown that these interventions can be effective for a variety of mental health disorder across different populations. However, their effectiveness for women in the perinatal period has not been reviewed. This review therefore aimed to provide a first overview of computer- or web-based interventions for women's perinatal mental health issues by systematically identifying and reviewing their characteristics and efficacy.

METHODS

Twelve electronic databases were searched for published and unpublished literature using keywords, supplemented by hand searches. Data were extracted for characteristics of the intervention and the study, study findings and the methodological quality was assessed.

RESULTS

The majority of the eleven eligible studies were randomized controlled trials. Interventions were targeted at depression, stress, and complicated grief during the antenatal or postpartum period or the time after pregnancy loss. Findings suggest that computer- or web-based interventions targeted at improving mental health, especially depression and complicated grief, may be effective.

LIMITATIONS

Findings and their generalizability is limited by the heterogeneity of reviewed interventions and study designs, as well as methodological limitations.

CONCLUSIONS

This systematic review constitutes the first synthesis of research on computer- or web-based interventions for perinatal mental health issues and provides preliminary support that this could be a promising form of treatment during this period. However, there are significant gaps in the current evidence-base so further research is needed.

First-time parents' shared representation of postpartum depressive symptoms: A qualitative analysis

RATIONALE

Maternal postpartum depression (PD) is a common, debilitating mental health problem. Yet despite effective treatments and widespread screening, treatment rates remain low. Previous studies suggest fathers are frequently consulted about maternal PD symptoms, but little is known about the process, content, or outcomes of these consultations.

OBJECTIVE

The aim of this work was to explore how couples communicate about PD symptoms.

METHODS

A single purposive sample of first-time parents stratified by maternal depression screening scores (Edinburgh Postnatal Depression Scale; EPDS) and partner status was drawn from a prospective survey of 300 parents in the U.S. Midwest. Partnered mothers with an elevated (EPDS≥10) depression screening score at one of four time points in the postpartum year comprised the majority of the sample. Smaller samples of participants with low EPDS scores and single participants were included to provide contrast in the consultation and decision making process. A total of 39 participants (22 married/EPDS-high, 10 married/EPDS-low, 5 single/ EPDS-high, 2 single/EPDS-low) were interviewed at one year postpartum. Mothers and fathers were interviewed separately to promote candid responses and allow comparison of illness conceptualizations. Interviews were transcribed, analyzed, and coded through an iterative process.

RESULTS

Couples' conversations about mood changes centered on two overarching questions: How bad is it? and What should we do about it? Answering How bad is it? involved parents comparing maternal mood changes to uncertain depression criteria, and mothers asking partners and female relatives whether changes were normal. Answering What should we do about it? had three themes: Fathers feeling unprepared to respond to depression, mothers and fathers expressing reluctance to seek treatment, and couples working collaboratively to accommodate treatment or self-care.

CONCLUSION

Themes suggest partners significantly contribute to women's conceptualization of mood changes and should be actively engaged in education, screening, and referral practices.

Care for Postpartum Depression: What Do Women and Their Partners Prefer?

PURPOSE

To compare the preferences of those who accept a mental health assessment and those who do not.

DESIGN AND METHODS

Thirty couples participated in a qualitative study. Nineteen couples accepted a mental health assessment and 11 declined.

FINDINGS

Acceptors wanted more contact with professionals. Decliners preferred support from their informal network, parental leave, and exercise. However, acceptors also cited these preferences.

PRACTICE IMPLICATIONS

Nurses should tailor care to couples' preferences, helping them identify and utilize preferred resources. Mental health care might be more acceptable to decliners if provided in obstetrical care.

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.

Maternal depression from pregnancy to 4 years postpartum and emotional/behavioural difficulties in children: results from a prospective pregnancy cohort study

Considerable attention has been focused on women's mental health in the perinatal period and the subsequent impacts on children. Comparatively, we know much less about maternal depression at later time points and the potential implications for child mental health. The objective of this paper was to explore the association between maternal depression and child emotional/behavioural difficulties at 4 years postpartum, taking into account earlier episodes of perinatal depression. The Maternal Health Study is a prospective cohort study of 1,507 nulliparous women. Maternal depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS) in early pregnancy and at 3, 6 and 12 months postpartum and again at 4 years postpartum. Maternal depressive symptoms at 4 years postpartum were associated with significantly increased odds of child emotional/behavioural difficulties (odds ratio (OR) = 3.46, 95 % confidence interval (CI) = 2.21-5.43). This remained significant after adjusting for earlier episodes of perinatal depression and socio-demographic characteristics (OR = 2.07, 95 % CI = 1.18-3.63). We also observed a robust association between child difficulties at age 4 and measures of socio-economic disadvantage. Our findings suggest a pressing need to rethink current paradigms of maternal health surveillance and extend mental health surveillance and support to at least 4 years postpartum.

"I didn't know it was possible to feel that tired": exploring the complex bidirectional associations between maternal depressive symptoms and fatigue in a prospective pregnancy cohort study

Depressive and fatigue symptoms are common health concerns for women in the postnatal period. Few studies have sought to investigate the role of fatigue in the development and maintenance of depressive symptoms. The aim of this paper was to examine the relationship between depressive symptoms and fatigue over the course of the first 4 years postpartum, in particular focusing on the extent to which fatigue at earlier time points predicted later depressive symptoms and vice versa. Data from over 1000 women participating in a longitudinal study of Australian women's physical and psychological health and recovery after childbirth were used. An autoregressive cross-lagged panel model was tested to assess the mutual influences of fatigue and depressive symptoms across five time points at 3, 6, 12 and 18 months postpartum, and at 4 years postpartum. A complex bidirectional relationship between fatigue and depressive symptoms from 3 months to 4 years postpartum was observed, where fatigue at earlier time points predicted depressive symptoms at later time points, and vice versa. The findings of this study suggest interventions targeting the prevention and management of fatigue may also confer some benefit in improving or preventing the development of depression symptoms in the early parenting period.

Early postnatal demoralisation among primiparous women in the community: measurement, prevalence and associated factors

Background

Demoralisation is a psychological state occurring in stressful life situations where a person feels unable to respond effectively to their circumstances, characterised by feelings of distress, subjective incompetence, helplessness and hopelessness. The period after the birth of a first baby is a time of great changes and disruptions to many aspects of the mother's physical, psychological and social functioning. This can lead to feelings of distress, a sense of incompetence and helplessness. This study aimed to examine: (1) the psychometric properties of the Demoralisation Scale in a community setting; (2) the prevalence of demoralisation symptoms among primiparous women in the community; and (3) factors that are uniquely associated with demoralisation in the early postnatal period.

Methods

Primiparous women attending community maternal health centres (n = 400) were recruited and administered the study's questionnaires through a telephone interview.

Results

The Demoralisation Scale was found to be a reliable and valid tool among women in the community who had recently given birth. Higher levels of demoralisation were independently associated with lower confidence on going home from the hospital after birth, lower rating of mother's self-rated global health, more than 3 h of infant crying and fussing in the last 24 h, and a controlling partner, after symptoms of depression and anxiety, and vulnerable personality characteristics were controlled for.

Conclusions

The relevance of demoralisation to postnatal health practitioners in the community is in helping them to better understand women's experiences and to intervene in a way that is more meaningful and less stigmatising to women.

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.

Exploring the views and experiences of callers to the PANDA Post and Antenatal Depression Association Australian National Perinatal Depression Helpline: a cross-sectional survey

BACKGROUND

Anxiety and depression are common in the perinatal period. Telephone interventions, including telephone peer support and counselling, have been developed to support those experiencing perinatal mental illness. PANDA Post and Antenatal Depression Association provides support to women and men experiencing perinatal mental illness via the Australian National Perinatal Depression Helpline, encompassing both volunteer peer support and professional counselling. This study aimed to explore the experiences of callers to the Helpline.

METHODS

A cross-sectional survey design was used. All new callers from 1(st) May to 30(th) September 2013 were invited to participate. The survey, adapted from a previous survey of PANDA callers, included 23 questions using Likert-type scales, demographic and open-ended questions. Thematic network analysis was undertaken for responses to open-ended questions.

RESULTS

124 responses were received (124/405; 30% response). The majority of callers had called the Helpline regarding themselves (90%), with over one third (33%) of all callers seeking crisis support and help. Ninety-nine per cent of respondents 'agreed' or 'strongly agreed' that staff and/or volunteers understood their concerns, and 97% 'agreed' or 'strongly agreed' that overall PANDA had helped them. Callers described the PANDA service as uniquely tailored to the perinatal period, providing accessible, non-judgemental understanding and support, with a global theme from open-ended comments describing PANDA as 'a safe space to be heard and receive support without judgement'. Recommendations for service changes included increased hours of availability.

CONCLUSIONS

Callers reported positive experiences of accessing support from the PANDA National Perinatal Depression Helpline. The Helpline was described as an accessible and acceptable telephone support for individuals experiencing perinatal mental illness. Recommendations for changes to the service included an increase in hours of operation to enable greater responsiveness at times of need, reduced waiting times, and access to continuity with the same volunteer and/or telephone counsellor. The findings of the study will be useful in informing future service provision, review, and implementation.

Mothers' perceptions of primary health-care providers: thematic analysis of responses to open-ended survey questions

General practitioners and maternal, child and family health nurses have a central role in postpartum primary health care for women and their infants. Positive client-provider relationships are particularly important for women experiencing mental health problems or unsettled infant behaviour. However, little is known about their experiences of postnatal primary health care. The study aimed to describe views of postnatal primary health care among women completing a residential early parenting programme and to identify potential strategies to enhance provider-patient interactions. Participants (n=138) were women admitted with their infants to a private or a public early parenting service in Melbourne, Australia. Women completed a detailed self-report survey, including open-ended questions about experiences of primary health-care services, and a structured psychiatric interview to diagnose anxiety and depression. Survey responses were analysed thematically. Womens' experiences of primary health care were influenced by their perceptions of provider competence and the quality of interactions. While similar positive characteristics of doctor and nurse care were valued, medical and nursing practices were judged in different ways. Women described GPs who listened, understood and were thorough as providing good care, and maternal, child and family health nurses were valued for providing support, advice and encouragement. Threats to therapeutic relationships with doctors included feeling rushed during consultations, believing that GPs were not mental health-care providers and the clinician not being 'good' with the infant; with nurses, problems included feeling judged or given advice that was inconsistent or lacked an evidence-base. Postpartum primary health care will be improved by unhurried consultations, empathic recognition, encouragement, evidence-informed guidance and absence of criticism.

Immigrant Afghan women's emotional well-being after birth and use of health services in Melbourne, Australia

OBJECTIVE

to investigate immigrant Afghan women's emotional well-being and experiences of postnatal depression after childbirth and their use of health services.

DESIGN

telephone interviews were conducted at four months after birth, using a semi-structured questionnaire; and a further in-depth face-to-face interview with a small number of women approximately one year after the birth. Women's emotional health was assessed at four months using the Edinburgh Postnatal Depression Scale (EPDS), as well as women's own descriptions of their emotional well-being since the birth.

SETTING

women were recruited from four hospital antenatal clinics or postnatal wards in Melbourne, Australia, between October 2006 and May 2007.

PARTICIPANTS

Immigrant women who were born in Afghanistan, spoke Dari/Persian or English, and had given birth to a live and healthy baby.

FINDINGS

Thirty nine women were interviewed at four months after birth; 41% reported feeling depressed or very unhappy since the birth and 31% scored as probably depressed on the EPDS. Ten women participated in further in-depth face-to-face interviews. Isolation, lack of support and being overwhelmed by life events were the most frequently reported contributing factors to women's emotional distress, and for many being a migrant appeared to intensify their experiences. The themes that emerged from both the telephone and face-to-face interviews revealed that some women were reluctant to discuss their emotional difficulties with health professionals and did not expect that health professionals could necessarily provide assistance.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

in this study a significant proportion of immigrant Afghan women experienced emotional distress after childbirth. Women's experiences of emotional distress and help-seeking were at times affected by their status as immigrants and their perceptions of possible causes and treatment for their emotional health problems. Understanding the effects of migration on women's lives and paying careful attention to individual needs and preferences are critically important in providing care for immigrant Afghan women.

The association between diet quality and mental health during the perinatal period. A systematic review

BACKGROUND

While maternal nutrition during pregnancy is known to play a critical role in the health of both mother and offspring, the magnitude of this association has only recently been realized. Novel, epigenetic data suggest that maternal dietary intake has permanent phenotypic consequences for offspring, highlighting the potency of antenatal diet. To date, the relationship between poor antenatal diet and maternal mental health specifically, remains poorly understood. Therefore, we aimed to systematically review evidence that has examined associations between antenatal diet quality and the experience of depressive, anxiety and stress symptoms during the perinatal period.

METHODS

A search for peer-reviewed papers was conducted using Medline Complete, PsycINFO, CINAHL, Academic Search Premiere and Psychology and Behavioral Science Collection.

RESULTS

Nine studies (cohort = 4, cross-sectional = 5) published between 2005 and 2013 were eligible for inclusion in this review. A synthesis of findings revealed positive associations between poor quality and unhealthy diets and antenatal depressive and stress symptoms. Healthy diets were inversely associated with antenatal depressive and anxiety symptoms. Postnatal depressive symptoms demonstrated inconsistent results.

CONCLUSIONS

Given the paucity of research examining diet quality and mental health in women during the perinatal period, further sufficiently powered studies are urgently required to examine this association.

Pediatric-based intervention to motivate mothers to seek follow-up for depression screens: The Motivating Our Mothers (MOM) trial

OBJECTIVE

To determine the initial effectiveness of a novel, pediatric office-based intervention in motivating mothers to seek further assessment of positive depression screens.

METHODS

In this pilot randomized controlled trial, English-speaking mothers (n = 104) with positive 2-question depression screens and presenting with children 0 to 12 years old for well-child care to a general pediatric training clinic received interventions from a trained research assistant. The Motivating Our Mothers (MOM) intervention included office-based written and verbal targeted depression education and motivational messages encouraging further depression assessment and a semistructured telephone booster delivered 2 days later. The control intervention included nontargeted written and verbal messages and 2 days later, an attention control telephone survey. Both groups received a list of depression care resources. The primary outcome was the proportion of mothers in each group who reported trying to contact any of 6 types of resources to discuss the positive screen at 2 weeks after intervention (ClinicalTrials.gov NCT01453790).

RESULTS

Despite 6 contact attempts, 10 MOM and 9 control mothers were lost to follow-up. More mothers in the MOM intervention tried to contact a resource compared to control (73.8% vs 53.5%, difference 20.3%, 95% confidence interval for difference -0.1 to 38.5, P = .052).

CONCLUSIONS

Mothers receiving the MOM intervention made more attempts to contact a resource for follow-up of positive depression screens. If found effective in larger studies, MOM may prove a promising approach for motivating depression screen-positive mothers identified in general pediatric settings within and beyond the postpartum period to seek further depression assessment and support.

Emotion and mood adaptations in the peripartum female:complementary contributions of GABA and oxytocin

Peripartum hormones and sensory cues from young modify the maternal brain in ways that can render females either at risk for, or resilient to, elevated anxiety and depression. The neurochemical systems underlying these aspects of maternal emotional and mood states include the inhibitory neurotransmitter GABA and the neuropeptide oxytocin (OXT). Data from laboratory rodents indicate that increased activity at the GABA(A) receptor contributes to the postpartum suppression of anxiety-related behaviour that is mediated by physical contact with offspring, whereas dysregulation in GABAergic signalling results in deficits in maternal care, as well as anxiety- and depression-like behaviours during the postpartum period. Similarly, activation of the brain OXT system accompanied by increased OXT release within numerous brain sites in response to reproductive stimuli also reduces postpartum anxiety- and depression-like behaviours. Studies of peripartum women are consistent with these findings in rodents. Given the similar consequences of elevated central GABA and OXT activity on maternal anxiety and depression, balanced and partly reciprocal interactions between these two systems may be essential for their effects on maternal emotional and mood states, in addition to other aspects of postpartum behaviour and physiology.

Study protocol for a randomized, controlled, superiority trial comparing the clinical and cost- effectiveness of integrated online mental health assessment-referral-care in pregnancy to usual prenatal care on prenatal and postnatal mental health and infant health and development: the Integrated Maternal Psychosocial Assessment to Care Trial (IMPACT)

BACKGROUND

Stress, depression, and anxiety affect 15 to 25% of pregnant women. However, fewer than 20% of prenatal care providers assess and treat mental health problems and fewer than 20% of pregnant women seek mental healthcare. For those who seek treatment, the lack of health system integration and existing barriers frequently prevent treatment access. Without treatment, poor prenatal mental health can persist for years and impact future maternal, child, and family well-being.

METHODS/DESIGN

The purpose of this randomized controlled trial is to evaluate the effectiveness of an integrated process of online psychosocial assessment, referral, and cognitive behavior therapy (CBT) for pregnant women compared to usual prenatal care (no formal screening or specialized care). The primary outcome is self-reported prenatal depression, anxiety, and stress symptoms at 6 to 8 weeks postrandomization. Secondary outcomes are postpartum depression, anxiety, and stress symptoms; self-efficacy; mastery; self-esteem; sleep; relationship quality; coping; resilience; Apgar score; gestational age; birth weight; maternal-infant attachment; infant behavior and development; parenting stress/competence; and intervention cost-effectiveness, efficiency, feasibility, and acceptability. Pregnant women are eligible if they: 1) are <28 weeks gestation; 2) speak/read English; 3) are willing to complete email questionnaires; 4) have no, low, or moderate psychosocial risk on screening at recruitment; and 5) are eligible for CBT. A sample of 816 women will be recruited from large, urban primary care clinics and allocation is by computer-generated randomization. Women in the intervention group will complete an online psychosocial assessment, and those with mild or moderate depression, anxiety, or stress symptoms then complete six interactive cognitive behavior therapy modules. All women will complete email questionnaires at 6 to 8 weeks postrandomization and at 3, 6, and 12 months postpartum. Clinic-based providers and researchers conducting chart abstraction and analysis are blinded. Qualitative interviews with 8 to 10 healthcare providers and 15 to 30 intervention group women will provide data on feasibility and acceptability of the intervention. Results of this trial will determine the feasibility and effectiveness of an integrated approach to prenatal mental healthcare and the use of highly accessible computer-based psychosocial assessment and CBT on maternal, infant, and family-based outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01901796.

Public views of acceptability of perinatal mental health screening and treatment preference: a population based survey

BACKGROUND

At a prevalence rate of 13-25%, mental health problems are among the most common morbidities of the prenatal and postnatal periods. They have been associated with increased risk of preterm birth and low birthweight, child developmental delay, and poor child mental health. However, very few pregnant and postpartum women proactively seek help or engage in treatment and less than 15% receive needed mental healthcare. While system-related barriers limit accessibility and availability of mental health services, personal barriers, such as views of mental health and its treatment, are also cited as significant deterrents of obtaining mental healthcare. The purposes of this population-based study were to identify the public's views regarding mental health screening and treatment in pregnant and postpartum women, and to determine factors associated with those views.

METHODS

A computer-assisted telephone survey was conducted by the Population Research Laboratory with a random sample of adults in Alberta, Canada. Questions were drawn from the Perinatal Depression Monitor, an Australian population-based survey on perinatal mental health; additional questions were developed and tested to reflect the Canadian context. Interviews were conducted in English and were less than 30 minutes in duration. Descriptive and multivariable regression analyses were conducted.

RESULTS

Among the 1207 respondents, 74.8% had post-secondary education, 16.3% were 18-34 years old, and two-thirds (66.1%) did not have children <18 years living at home. The majority of respondents strongly agreed/agreed that all women should be screened in the prenatal (63.0%) and postpartum periods (72.7%). Respondents reported that when seeking help and support their first choice would be a family doctor. Preferred treatments were talking to a doctor or midwife and counseling. Knowledge of perinatal mental health was the main factor associated with different treatment preferences.

CONCLUSIONS

The high acceptability of universal perinatal mental health screening among the public provides a strong message regarding the public value for routine screening during pregnancy and postpartum periods. Perinatal mental health literacy is the most prominent determinant of screening and treatment acceptability and preference. Efforts to enhance population literacy as part of a multifaceted perinatal mental health strategy may optimize pregnant and postpartum women's mental health.

Symptoms of the anxiety disorders in a perinatal psychiatric sample: a chart review

Symptoms of anxiety are a central feature of perinatal mental health, yet the anxiety disorders have received considerably less attention than depression in both perinatal research and practice. The present investigation involved a retrospective review of the clinical records of 334 patients seen at a psychiatric day hospital program serving pregnant and postpartum women. We examined the frequency with which the patients in this setting reported symptoms of anxiety, clinical correlates of elevated anxiety, and patterns of diagnosis in the clinical record. The results suggest that anxiety symptoms are very common in this population and that the presence of anxiety is associated with a more severe clinical profile, including higher rates of suicidality and increased use of psychotropic medications during pregnancy and postpartum. Although anxiety symptom levels were markedly elevated in this sample, anxiety disorders were diagnosed at relatively low rates. Implications for clinical practice, including discharge and treatment planning, are discussed.

Comparing the feasibility, acceptability, clinical-, and cost-effectiveness of mental health e-screening to paper-based screening on the detection of depression, anxiety, and psychosocial risk in pregnant women: a study protocol of a randomized, parallel-group, superiority trial

BACKGROUND

Stress, depression, and anxiety affect 15% to 25% of pregnant women. However, substantial barriers to psychosocial assessment exist, resulting in less than 20% of prenatal care providers assessing and treating mental health problems. Moreover, pregnant women are often reluctant to disclose their mental health concerns to a healthcare provider. Identifying screening and assessment tools and procedures that are acceptable to both women and service providers, cost-effective, and clinically useful is needed.

METHODS/DESIGN

The primary objective of this randomized, parallel-group, superiority trial is to evaluate the feasibility and acceptability of a computer tablet-based prenatal psychosocial assessment (e-screening) compared to paper-based screening. Secondary objectives are to compare the two modes of screening on: (1) the level of detection of prenatal depression and anxiety symptoms and psychosocial risk; (2) the level of disclosure of symptoms; (3) the factors associated with feasibility, acceptability, and disclosure; (4) the psychometric properties of the e-version of the assessment tools; and (5) cost-effectiveness. A sample of 542 women will be recruited from large, primary care maternity clinics and a high-risk antenatal unit in an urban Canadian city. Pregnant women are eligible to participate if they: (1) receive care at one of the recruitment sites; (2) are able to speak/read English; (3) are willing to be randomized to e-screening; and (4) are willing to participate in a follow-up diagnostic interview within 1 week of recruitment. Allocation is by computer-generated randomization. Women in the intervention group will complete an online psychosocial assessment on a computer tablet, while those in the control group will complete the same assessment in paper-based form. All women will complete baseline questionnaires at the time of recruitment and will participate in a diagnostic interview within 1 week of recruitment. Research assistants conducting diagnostic interviews and physicians will be blinded. A qualitative descriptive study involving healthcare providers from the recruitment sites and women will provide data on feasibility and acceptability of the intervention. We hypothesize that mental health e-screening in primary care maternity settings and high-risk antenatal units will be as or more feasible, acceptable, and capable of detecting depression, anxiety, and psychosocial risk compared to paper-based screening.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01899534.

Postpartum depression, infant feeding practices, and infant weight gain at six months of age

INTRODUCTION

This study examined postpartum depression (PPD) as a potential risk factor for non-adherence to infant feeding guidelines and subsequent infant weight gain.

METHODS

Participants were mother-infant dyads from the Infant Feeding Practices Study II (N = 1447). Main study variables were PPD, breastfeeding intensity, addition of cereal to infant formula, and age of introduction to solid foods.

RESULTS

In logistic models adjusted for sociodemographic factors, mothers with PPD were 1.57 times (95% confidence interval [CI]: 1.16, 2.13) more likely to breastfeed at low intensity and 1.77 times (95% CI: 1.16, 2.68) more likely to add cereal to infant formula. Although PPD was associated with the early introduction to solid foods (odds ratio: 1.42; 95% CI: 1.07, 1.89), this relationship was not significant after adjusting for potential confounders. A small but significantly greater average weight gain at 6 months was observed among infants of mothers with PPD (10.15 lb, SD = 2.32 vs. 9.85 lb, SD = 2.32).

DISCUSSION

Screening for PPD at well-child visits may lead to improved maternal health outcomes and the prevention of early life risk factors for childhood obesity.

Patient's views on depression care in obstetric settings: how do they compare to the views of perinatal health care professionals?

OBJECTIVES

The objectives were to examine patients' perspectives on patient-, provider- and systems-level barriers and facilitators to addressing perinatal depression in outpatient obstetric settings. We also compare the views of patients and perinatal health care professionals.

METHOD

Four 90-min focus groups were conducted with women 3-36 months after delivery (n=27) who experienced symptoms of perinatal depression, anxiety or emotional distress. Focus groups were transcribed, and resulting data were analyzed using a grounded theory approach.

RESULTS

Barriers to addressing perinatal depression included fear of stigma and loss of parental rights, negative experiences with perinatal health care providers and lack of depression management knowledge/skills among professionals. Facilitators included psychoeducation, peer support and training for professionals.

CONCLUSIONS

Patients perceive many multilevel barriers to treatment that are similar to those found in our previous similar study of perinatal health care professionals' perspectives. However, patients and professionals do differ in their perceptions of one another. Interventions would need to close these gaps and include an empathic screening and referral process that facilitates discussion of mental health concerns. Interventions should leverage strategies identified by both patients and professionals, including empowering both via education, resources and access to varied mental health care options.

Strategies for improving perinatal depression treatment in North American outpatient obstetric settings

OBJECTIVE

To identify core barriers and facilitators to addressing perinatal depression and review clinical, programmatic, and system level interventions that may optimize perinatal depression treatment.

METHOD

Eighty-four MEDLINE/PubMed searches were conducted using the terms perinatal depression, postpartum depression, antenatal depression, and prenatal depression in association with 21 other terms. Of 7768 papers yielded in the search, we identified 49 papers on barriers and facilitators, and 17 papers on interventions in obstetric settings aimed to engage women and/or providers in treatment.

RESULTS

Barriers include stigma, lack of obstetric provider training, lack of resources and limited access to mental health treatment. Facilitators include validating and empowering women during interactions with health care providers, obstetric provider and staff training, standardized screening and referral processes, and improved mental health resources.

CONCLUSION

Specific clinical, program, and system level changes are recommended to help change the culture of obstetric care settings to optimize depression treatment.

Prenatal and postpartum maternal psychological distress and infant development: a systematic review

Infant development plays a foundational role in optimal child development and health. Some studies have demonstrated an association between maternal psychological distress and infant outcomes, although the main emphasis has been on postpartum depression and infant-maternal attachment. Prevention and early intervention strategies would benefit from an understanding of the influence of both prenatal and postpartum maternal distress on a broader spectrum of infant developmental outcomes. We conducted a systematic review of studies assessing the effect of prenatal and postpartum maternal psychological distress on five aspects of infant development: global; cognitive; behavioral; socio-emotional; and psychomotor. These findings suggest that prenatal distress can have an adverse effect on cognitive, behavioral, and psychomotor development, and that postpartum distress contributes to cognitive and socio-emotional development.

Physical health and recovery in the first 18 months postpartum: does cesarean section reduce long-term morbidity?

BACKGROUND

Research examining long-term health outcomes for women after childbirth has been limited. The objective of this study was to investigate the natural history of common morbidities in the 18 months after the birth of a first child, and to explore the hypothesis that women who have a cesarean section for a first birth experience less overall morbidity in the postnatal period.

METHODS

A prospective nulliparous pregnancy cohort study was conducted of 1,507 women recruited in early pregnancy from six public hospitals in Melbourne, Australia (mean gestation 15 weeks). Follow-up questionnaires at 3, 6, 12, and 18 months postpartum included standardized measures of urinary and fecal incontinence, and a symptom checklist asking about common physical health problems.

RESULTS

At 6, 12, and 18 months postpartum, no statistically significant differences were found in the proportion of women reporting three or more health problems by method of birth. Compared with women who had a spontaneous vaginal birth, women who had a cesarean section were more likely to report extreme tiredness at 6 months postpartum (adjusted OR: 1.39; 95% CI: 1.07-1.82) and at 12 months postpartum (adjusted OR: 1.40; 95% CI: 1.05-1.85), and were more likely to report back pain at 6 months postpartum (adjusted OR: 1.37; 95% CI: 1.06-1.77) and at 12 months postpartum (adjusted OR: 1.41; 95% CI: 1.06-1.87). Women who had a cesarean section were less likely to report urinary incontinence at 3, 6, and 12 months postpartum, respectively (adjusted OR: 0.26; 95% CI: 0.19-0.36; adjusted OR: 0.36; 95% CI: 0.25-0.52; adjusted OR: 0.48; 95% CI: 0.33-0.68). For all other physical health problems the pattern of morbidity did not differ between cesarean section and spontaneous vaginal birth.

CONCLUSIONS

Physical health problems commonly persist or recur throughout the first 18 months postpartum, with potential long-term consequences for women's health. Cesarean section does not result in women experiencing less overall morbidity in the postpartum period compared with women who have a spontaneous vaginal birth.

Development of a prenatal psychosocial screening tool for post-partum depression and anxiety

BACKGROUND

Post-partum depression (PPD) is the most common complication of pregnancy in developed countries, affecting 10-15% of new mothers. There has been a shift in thinking less in terms of PPD per se to a broader consideration of poor mental health, including anxiety after giving birth. Some risk factors for poor mental health in the post-partum period can be identified prenatally; however prenatal screening tools developed to date have had poor sensitivity and specificity. The objective of this study was to develop a screening tool that identifies women at risk of distress, operationalized by elevated symptoms of depression and anxiety in the post-partum period using information collected in the prenatal period.

METHODS

Using data from the All Our Babies Study, a prospective cohort study of pregnant women living in Calgary, Alberta (N = 1578), we developed an integer score-based prediction rule for the prevalence of PPD, as defined as scoring 10 or higher on the Edinburgh Postnatal Depression Scale (EPDS) at 4-months postpartum.

RESULTS

The best fit model included known risk factors for PPD: depression and stress in late pregnancy, history of abuse, and poor relationship quality with partner. Comparison of the screening tool with the EPDS in late pregnancy showed that our tool had significantly better performance for sensitivity. Further validation of our tool was seen in its utility for identifying elevated symptoms of postpartum anxiety.

CONCLUSION

This research heeds the call for further development and validation work using psychosocial factors identified prenatally for identifying poor mental health in the post-partum period.

Life course pathways to prenatal maternal stress

OBJECTIVE

To evaluate the impact of childhood stressors, recalled childhood stress, and stressors in adulthood on perceived stress in pregnancy.

DESIGN

Prospective cohort study.

SETTING

Pregnant women were recruited from pre-birth clinics in two communities.

PARTICIPANTS

Four-hundred and twenty-one pregnant women.

RESULTS

Perceived prenatal maternal stress was the main outcome measure. Recalled childhood stress was positively associated with prenatal stress (β = .54) after adjusting for other child and adult factors. Low family cohesion during childhood was indirectly associated with prenatal stress through its effects on recalled childhood stress, current family cohesion, and current subjective socioeconomic position (SEP). Low levels of adult subjective SEP (β = -.44) and family cohesion (β = -.25) were directly associated with prenatal stress. Perceived social support during childhood was indirectly associated with prenatal stress through its effect on recalled childhood stress and perceived social support in adulthood. Childhood subjective SEP indirectly influenced prenatal stress through its effect on adult subjective SEP and recalled childhood stress.

CONCLUSIONS

Prenatal stress is a result of the interplay between factors from childhood and adulthood. The study findings can be used to inform psychosocial risk assessment and interventions across the lifespan to decrease prenatal stress and its adverse outcomes.

Easing maternal anxiety: an update

Maternal mental health is an important public health issue because of its effects not only on the mother's well-being and functional status, but also her relationship with her partner and the development of her children. There is accumulating evidence of the adverse sequelae of maternal anxiety on fetal development, obstetrical complications, pregnancy outcomes such as low birth weight, and subsequent child development. Evaluation of maternal anxiety and intervention to reduce these symptoms, may ensure optimal developmental outcomes, particularly in high-risk infants such as those born at very low birth weights. This article will outline recent advances in our understanding of the etiology, assessment and impact of maternal anxiety, and describe intervention strategies to promote maternal well-being.

Screening for depression and help-seeking in postpartum women during well-baby pediatric visits: an integrated review

PURPOSE

The purposes of this integrated review are to examine the literature on screening for depression and help-seeking behaviors by postpartum women during pediatric well-baby visits; to identify gaps in the literature relating to depression and help-seeking behaviors; and to discuss implications for practice and future research.

METHOD

An extensive search of primary source documents was conducted in Academic Search Premier, CINAHL, MEDLINE, Mental Measurements Yearbook, PsycINFO, PsycARTICLES, and Women's Studies International using the key words postpartum, postpartum depression (PPD), help seeking, and pediatric setting or pediatrician. Thirty-five articles relevant to help seeking, PPD, and screening in the pediatric setting were included in this review. Research studies included both quantitative and qualitative articles.

RESULTS

PPD affects 10% to 15% of all women after birth. Postpartum women generally do not seek help for depression. Untreated PPD has significant adverse affects on parenting, maternal bonding, and the infant's emotional and behavioral development. Interaction with the woman's obstetric provider ends shortly after the baby's birth. However, interactions with the pediatric office are initiated and continue throughout the infant's first two years of life.

DISCUSSION

Early recognition of PPD and appropriate treatment are imperative for positive maternal-infant outcomes. A majority of women do not seek help for depression from any source. Because mothers have routine interactions with pediatric office staff during the first few years after giving birth, pediatric nurse practitioners and pediatricians have the perfect opportunity to screen and educate women regarding symptoms, treatment, and available resources for PPD.

Detection and management of mood disorders in the maternity setting: the Australian Clinical Practice Guidelines

BACKGROUND

Mood disorders arising in the perinatal period (conception to the first postnatal year), occur in up to 13% of women. The adverse impact of mood disorders on mother, infant and family with potential long-term consequences are well documented. There is a need for clear, evidence-based, guidelines for midwives and other maternity care providers.

AIM

To describe the process undertaken to develop the Australian Clinical Practice Guidelines for Depression and Related Disorders in the Perinatal Period and to highlight the key recommendations and their implications for the maternity sector.

METHOD

Using NHMRC criteria, a rigorous systematic literature review was undertaken synthesising the evidence used to formulate graded guideline recommendations. Where there was insufficient evidence for recommendations, Good Practice Points were formulated. These are based on lower quality evidence and/or expert consensus.

FINDINGS

The quality of the evidence was good in regards to the use of the Edinburgh Postnatal Depression Scale and psychological interventions, but limited as regards medication use and safety perinatally. Recommendations were made for staff training in psychosocial assessment; universal screening for depression across the perinatal period; and the use of evidence based psychological interventions for mild to moderate depression postnatally. Good Practice Points addressed the use of comprehensive psychosocial assessment--including risk to mother and infant, and consideration of the mother-infant interaction--and gave advice around the use and safety of psychotropic medications in pregnancy and breastfeeding. In contrast to their international counterparts, the Australian guidelines emphasize a more holistic, woman and family centred approach to the management of mental health and mood disorders in the perinatal setting.

CONCLUSION

The development of these Guidelines is a first step in translating evidence into practice and providing Australian midwives and other maternity care providers with clear guidance on the psychosocial management of women and families.

Reducing postnatal depression, anxiety and stress using an infant sleep intervention

OBJECTIVE

To examine the psychological well-being of mothers following participation in a behavioural modification programme previously shown to improve infant sleep.

DESIGN, SETTING AND PARTICIPANTS

A 45 min consultation with either a general practitioner (GP) or trained nurse providing verbal and written information describing sleep physiology in infants and strategies to improve infant sleep. Eighty mothers of infants 6-12 months of age with established infant sleep problems at a single general practice, Adelaide, South Australia.

MAIN OUTCOME MEASURES

The Depression Anxiety Stress Scale 21 (DASS21) immediately prior to the first consultation and again at follow-up approximately 3 weeks later. The number of infant nocturnal awakenings requiring parental support was also reported by mothers on both occasions.

RESULTS

All measures of maternal well-being and infant nocturnal awakenings improved significantly. The mean number of maximum nocturnal awakenings decreased from 5.0 to 0.5 (mean difference 4.4, 95% CI 3.4 to 5.5). All measures of DASS21 improved significantly. The mean total DASS21 decreased from 29.1 to 14.9 (mean decrease 14.2, 95% CI 10.2 to 18.2); mean depression decreased from 7.9 to 2.8 (mean difference 5.2, 95% CI 3.7 to 6.7); mean anxiety decreased from 4.6 to 2.6 (mean difference 2.0, 95% CI 0.7 to 3.2); mean stress decreased from 16.6 to 9.5 (mean difference 7.0, 95% CI 5.1 to 9.0). The proportion of mothers assessed as having any degree of depression decreased by 85% from 26/80 (32.5%) to 4/80 (5%).

CONCLUSIONS

The number of nocturnal awakenings requiring parental support among infants aged 6-12 months significantly decreased following a single consultation on infant sleep physiology and teaching behavioural strategies to improve sleep. Significant improvements in maternal stress, anxiety and depression were also observed.

Parents' dietary patterns are significantly correlated: findings from the Melbourne Infant Feeding Activity and Nutrition Trial Program

The objectives of the present study were to identify dietary patterns independently in first-time mothers and fathers, and to examine whether these patterns were correlated within families. Dietary intakes were collected at baseline in the Melbourne Infant Feeding Activity and Nutrition Trial Program using a validated FFQ in 454 pairs of first-time mothers and fathers. Education level was reported in associated questionnaires. Principal components analyses included frequencies of fifty-five food groups and were performed independently in mothers and fathers. Spearman's correlation coefficients were used to assess associations between dietary pattern scores. A total of four dietary patterns were identified in mothers and fathers. Of these, three dietary patterns had similar characteristics between these two populations, namely ‘Fruits and vegetables’, ‘High-energy snack and processed foods’, ‘High-fat foods’ in mothers; and ‘Fruits’, ‘High-energy snack and processed foods’, ‘High-fat foods’ in fathers. The following two additional patterns were identified: ‘Cereals and sweet foods’ in mothers and ‘Potatoes and vegetables’ in fathers. Patterns incorporating healthier food items were found to be positively associated with parent education. An inverse association with education was found for the ‘High-fat foods’ and ‘High-energy snack and processed foods’ dietary patterns. Qualitatively similar patterns between corresponding mothers and fathers were the most strongly correlated (ρ = 0·34–0·45, P < 0·001). There were some differences in dietary patterns between mothers and fathers, suggesting that it is worth deriving patterns separately when considering couples, and more generally between men and women. Exploring how these various patterns correlate within households provides important insights to guide the development and implementation of family-based interventions.

Anxiety measures validated in perinatal populations: a systematic review

BACKGROUND

Research and screening of anxiety in the perinatal period is hampered by a lack of psychometric data on self-report anxiety measures used in perinatal populations. This paper aimed to review self-report measures that have been validated with perinatal women.

METHODS

A systematic search was carried out of four electronic databases. Additional papers were obtained through searching identified articles. Thirty studies were identified that reported validation of an anxiety measure with perinatal women.

RESULTS

Most commonly validated self-report measures were the General Health Questionnaire (GHQ), State-Trait Anxiety Inventory (STAI), and Hospital Anxiety and Depression Scales (HADS). Of the 30 studies included, 11 used a clinical interview to provide criterion validity. Remaining studies reported one or more other forms of validity (factorial, discriminant, concurrent and predictive) or reliability. The STAI shows criterion, discriminant and predictive validity and may be most useful for research purposes as a specific measure of anxiety. The Kessler 10 (K-10) may be the best short screening measure due to its ability to differentiate anxiety disorders. The Depression Anxiety Stress Scales 21 (DASS-21) measures multiple types of distress, shows appropriate content, and remains to be validated against clinical interview in perinatal populations.

LIMITATIONS

Nineteen studies did not report sensitivity or specificity data. The early stages of research into perinatal anxiety, the multitude of measures in use, and methodological differences restrict comparison of measures across studies.

CONCLUSION

There is a need for further validation of self-report measures of anxiety in the perinatal period to enable accurate screening and detection of anxiety symptoms and disorders.

Long-term outcomes of participants in a perinatal depression early detection program

BACKGROUND

Long-term follow-up studies are required to better understand the extent of the effectiveness of early detection programs for perinatal depression. We followed up participants in such a program to investigate the long-term depression, treatment and relationship outcomes of mothers originally identified as 'probably depressed' (screened positive).

METHODS

At 2 years postpartum all participants who had 'screened positive' (N=159) and a random sample of participants who had 'screened negative' were invited to participate in a mailed survey. Measures included: current mood; coping; access to treatment; quality of partner relationship; and mother-infant bonding.

RESULTS

Mothers originally detected as probably depressed (n=98) fared significantly worse than 'screened negative' mothers (n=101) both in terms of their higher mean depression scores (EPDS: Ms=11.0 vs. 6.4) and greater proportions categorised as probably depressed at 2 years postpartum (40% vs. 11% respectively, p<.001, phi=.33). Elevated depression symptoms at 2 years postpartum were associated with poorer partner relationships and mother-infant bonding. Moreover, there appears to be a double dose effect for women who screen positive on two occasions. Thirty-seven percent of depressed mothers did not take up treatment, frequently citing a preference for using their own resources.

LIMITATIONS

Limitations include the use of self-report measures to assess depression symptoms and mother-infant bonding. Treatment data was collected retrospectively.

CONCLUSIONS

Despite being offered treatment options, a substantial proportion of women who screened positive had poor long-term mental health and relationship outcomes. This paper discusses some of the implications for perinatal early detection and treatment programs.