The antenatal risk questionnaire (ANRQ): acceptability and use for psychosocial risk assessment in the maternity setting

Screening for depression with the Edinburgh Postnatal Depression Scale and finding borderline personality disorder

OBJECTIVE

The aim of the study was to explore the range of psychiatric diagnoses seen in pregnant women who score above the 'cut-off' on the Edinburgh Postnatal Depression Scale when this is used as a routine screening instrument in the antenatal period.

METHOD

Subjects were all pregnant women referred to and seen by the Perinatal Consultation-Liaison Psychiatry Team of a tertiary public hospital over a 14-month period. Edinburgh Postnatal Depression Scale score at maternity 'booking-in' visit, demographic and clinical data were recorded and diagnoses were made according to Diagnostic and Statistical Manual of Mental Disorders (5th ed.) criteria following clinical interview(s) and review of documented past history. Data were analysed using descriptive statistics.

RESULTS

A total of 200 patients who had completed the Edinburgh Postnatal Depression Scale were seen for assessment; 86 (43%) scored ⩾13 on Edinburgh Postnatal Depression Scale. Of those scoring 13 or more on Edinburgh Postnatal Depression Scale, 22 (25.6%) had a depressive disorder. In total, 12 patients (14%) had an anxiety disorder, 14 (16.3%) had borderline personality disorder and 13 (15.1%) had a substance use disorder. An additional 23 women (26.7%) had two or more borderline personality traits.

CONCLUSION

Psychiatric assessment of women who scored 13 or more on the Edinburgh Postnatal Depression Scale at routine antenatal screening identified a significant number with borderline personality disorder or borderline personality traits rather than depressive or anxiety disorders. Clinical Practice Guidelines note the importance of further assessment for all women who score 13 or more on the Edinburgh Postnatal Depression Scale. The findings here suggest that this assessment should be made by a clinician able to identify personality pathology and organise appropriate and timely interventions.

Cognitive correlates of women's postpartum depression risk and symptoms: the contribution of dysfunctional beliefs and negative thoughts

Background: Despite the extensive research on interpersonal and clinical risk factors for postpartum depression (PPD), there is a paucity of research on the potential role of cognitive variables (dysfunctional beliefs and negative thoughts) as correlates of PPD symptoms.Aims: This exploratory study aimed to understand the cognitive processes of women at a higher risk (i.e. presenting well-established interpersonal and clinical risk factors) for PPD by: (a) comparing women's dysfunctional motherhood-related beliefs and frequency of automatic thoughts, as a function of their levels of PPD risk and symptoms; (b) examining the cognitive correlates of PPD symptoms, controlling for the presence of well-established risk factors.Method: A cross-sectional internet survey comprising 441 postpartum women was conducted.Results: Women presenting high-risk for PPD showed more dysfunctional motherhood-related attitudes (p < 0.001), more frequent negative thoughts (p < 0.001) and less frequent positive thoughts (p < 0.001) than low-risk women. More dysfunctional beliefs related to maternal responsibility, more frequent negative thoughts related with personal maladjustment and with the metacognitive appraisal of the thoughts' content, and less frequent positive thoughts were found to be significantly associated with PPD symptoms.Conclusion: The inclusion of cognitive variables in risk assessment and preventive efforts for PPD may hold potential to increase its clinical efficacy.

Parenting after a history of childhood maltreatment: A scoping review and map of evidence in the perinatal period

Background and aims

Child maltreatment is a global health priority affecting up to half of all children worldwide, with profound and ongoing impacts on physical, social and emotional wellbeing. The perinatal period (pregnancy to two years postpartum) is critical for parents with a history of childhood maltreatment. Parents may experience ‘triggering’ of trauma responses during perinatal care or caring for their distressed infant. The long-lasting relational effects may impede the capacity of parents to nurture their children and lead to intergenerational cycles of trauma. Conversely, the perinatal period offers a unique life-course opportunity for parental healing and prevention of child maltreatment. This scoping review aims to map perinatal evidence regarding theories, intergenerational pathways, parents’ views, interventions and measurement tools involving parents with a history of maltreatment in their own childhoods.

Methods and results

We searched Medline, Psychinfo, Cinahl and Embase to 30/11/2016. We screened 6701 articles and included 55 studies (74 articles) involving more than 20,000 parents. Most studies were conducted in the United States (42/55) and involved mothers only (43/55). Theoretical constructs include: attachment, social learning, relational-developmental systems, family-systems and anger theories; ‘hidden trauma’, resilience, post-traumatic growth; and ‘Child Sexual Assault Healing’ and socioecological models. Observational studies illustrate sociodemographic and mental health protective and risk factors that mediate/moderate intergenerational pathways to parental and child wellbeing. Qualitative studies provide rich descriptions of parental experiences and views about healing strategies and support. We found no specific perinatal interventions for parents with childhood maltreatment histories. However, several parenting interventions included elements which address parental history, and these reported positive effects on parent wellbeing. We found twenty-two assessment tools for identifying parental childhood maltreatment history or impact.

Conclusions

Perinatal evidence is available to inform development of strategies to support parents with a history of child maltreatment. However, there is a paucity of applied evidence and evidence involving fathers and Indigenous parents.

Maternal Attachment Style, Interpersonal Trauma History, and Childbirth-Related Post-traumatic Stress

Childbirth-related post-traumatic stress has potentially negative and enduring consequences for the well-being of women and their families. Although research to date has identified attachment style and trauma history as individual risk factors, they have yet to be examined as integrative processes in the development and maintenance of childbirth-related post-traumatic stress. The current investigation aimed to examine whether attachment style may moderate the impact of a history of interpersonal trauma on initial levels and the rate of change in post-traumatic stress symptomatology across the first 6 months of the postpartum period. A large community sample of women were recruited from two Canadian urban hospitals. Childbirth-related post-traumatic stress symptoms were assessed longitudinally at 5 weeks, 2 months, and 6 months postpartum. Latent growth curve modeling (n = 251) revealed that attachment style moderated the impact of a history of interpersonal trauma on initial levels and the rate of change in post-traumatic stress symptomatology, while controlling for other well-established psychosocial (e.g., trait anxiety, previous psychopathology, lack of perceived support) and childbirth-related (e.g., mode of birth, labor pain, subjective experience) risk factors. More secure attachment conferred resiliency and more fearful attachment conferred vulnerability among women without a history of interpersonal trauma, while more preoccupied and more dismissing attachment conferred resiliency among women with a history of interpersonal trauma. These findings highlight the importance of understanding the integrative processes among risk and protective factors underlying the development of and ability to cope with childbirth-related post-traumatic stress. Attachment style and trauma history, which can be quickly measured, should be considered as targets in antenatal screening.

Use of the Antenatal Risk Questionnaire to Assess Psychosocial Risk Factors Associated with Risk for Postpartum Depression: A Pilot Study

INTRODUCTION

Postpartum depression is the most common complication of childbirth. The purpose of this pilot study was to examine use of the Antenatal Risk Questionnaire (ANRQ) to assess psychosocial risk factors associated with increased risk for the development of symptoms of postpartum depression.

METHODS

This study was a prospective investigation of women during the third trimester of pregnancy. Women were recruited from a high-volume collaborative obstetric and midwifery practice in a large academic tertiary-care hospital. Participants were enrolled during their third trimesters of pregnancy and studied through 6 weeks postpartum. Surveys were completed for psychosocial risk (ANRQ), perceived stress, and symptoms of depression. Bivariate analysis was conducted and multiple regression analysis was performed to examine the effects of the predictor variables on the outcome variable, symptoms of depression at 6 weeks postpartum.

RESULTS

Thirty-five women participated in the study. Prenatal ANRQ scores, Perceived Stress Scale (PSS) scores, and Edinburgh Postnatal Depression Scale (EPDS) scores were significantly correlated with EPDS scores at 6 weeks postpartum. In the multiple regression analysis, the prenatal ANRQ score was a significant predictor of the postpartum EPDS score, whereas the prenatal PSS and EPDS scores were not significant. This regression model explained 57% of the variance in symptoms of depression at 6 weeks postpartum.

DISCUSSION

Key past and present psychosocial risk factors experienced by women (measured by the prenatal ANRQ) were a significant predictor of postpartum depressive symptoms. In light of our results, use of the ANRQ in clinical practice warrants further exploration.

Postnatal psychosocial assessment and clinical decision-making, a descriptive study

AIMS AND OBJECTIVES

To describe experienced child and family health nurses' clinical decision-making during a postnatal psychosocial assessment.

BACKGROUND

Maternal emotional well-being in the postnatal year optimises parenting and promotes infant development. Psychosocial assessment potentially enables early intervention and reduces the risk of a mental disorder occurring during this time of change. Assessment accuracy and the interventions used are determined by the standard of nursing decision-making.

DESIGN

A qualitative methodology was employed to explore decision-making behaviour when conducting a postnatal psychosocial assessment.

METHODS

This study was conducted in an Australian early parenting organisation. Twelve experienced child and family health nurses were interviewed. A detailed description of a postnatal psychosocial assessment process was obtained using a critical incident technique. Template analysis was used to determine the information domains the nurses accessed, and content analysis was used to determine the nurses' thinking strategies, to make clinical decisions from this assessment.

RESULTS

The nurses described 24 domains of information and used 17 thinking strategies, in a variety of combinations. The four information domains most commonly used were parenting, assessment tools, women-determined issues and sleep. The seven thinking strategies most commonly used were searching for information, forming relationships between the information, recognising a pattern, drawing a conclusion, setting priorities, providing explanations for the information and judging the value of the information.

CONCLUSION

The variety and complexity of the clinical decision-making involved in postnatal psychosocial assessment confirm that the nurses use information appropriately and within their scope of nursing practice. The standard of clinical decision-making determines the results of the assessment and the optimal access to care.

RELEVANCE TO CLINICAL PRACTICE

Knowledge of the information domains and the decision-making strategies that experienced nurses use for psychosocial assessment potentially improves practice by providing a framework for education and mentoring.

Physical health, breastfeeding problems and maternal mood in the early postpartum: a prospective cohort study

This study aimed to investigate prospectively the contribution of maternal physical health and/or breastfeeding problems to maternal mood (depression, anxiety, fatigue, irritability, confusion, vigor) at 8-weeks postpartum. A prospective study was conducted. Participants were recruited antenatally from a public and a private maternity hospital in Melbourne, Australia. Nulliparous pregnant women (N = 229), ≥ 18 years of age, ≥ 36-week gestation, singleton pregnancy and with sufficient English were eligible. Data were collected by self-report questionnaire (pregnancy, weeks 1-4 postpartum) and telephone interview (week 8 postpartum). A high burden of physical problems was classified as ≥ 3 problems (caesarean/perineal pain; back pain; constipation; haemorrhoids; urinary and bowel incontinence) for ≥ 2 time points. A high burden of breastfeeding problems was having ≥ 2 problems (mastitis; nipple pain; frequent expressing; over- or under-supply of milk) for ≥ 2 time points. Multivariate linear regression was used to investigate the relationship between maternal mood, assessed using Profile of Mood States (8-week postpartum), and a high burden of breastfeeding and/or physical health problems. Forty-six women (20.1%) had a high burden of physical symptoms, 44 (19.2%) a high burden of breastfeeding problems only and 25 women (11.0%) had both. A high burden of breastfeeding problems alone (β = 10.6, p = 0.01) or with co-morbid physical problems (β = 15.35, p = 0.002) was significantly associated with poorer maternal mood at 8 weeks. Early, effective postnatal treatment of maternal health and breastfeeding problems could reduce women's risk for poor mental health.

The Health-e Babies App for antenatal education: Feasibility for socially disadvantaged women

Background

The use of mobile technology such as phone applications (apps) has been proposed as an efficient means of providing health and clinical information in a variety of healthcare settings. We developed the Health-e Babies app as an Android smart phone application for pregnant women attending a tertiary hospital in a low socio-economic community, with the objective of providing health information about early pregnancy that would increase maternal confidence and reduce anxiety. Based on our earlier research, this form of health communication was viewed as a preferred source of information for women of reproductive age. However, the pilot study had a poor participation rate with 76% (n = 94) not completing the study requirements. These initial findings raised some very important issues in relation to the difficulties of engaging women with a pregnancy app. This paper analyses the characteristics of the participants who did not complete the study requirements in an attempt to identify potential barriers associated with the implementation of a pregnancy app.

Methods

This retrospective review of quantitative and qualitative data collected at the commencement of the Health-e Babies App trial, related to the participant’s communication technology use, confidence in knowing where to seek help and mental health status, maternal-fetal attachment and parenting confidence. Engagement and use of the Health-e Babies App was measured by the completion of a questionnaire about the app and downloaded data from participant’s phones. Mental health status, confidence and self-efficacy were measured by questionnaires.

Results

All women were similar in terms of age, race, marital status and level of education. Of the 94 women (76%) who did not complete the trial, they were significantly more anxious as indicated by State Trait Anxiety Inventory (p = 0.001 Student T-test) and more likely to be unemployed (50% vs 31%, p = 0.012 Student T-Test).

Conclusion

This study provides important information about the challenges associated with the implementation of a pregnancy app in a socially disadvantaged community. The data suggests that factors including social and mental health issues, financial constraints and technological ability can affect women’s engagement with a mobile phone app.

An evaluation of routine antenatal depression screening and psychosocial assessment in a regional private maternity setting in Australia

BACKGROUND

There is limited information relating to routine depression screening and psychosocial assessment programs in private maternity settings in Australia.

AIMS

To describe the psychosocial profile of a sample of private maternity patients who participated in a depression screening and psychosocial risk assessment program as part of routine antenatal care, and to explore women's experience of receiving this component of pregnancy care.

MATERIALS AND METHODS

We conducted a retrospective medical records audit of 455 consecutive women having a routine psychosocial assessment and referral. Assessment was undertaken using the Edinburgh Postnatal Depression Scale (EPDS) and the Antenatal Risk Questionnaire (ANRQ) for psychosocial risk; 101 women completed a feedback survey about their experience of receiving routine psychosocial care.

RESULTS

Of the 87.7% of women who completed both EPDS and ANRQ, 4.3% scored 13 or more on the EPDS. On the ANRQ, 25.3% of women endorsed one risk factor, 11.6% two risk factors and 10.5% three or more risk factors. Elevated EPDS scores were associated with major stresses in the last 12 months, high trait anxiety and significant past mental health issue/s. Acceptability of depression screening and psychosocial risk assessment was high.

CONCLUSIONS

This study highlights the need for, and acceptability of, depression and psychosocial assessment in the private maternity sector. These findings are particularly timely given the provision of new Medicare Benefits Scheme items for obstetricians to undertake psychosocial assessment (both antenatally and postnally) in line with recommended clinical best practice.

Trajectories of anxiety and health related quality of life during pregnancy

Anxiety and health related Quality of Life (HRQoL) have emerged as important mental health measures in obstetric care. Few studies have systematically examined the longitudinal trajectories of anxiety and HRQoL in pregnancy. Using a linear growth modeling strategy, we analyzed the course of State-Trait Anxiety Inventory (STAI)- and Short Form (36) Health Survey (SF-36) scores between the 12th and the 36th week of gestation, in a sample of 355 women. We additionally analyzed the impact of depressive symptoms and a chronic medical condition (asthma), on STAI and SF-36 trajectory curves. STAI scores remained stable throughout pregnancy. A previous history of anxiety increased the overall STAI scores. Asthma and depressive symptoms scores had no impact on the STAI trajectory. Physical SF-36 scores decreased over the course of pregnancy, whereas mental SF-36 trended towards improvement. Asthma reduced physical SF-36 overall. While high depressive symptoms decreased the overall mental SF-36, they were also significantly associated with mental SF-36 improvements over time. Anxiety symptoms are stable during pregnancy and are not modulated by depressive symptoms or asthma. Physical HRQoL declines in pregnancy. In contrast, mental HRQoL appears to improve, particularly in women with high initial levels of depressive symptoms.

Study protocol for a comparative effectiveness trial of two models of perinatal integrated psychosocial assessment: the PIPA project

BACKGROUND

Studies examining psychosocial and depression assessment programs in maternity settings have not adequately considered the context in which psychosocial assessment occurs or how broader components of integrated care, including clinician decision-making aids, may optimise program delivery and its cost-effectiveness. There is also limited evidence relating to the diagnostic accuracy of symptom-based screening measures used in this context. The Perinatal Integrated Psychosocial Assessment (PIPA) Project was developed to address these knowledge gaps. The primary aims of the PIPA Project are to examine the clinical- and cost-effectiveness of two alternative models of integrated psychosocial care during pregnancy: 'care as usual' (the SAFE START model) and an alternative model (the PIPA model). The acceptability and perceived benefit of each model of care from the perspective of both pregnant women and their healthcare providers will also be assessed. Our secondary aim is to examine the psychometric properties of a number of symptom-based screening tools for depression and anxiety when used in pregnancy.

METHODS

This is a comparative-effectiveness study comparing 'care as usual' to an alternative model sequentially over two 12-month periods. Data will be collected from women at Time 1 (initial antenatal psychosocial assessment), Time 2 (2-weeks after Time 1) and from clinicians at Time 3 for each condition. Primary aims will be evaluated using a between-groups design, and the secondary aim using a within group design.

DISCUSSION

The PIPA Project will provide evidence relating to the clinical- and cost- effectiveness of psychosocial assessment integrated with electronic clinician decision making prompts, and referral options that are tailored to the woman's psychosocial risk, in the maternity care setting. It will also address research recommendations from the Australian (2011) and NICE (2015) Clinical Practice Guidelines.

TRIAL REGISTRATION

ACTRN12617000932369.

Postpartum midwifery care and familial psychosocial risk factors in Switzerland: A secondary data analysis / Hebammenbetreuung im Wochenbett und familiäre psychosoziale Risikofaktoren in der Schweiz: eine Sekundäranalyse

Introduction

Psychosocial resources of parents are vital for the health and development of their children. Families in stressful circumstances should receive early seamless care to strengthen their parental resources. Independent midwives provide ambulant postpartum care in most families in Switzerland, and hence could play an important role in the early assessment and care of families at risk.

Methods

Comprehensive routine data of Swiss independent midwives were used for secondary analysis. Frequencies of known psychosocial risk factors were derived and compared to other data sources. Group comparisons were made with respect to family characteristics and midwifery care.

Results

Only some of the considered risk factors are representable in the midwives‘ data. 18.6% of all families have one and 6.25% have multiple such representable risk factors. Immigrant mothers from developing and emerging countries, very young or older mothers and large families are thereby particularly often affected. Burdened families receive more home visits, but have a later onset of ambulant postpartum care. They suffer more often from breast-feeding problems and are more frequently referred to other disciplines.

Discussion

Independent midwives in Switzerland document some of the known psychosocial risk factors and adapt their care in routine practice. The collection of data with a better coverage of the known psychosocial risk factors, ideally using validated assessment instruments, is recommended, and further research is required for a more in-depth understanding of the current interdisciplinary collaboration and the needs of families and care providers.

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).

The prevalence of symptoms of depression and anxiety, and the level of life stress and worry in New Zealand Māori and non-Māori women in late pregnancy

OBJECTIVE

To describe the prevalence of symptoms of depression and anxiety, and the level of life stress and worry in late pregnancy for Māori and non-Māori women.

METHODS

In late pregnancy, women completed a questionnaire recording their prior history of mood disorders; self-reported current depressive symptoms (⩾13 on the Edinburgh Postnatal Depression Scale), current anxiety symptoms (⩾6 on the anxiety items from the Edinburgh Postnatal Depression Scale), significant life stress (⩾2 items on life stress scale) and dysfunctional worry (>12 on the Brief Measure of Worry Scale).

RESULTS

Data were obtained from 406 Māori women (mean age = 27.6 years, standard deviation=6.3 years) and 738 non-Māori women (mean age = 31.6 years, standard deviation=5.3 years). Depressive symptoms (22% vs 15%), anxiety symptoms (25% vs 20%), significant life stress (55% vs 30%) and a period of poor mood during the current pregnancy (18% vs 14%) were more prevalent for Māori than non-Maori women. Less than 50% of women who had experienced ⩾2 weeks of poor mood during the current pregnancy had sought help. Being young was an independent risk factor for depressive symptoms, significant life stress and dysfunctional worry. A prior history of depression was also consistently associated with a greater risk of negative affect in pregnancy.

CONCLUSION

Antenatal mental health requires at least as much attention and resourcing as mental health in the postpartum period. Services need to specifically target Māori women, young women and women with a prior history of depression.

Impact of a history of maternal depression and anxiety on asthma control during pregnancy

OBJECTIVE

To determine the impact of self-reported maternal depression/anxiety on asthma control during pregnancy.

METHOD

Pregnant women with a doctor diagnosis of asthma (n = 189) were prospectively recruited at their antenatal booking visit, and the presence of maternal depression and anxiety was identified using self-report and routine questionnaire assessments. Data on exacerbations and asthma control were collected during gestation. Asthma control was assessed using the Juniper Asthma Control Questionnaire (ACQ) and women were classified as having recurrent uncontrolled asthma if their ACQ score was >1.5 during two or more consecutive study visits. Exacerbations were defined as events that led to increased treatment requirements, and doctor or hospital visits.

RESULTS

There were 85 women with self-reported depression/anxiety and 104 women without self-reported depression/anxiety. The presence of depression/anxiety was associated with an increased likelihood (adjusted hazard ratio (HR) 1.67: 95% confidence interval (CI) 1.03-2.72) and incidence (adjusted incidence rate ratio (IRR) 1.71: 95% CI 1.13-2.58) of uncontrolled asthma during pregnancy, as well as an increased risk of recurrent uncontrolled asthma during 2 or more study visits (adjusted relative risk (RR) 1.98: 95% CI 1.00-3.91). No impact of depression/anxiety was observed with respect to the likelihood (adjusted HR 0.70: 95% CI 0.35-1.41) or incidence of exacerbations during pregnancy (adjusted IRR 0.66: 95% CI 0.35-1.26).

CONCLUSIONS

This study provides evidence that the presence of maternal depression/anxiety is associated with an increased likelihood and incidence of uncontrolled asthma during pregnancy. Given the high prevalence of co-morbid depression/anxiety among asthmatics, further research investigating such associations is urgently required.

Delusional ideation during the perinatal period in a community sample

BACKGROUND

Despite the prevalence of mental health problems during the perinatal period, little research has examined psychotic symptoms in a community sample across pregnancy and the postpartum. Exposure to environmental risk factors, and immigration in particular, are associated with increased risk for psychotic disorders. The current investigation examined whether psychosocial risk and immigrant status would predict levels of delusional ideation across the perinatal period when controlling for depression, anxiety, and demographic factors.

METHODS

A community sample of 316 pregnant women was assessed at 12-14 and 32-34weeks gestation during routine clinic visits, and at 7-9weeks postpartum during a home visit. Measures included self-report ratings of psychosocial risk (e.g., history of mental health problems or abuse, stressful life events, lack of social support), pregnancy-related anxiety, depressive symptomatology, and delusional ideation.

RESULTS

There was less delusional ideation during the postpartum period than during early pregnancy. Across all time points, levels of delusional ideation were lower than in the general population. Analyses using multilevel modeling indicated significant fixed-effects for the variables time, age, partnership, being religious and prenatal anxiety, but not depressive symptomatology, on delusional ideation. Immigrant status moderated the effect of psychosocial risk such that greater psychosocial risk predicted more symptoms of delusional ideation among immigrants, but not non-immigrants.

CONCLUSION

Psychosocial risk factors place immigrant women at an increased likelihood for experiencing delusional ideation during the perinatal period.

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.

Responding to families with complex needs: a national survey of child and family health nurses

AIMS

The aim of this study was to explore the extent to which Australian child and family health nurses work with families with complex needs and how their practice responds to the needs of these families.

BACKGROUND

Many families with young children face challenges to their parenting capacity, potentially placing their children at risk of poorer developmental outcomes. Nurses increasingly work with families with mental health problems, trauma histories and/or substance dependence. Universal child health services must respond effectively to these challenges, to address health inequalities and to promote the best outcomes for all children and families.

DESIGN

The descriptive study used cross-sectional data from the first national survey of child and family health nurses in Australia, conducted during 2011.

METHODS

Survey data reported how often, where and how child and family health nurses worked with families with complex needs and their confidence in nursing tasks.

FINDINGS

Many, but not all, of the 679 respondents saw families with complex needs in their regular weekly caseload. Child and family health nurses with diverse and complex caseloads reported using varied approaches to support their clients. They often undertook additional professional development and leadership roles compared with nurses who reported less complex caseloads. Most respondents reported high levels of professional confidence.

CONCLUSION

For health services providing universal support and early intervention for families at risk, the findings underscore the importance of appropriate education, training and support for child and family health professionals. The findings can inform the organization and delivery of services for families in Australia and internationally.

Antenatal depression and adversity in urban South Africa

BACKGROUND

In low and middle-income countries (LMIC), common mental disorders affecting pregnant women receive low priority, despite their disabling effect on maternal functioning and negative impact on child health and development. We investigated the prevalence of risk factors for antenatal depression among women living in adversity in a low-resource, urban setting in Cape Town, South Africa.

METHODS

The MINI Neuropsychiatric Interview (MINI Plus) was used to measure the diagnostic prevalence of depression amongst women attending their first antenatal visit at a primary-level, community-based clinic. Demographic data were collected followed by administration of questionnaires to measure psychosocial risk. Analysis examined the association between diagnosis of depression and psychosocial risk variables, and logistic regression was used to investigate predictors for major depressive episode (MDE).

RESULTS

Among 376 women participating, the mean age was 26 years. The MINI-defined prevalence of MDE was 22%, with 50% of depressed women also expressing suicidality. MDE diagnosis was significantly associated with multiple socioeconomic and psychosocial risk factors, including a history of depression or anxiety, food insecurity, experience of threatening life events and perceived support from family.

LIMITATIONS

The use of self-report measures may have led to recall bias. Retrospective collection of clinical data limited our ability to examine some known risk factors for mental distress.

CONCLUSION

These findings confirm the high prevalence of MDE among pregnant women in LMIC settings. Rates of depression may be increased in settings where women are exposed to multiple risks. These risk factors should be considered when planning maternal mental health interventions.

Prenatal screening for psychosocial risks in a high risk-population in Peru using the KINDEX interview

BACKGROUND

Prenatal stress and other prenatal risk factors (e.g. intimate partner violence) have a negative impact on mother's health, fetal development as well as enduring adverse effects on the neuro-cognitive, behavioral and physical health of the child. Mothers of low socio-economic status and especially those living in crime-ridden areas are even more exposed to a host of risk factors. Societies of extreme violence, poverty and inequalities, often present difficulties to provide adequate mental health care to the most needed populations. The KINDEX, a brief standardized instrument that assesses 11 different risk factors was used by midwives to identify pregnant women at-risk, in a suburban area with one of the highest levels of domestic violence in Lima. The instrument was designed to be used by medical staff to identify high-risk child-bearing women and, based on the results, to refer them to the adequate psychological or social support providers. The aim of this study is to assess the feasibility of psychosocial screening using the KINDEX in a Latin American Country for the first time, and to explore the relationship of the KINDEX with thee major risk areas, maternal psychopathology, perceived stress and traumatic experiences.

METHODS

The study was conducted in cooperation with the gynecological department of a general hospital in a suburban area of Lima. Nine midwives conducted interviews using the KINDEX of ninety-five pregnant women attending the gynecological unit of the hospital. From these, forty pregnant women were re-interviewed by a clinical psychologist using established instruments in order to assess the feasibility of the prenatal assessment in public health settings and the relationship of the KINDEX with maternal perceived stress, psychopathology symptoms and trauma load during pregnancy.

RESULTS

We found high rates of risk factors in the examined pregnant women comparable with those found in the general population. Significant correlations were found between the KINDEX sum score and the three risks areas, stress, psychopathology and trauma load as assessed in the Clinical Expert interviews. The different risks assessed by the KINDEX are related to higher levels of stress, psychopathology and trauma load, depending on the risk.

CONCLUSIONS

The relationship between past adverse experience and current stressors with perceived maternal stress, psychopathology symptoms and traumatic experiences confirm the importance of prenatal assessment for psychosocial risks. The use of KINDEX by midwives providing obstetrical care to pregnant women in urban Peru is feasible and can be used to identify high-risk women and refer them to the adequate mental health or social services for necessary attention and support. Early interventions are essential to mitigating the adverse effects of maternal stress, trauma and psychopathology on the fetus and child.

Pregnant Women's Perceptions of Harms and Benefits of Mental Health Screening

Background

A widely held concern of screening is that its psychological harms may outweigh the benefits of early detection and treatment. This study describes pregnant women's perceptions of possible harms and benefits of mental health screening and factors associated with identifying screening as harmful or beneficial.

Methods

This study analyzed a subgroup of women who had undergone formal or informal mental health screening from our larger multi-site, cross-sectional study. Pregnant women >16 years of age who spoke/read English were recruited (May-December 2013) from prenatal classes and maternity clinics in Alberta, Canada. Descriptive statistics were generated to summarize harms and benefits of screening and multivariable logistic regression identified factors associated with reporting at least one harm or affirming screening as a positive experience (January-December 2014).

Results

Overall study participation rate was 92% (N = 460/500). Among women screened for mental health concerns (n = 238), 63% viewed screening as positive, 69% were glad to be asked, and 87% took it as evidence their provider cared about them. Only one woman identified screening as a negative experience. Of the 6 harms, none was endorsed by >7% of women, with embarrassment being most cited. Women who were very comfortable (vs somewhat/not comfortable) with screening were more likely to report it as a positive experience.

Limitations

Women were largely Caucasian, well-educated, partnered women; thus, findings may not be generalizable to women with socioeconomic risk.

Conclusions

Most women perceived prenatal mental health screening as having high benefit and low harm. These findings dispel popular concerns that mental health screening is psychologically harmful.

A systematic review on the acceptability of perinatal depression screening

BACKGROUND

Perinatal depression (PND) affects approximately 10-15% of women, worldwide. PND screening, using screening tools, has been undertaken by a broad range of healthcare professionals in different settings. Our objective was to explore the acceptability of PND screening and how acceptability was being assessed.

METHODS

A systematic literature review of studies that explored the acceptability of PND screening was carried out throughout MEDLINE, PsycINFO, PubMed, CINAHL, Embase, Maternity and Infant Care and Joanna Briggs Institute databases.

RESULTS

Twenty-eight out of twenty-nine publications reported PND screening to be acceptable to most participants. A wide range of terms, questions and statements was used to infer, assess or report on acceptability. There was no uniform, psychometrically tested tool used to measure acceptability across the studies.

LIMITATIONS

Broad inclusion criteria and methodological differences limited comparisons, but are overcome by the comprehensiveness of the data and the lack of uniformity across studies.

CONCLUSIONS

Even though PND screening appears acceptable, it is difficult to draw conclusions about PND screening acceptability as studies used different methods to infer, assess or report on acceptability. The lack of a uniform, psychometrically tested tool to measure acceptability is not unique to PND. Nonetheless, the majority of perinatal women and healthcare professionals reported positive attitudes towards PND screening using different tools in different settings, indicating that it may be the responsibility of all healthcare professionals who come into contact with perinatal women.

Preferences for Mental Health Screening Among Pregnant Women: A Cross-Sectional Study

INTRODUCTION

The process of mental health screening can influence disclosure, uptake of referral, and treatment; however, no studies have explored pregnant women's views of methods of mental health screening. The objectives of this study are to determine pregnant women's comfort and preferences regarding mental health screening.

METHODS

Pregnant women were recruited (May-December 2013) for this cross-sectional descriptive survey from prenatal classes and maternity clinics in Alberta, Canada, if they were aged >16 years and spoke/read English. Descriptive statistics summarized acceptability of screening, and multivariable logistic regression identified factors associated with women's comfort with screening methods. Analysis was conducted in January-December 2014.

RESULTS

The participation rate was 92% (N=460/500). Overall, 97.6% of women reported that they were very (74.8%) or somewhat (22.8%) comfortable with mental health screening in pregnancy. Women were most comfortable with completing paper- (>90%) and computer-based (>82%) screening in a clinic or at home, with fewest reporting comfort with telephone-based screening (62%). The majority of women were very/somewhat comfortable with provider-initiated (97.4%) versus self-initiated (68.7%) approaches. Women's ability to be honest with their provider about emotional health was most strongly associated with comfort with each method of screening.

CONCLUSIONS

The majority of pregnant women viewed prenatal mental health screening favorably and were comfortable with a variety of screening methods. These findings provide evidence of high acceptability of screening--a key criterion for implementation of universal screening--and suggest that providers can select from a variety of screening methods best suited for their clinical setting.

Psychobiobehavioral Model for Preterm Birth in Pregnant Women in Low- and Middle-Income Countries

Preterm birth (PTB) is a final common outcome resulting from many interrelated etiological pathways; of particular interest is antenatal psychosocial distress (i.e., stress, anxiety, and depression). In LMI countries, both exposure to severe life stressors and rate of PTB are on average greater when compared with high-income countries. In LMI countries women are exposed to some of the most extreme psychosocial stress worldwide (e.g., absolute poverty, limited social resources). High prevalence of antenatal stress and depression have been observed in some studies from LMI countries. We propose a psychosocial, biological, and behavioral model for investigating the complex multisystem interactions in stress responses leading to PTB and explain the basis of this approach. We discuss ethical considerations for a psychosocial, biological, and behavioral screening tool to predict PTB from a LMI country perspective.

Predictors of persistent maternal depression trajectories in early childhood: results from the EDEN mother-child cohort study in France

BACKGROUND

Maternal depression in the pre- and postpartum period may set women on a course of chronic depressive symptoms. Little is known about predictors of persistently elevated depressive symptoms in mothers from pregnancy onwards. The aims of this study are to determine maternal depression trajectories from pregnancy to the child's fifth birthday and identify associated risk factors.

METHOD

Mothers (N = 1807) from the EDEN mother-child birth cohort study based in France (2003-2011) were followed from 24-28 weeks of pregnancy to their child's fifth birthday. Maternal depression trajectories were determined with a semi-parametric group-based modelling strategy. Sociodemographic, psychosocial and psychiatric predictors were explored for their association with trajectory class membership.

RESULTS

Five trajectories of maternal symptoms of depression from pregnancy onwards were identified: no symptoms (60.2%); persistent intermediate-level depressive symptoms (25.2%); persistent high depressive symptoms (5.0%); high symptoms in pregnancy only (4.7%); high symptoms in the child's preschool period only (4.9%). Socio-demographic predictors associated with persistent depression were non-French origin; psychosocial predictors were childhood adversities, life events during pregnancy and work overinvestment; psychiatric predictors were previous mental health problems, psychological help, and high anxiety during pregnancy.

CONCLUSIONS

Persistent depression in mothers of young children is associated to several risk factors present prior to or during pregnancy, notably anxiety. These characteristics precede depression trajectories and offer a possible entry point to enhance mother's mental health and reduce its burden on children.

Identifying women who are afraid of giving birth: A comparison of the fear of birth scale with the WDEQ-A in a large Australian cohort

BACKGROUND

The WDEQ-A is the most widely used measure of childbirth fear in pregnant women; however there is increasing discussion in the literature that simpler, more culturally transferrable tools may offer a better solution to identifying fearful women in clinical practice.

AIM

To compare the two item Fear of Birth Scale (FOBS) with the 33 item WDEQ-A in a large cohort of Australian pregnant women.

METHOD

Self-report questionnaires during second trimester including Wijma Delivery Expectancy Questionnaire (WDEQ-A) and Fear of Birth Scale (FOBS). Correlation of FOBS and WDEQ-A was tested using Spearman's correlation coefficients. Receiver operating characteristic (ROC) curve assessed the sensitivity and specificity of possible cut-points on the FOBS against WDEQ-A cut-point of ≥85. Sensitivity, specificity, positive and negative predictive values were determined. Fearful and non-fearful women as classified by both instruments were compared for differences in demographic, psycho-social and obstetric characteristics.

RESULTS

1410 women participated. The correlation between the instruments was strong (Spearman's Rho = 0.66, p < 0.001). The area under the ROC was 0.89 indicating high sensitivity with a FOBS cut-point of 54. Sensitivity was 89%, specificity 79% and Youden index 0.68. Positive predictive value was 85% and negative predictive value 79%. Both instruments identified high fear as significantly associated with first time mothers, previous emergency caesarean and women with self-reported anxiety and/or depression. Additionally FOBS identified a significant association between fearful women and preference for caesarean.

CONCLUSION

This study supports the use of the FOBS in clinical practice to identify childbirth fear in pregnant women.

Attachment security and recent stressful life events predict oxytocin levels: a pilot study of pregnant women with high levels of cumulative psychosocial adversity

PURPOSE

Recent reports indicate that prenatal levels of the neuropeptide oxytocin (OT) are inversely related to depressive symptomatology and positively associated with more optimal interactive behaviors in mothers with high levels of cumulative psychosocial adversity (CPA). In the present pilot study, we aimed to identify factors associated with high versus low levels of OT in pregnant women with high levels of CPA. We hypothesized that insecurely attached women, and those who recently experienced stressful life events (SLE), would have lower levels of prenatal OT.

METHODS

Thirty pregnant women with mood and anxiety disorders and high levels of CPA were recruited from the perinatal mental health service of a general hospital. Participants completed self-report measures of psychosocial stress and adult attachment style, and blood was then drawn to assess OT.

RESULTS AND CONCLUSIONS

Lower OT levels were found among those who were insecurely attached, and among those who experienced SLE within the last year. In a multiple linear regression, both attachment security and SLE significantly contributed to a model of prenatal OT levels. These individual difference factors explained 38% of the variance in prenatal OT, which may in turn predict poorer maternal mental health and caregiving outcomes during the postpartum period.

Development and psychometric testing of the Chinese Postnatal Risk Factors Questionnaire (CPRFQ) for postpartum depression

This article describes the development and psychometric assessment of the Chinese Postnatal Risk Factors Questionnaire (CPRFQ). There were four phases in this process: (1) the items were generated using a literature review and a focus group, (2) content validity was evaluated by an expert panel, (3) a pilot study was conducted with 45 postpartum women to refine the scale, and (4) a convenience sample of 256 postpartum women in China was recruited to complete the questionnaire. Construct validity was established by exploratory factor analysis; a four-factor structure of the scale was accepted (social and family, personality and relationship, mother and infant, maternal feelings and 'doing the month'). These factors explained 47.46 % of the variance. Pearson's correlation coefficient was conducted to test convergent validity with the Edinburgh Postnatal Depression Scale (EPDS) (r = 0.54; p < 0.001). The Cronbach's alpha coefficient of the four subscales ranged from 0.58 to 0.71. The final 18-item version of the questionnaire is potentially a valuable tool for assessing postnatal risk factors in Chinese postpartum mothers.

Obstetric care providers are able to assess psychosocial risks, identify and refer high-risk pregnant women: validation of a short assessment tool - the KINDEX Greek version

Background

Prenatal assessment for psychosocial risk factors and prevention and intervention is scarce and, in most cases, nonexistent in obstetrical care. In this study we aimed to evaluate if the KINDEX, a short instrument developed in Germany, is a useful tool in the hands of non-trained medical staff, in order to identify and refer women in psychosocial risk to the adequate mental health and social services. We also examined the criterion-related concurrent validity of the tool through a validation interview carried out by an expert clinical psychologist. Our final objective was to achieve the cultural adaptation of the KINDEX Greek Version and to offer a valid tool for the psychosocial risk assessment to the obstetric care providers.

Methods

Two obstetricians and five midwives carried out 93 KINDEX interviews (duration 20 minutes) with pregnant women to assess psychosocial risk factors present during pregnancy. Afterwards they referred women who they identified having two or more psychosocial risk factors to the mental health attention unit of the hospital. During the validation procedure an expert clinical psychologist carried out diagnostic interviews with a randomized subsample of 50 pregnant women based on established diagnostic instruments for stress and psychopathology, like the PSS-14, ESI, PDS, HSCL-25.

Results

Significant correlations between the results obtained through the assessment using the KINDEX and the risk areas of stress, psychopathology and trauma load assessed in the validation interview demonstrate the criterion-related concurrent validity of the KINDEX. The referral accuracy of the medical staff is confirmed through comparisons between pregnant women who have and have not been referred to the mental health attention unit.

Conclusions

Prenatal screenings for psychosocial risks like the KINDEX are feasible in public health settings in Greece. In addition, validity was confirmed in high correlations between the KINDEX results and the results of the validation interviews. The KINDEX Greek version can be considered a valid tool, which can be used by non-trained medical staff providing obstetrical care to identify high-risk women and refer them to adequate mental health and social services. These kind of assessments are indispensable for the promotion of a healthy family environment and child development.

An integrated web-based mental health intervention of assessment-referral-care to reduce stress, anxiety, and depression in hospitalized pregnant women with medically high-risk pregnancies: a feasibility study protocol of hospital-based implementation

Background

At prevalence rates of up to 40%, rates of depression and anxiety among women with medically complex pregnancies are 3 times greater than those in community-based samples of pregnant women. However, mental health care is not a component of routine hospital-based antenatal care for medically high-risk pregnant women.

Objective

The purpose of this study is to evaluate the effectiveness and feasibility of the hospital-based implementation of a Web-based integrated mental health intervention comprising psychosocial assessment, referral, and cognitive behavioral therapy (CBT) for antenatal inpatients.

Methods

This study is a quasi-experimental design. Pregnant women are eligible to participate if they are (1) <37 weeks gestation, (2) admitted to the antenatal inpatient unit for >72 hours, (3) able to speak and read English or be willing to use a translation service to assist with completion of the questionnaires and intervention, (4) able to complete follow-up email questionnaires, (5) >16 years of age, and (6) not actively suicidal. Women admitted to the unit for induction (eg, <72-hour length of stay) are excluded. A minimum sample of 54 women will be recruited from the antenatal high-risk unit of a large, urban tertiary care hospital. All women will complete a Web-based psychosocial assessment and 6 Web-based CBT modules. Results of the psychosocial assessment will be used by a Web-based clinical decision support system to generate a clinical risk score and clinician prompts to provide recommendations for the best treatment and referral options. The primary outcome is self-reported prenatal depression, anxiety, and stress symptoms at 6-8 weeks postrecruitment. 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 at 3-months postpartum; and intervention cost-effectiveness, efficiency, feasibility, and acceptability. All women will complete email questionnaires at 6-8 weeks postrecruitment and 3-months postpartum. Qualitative interviews with 10-15 health care providers and 15-30 women will provide data on feasibility and acceptability of the intervention.

Results

The study was funded in September, 2014 and ethics was approved in November, 2014. Subject recruitment will begin January, 2015 and results are expected in December, 2015. Results of this study will determine (1) the effectiveness of an integrated Web-based prenatal mental health intervention on maternal and infant outcomes and (2) the feasibility of implementation of the intervention on a high-risk antenatal unit.

Conclusions

This study will provide evidence and guidance regarding the implementation of a Web-based mental health program into routine hospital-based care for women with medically high-risk pregnancies.

Obstetric care providers assessing psychosocial risk factors during pregnancy: validation of a short screening tool - the KINDEX Spanish Version

BACKGROUND

High levels of stress due to diverse psychosocial factors have a direct impact on the mothers' wellbeing during pregnancy and both direct and indirect effects on the fetus. In most cases, psychosocial risk factors present during pregnancy will not disappear after delivery and might influence the parent-child relationship, affecting the healthy development of the offspring in the long term. We introduce a short innovative prenatal assessment to detect psychosocial risk factors through an easy to use instrument for obstetrical medical staff in the daily clinical practice, the KINDEX Spanish Version.

METHODS

In the present study midwives and gynecologists interviewed one hundred nineteen pregnant women in a public health center using the KINDEX Spanish Version. Sixty-seven women were then randomly selected to participate in an extended standardized validation interview conducted by a clinical psychologist using established questionnaires to assesses current stress (ESI, PSS-14), symptoms of psychopathology (HSCL-25, PDS) and traumatic experiences (PDS, CFV). Ethical approval was granted and informed consent was required for participation in this study.

RESULTS

The KINDEX sum score, as assessed by medical staff, correlated significantly with stress, psychopathology and trauma as measured during the clinical expert interview. The KINDEX shows strong concurrent validity. Its use by medical staff in daily clinical practice is feasible for public health contexts. Certain items in the KINDEX are related to the respective scales assessing the same risks (e.g.PSS-4 as the shorter version of the PSS-14 and items from the ESI) used in the validation interview.

CONCLUSIONS

The KINDEX Spanish Version is a valid tool in the hands of medical staff to identify women with multiple psychosocial risk factors in public health settings. The KINDEX Spanish Version could serve as a base-instrument for the referral of at-risk women to appropriate psychosocial intervention. Such early interventions could prove pivotal in preventing undesirable mother-child relationships and adverse child development.

Psychosocial stress moderates the relationships between oxytocin, perinatal depression, and maternal behavior

The hormone oxytocin (OT) is of particular interest in the study of childbearing women, as it has a role in the onset and course of labor and breastfeeding. Recent research has linked OT to maternal caregiving behavior towards her infant, and to postpartum depressive symptomatology. There is also evidence that psychosocial adversity affects the oxytocin system. The present study investigated the relationship of endogenous OT in women during pregnancy and at 8weeks postpartum to psychosocial stress, maternal symptoms of depression, and maternal sensitive behavior. It was hypothesized that OT would mediate the effects of maternal depressive symptoms on maternal interactive behavior. We also tested the hypothesis that psychosocial stress would moderate the relationship between OT and maternal depressive symptoms and sensitive behavior. A community sample of 287 women was assessed at 12-14weeks of gestation, 32-34weeks of gestation, and 7-9weeks postpartum. We measured plasma OT, maternal symptoms of depression and psychosocial stress. At the postpartum home visit, maternal behavior in interaction with the infant was videotaped, and then coded to assess sensitivity. In the sample as a whole, OT was not related to maternal depressive symptoms or to sensitive maternal behavior. However, among women who reported high levels of psychosocial stress, higher levels of plasma OT were associated with fewer depressive symptoms and more sensitive maternal behavior. These results suggest that endogenous OT may act as a buffer against the deleterious effects of stress, thereby protecting high risk women from developing depressive symptoms and promoting more sensitive maternal interactive behavior.

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.

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.

The mental health of mothers of unsettled infants: is there value in routine psychosocial assessment in this context?

This study aims to investigate the (1) pattern of psychosocial risk factors among mothers of unsettled infants, (2) the relationship between these risk factors and current mental health status and (3) acceptability of psychosocial risk assessment in the parentcraft setting. Women with unsettled infants aged up to 12 months were assessed using the Edinburgh Postnatal Depression Scale, a diagnostic interview (Mini-International Neuropsychiatric Interview (MINI)) and a psychosocial assessment tool, the Postnatal Risk Questionnaire (PNRQ). Of the women, 27.5 % met the MINI diagnostic criteria for a current (predominantly) anxiety disorder, and 43.1 %, for a past psychiatric diagnosis. On the Edinburgh Postnatal Depression Scale, 29.9 % of women scored above 12 (mean 9.8; SD 5.1). The most common psychosocial risk factors were high trait anxiety (40.9 %), past mental health problems (40.7 %), perfectionistic traits (38.1 %) and 'abuse trauma' of any kind (31.6 %). The likelihood of meeting diagnostic criteria for a current mental illness was significantly increased for women who experienced emotional abuse during childhood (adj. odds ratio (OR) 3.386; p = 0.006), had high trait anxiety (adj. OR = 2.63, p = 0.003) or had a negative birth experience (adj. OR 2.78; p = 0.015). The majority of women (78 %) felt moderately to very comfortable completing the PNRQ. The results showed high rates of current anxiety disorders (almost twice that of the general postnatal population) and multiple significant psychosocial risk factors among mothers with unsettled infants. Identification of specific psychosocial risk factors in mothers of unsettled infants can help to address issues beyond infant settling difficulties such as mother-infant interaction, especially for mothers with unresolved issues around their own parenting or trauma history.

Marcé International Society position statement on psychosocial assessment and depression screening in perinatal women

The position statement aims to articulate the arguments for and against universal psychosocial assessment and depression screening, and provide guidance to assist decision-making by clinicians, policy makers and health services. More specifically it: 1. Outlines the general principles and concepts involved in psychosocial assessment and depression screening; 2. Outlines the current debate regarding benefits and risks in this area of practice including the clinical benefits and the ethical, cultural and resource implications of undertaking universal psychosocial assessment in the primary health care setting; 3. Provides a document that will assist with advocacy for the development of perinatal mental health services in the primary care setting. The statement does not set out to make specific recommendations about psychosocial assessment and depression screening (as these will need to be devised locally depending on existing resources and models of care) nor does it attempt to summarise the vast evidence-base relevant to this debate.

Screening for perinatal depression

Perinatal depression is prevalent, under-diagnosed and can have serious long-term effects on the wellbeing of women, their partners and infants. In the absence of active identification strategies, most women with perinatal depression will neither seek nor receive help. To enable early detection and timely intervention, universal screening is coming to be seen as best practice in many settings. Although the strength of recommendations and the preferred methods of identification vary in different countries (e.g. the Edinburgh Postnatal Depression Scale, brief case-finding questions), appropriate training for health professionals in wider psychosocial assessment is essential to maximise usefulness while minimising potential harms. Clear pathways of systematic follow up of all positive screening results with a diagnostic procedure and access to effective treatment are centrally important both for the clinical effectiveness of screening and for health system costs. It is also necessary to further build on the emerging evidence base for the clinical effectiveness of screening.

Major depressive disorder in the perinatal period: using data linkage to inform perinatal mental health policy

This study aims to investigate hospital admission of major depressive disorders (MDD) before and after birth. Population data for all primiparous women admitted to the hospital with depressive disorders before and after birth were used. The comparison group consisted of 10 % of primiparous women not admitted to the hospital with a diagnosis of a psychiatric disorder or substance use. A total of 728 women had a first admission with depressive disorders (501 in the first postpartum year). The rate of first hospital admission for depressive disorders decreased during pregnancy and increased markedly in the first three months after birth (peaking in the second month with a rate of 10.74/1,000 person year and rate ratio of 12.56) compared with the 6 months prior to pregnancy. Admission remained elevated in the second postpartum year. Older maternal age, smoking, elective caesarian section and admission to a neonatal intensive care unit or special care nursery were associated with a higher rate of admission. Women born outside Australia and those most socioeconomically disadvantaged were less likely to be admitted to the hospital in the first postpartum year. Overall risk of hospital admission with depressive disorders rose significantly across the entire first postpartum year. This has significant implications for policy and service planning for women with mood disorders in the perinatal period.

Measuring perinatal mental health risk

The purpose of this review was to critically analyse existing tools to measure perinatal mental health risk and report on the psychometric properties of the various approaches using defined criteria. An initial literature search revealed 379 papers, from which 21 papers relating to ten instruments were included in the final review. A further four papers were identified from experts (one excluded) in the field. The psychometric properties of six multidimensional tools and/or criteria were assessed. None of the instruments met all of the requirements of the psychometric properties defined. Some had used large sample sizes but reported low positive predictive values (Antenatal Risk Questionnaire (ANRQ)) or insufficient information regarding their clinical performance (Antenatal Routine Psychosocial Assessment (ARPA)), while others had insufficient sample sizes (Antenatal Psychosocial Health Assessment Tool, Camberwell Assessment of Need-Mothers and Contextual Assessment of Maternity Experience). The ANRQ has fulfilled the requirements of this analysis more comprehensively than any other instrument examined based on the defined rating criteria. While it is desirable to recommend a tool for clinical practice, it is important that clinicians are made aware of their limitations. The ANRQ and ARPA represent multidimensional instruments commonly used within Australia, developed within large samples with either cutoff scores or numbers of risk factors related to service outcomes. Clinicians can use these tools, within the limitations presented here, to determine the need for further intervention or to refer women to mental health services. However, the effectiveness of routine perinatal psychosocial assessment continues to be debated, with further research required.

Parental care and control during childhood: associations with maternal perinatal mood disturbance and parenting stress

This study examined the associations between perceived parental care and control in childhood and maternal anxiety, depression and parenting stress during the transition to parenthood. Eighty-eight women completed the Parental Bonding Instrument, self-report measures of anxiety and depression and a structured diagnostic interview (Mini-plus International Neuropsychiatric Interview) during the third trimester of pregnancy. The MINI-Plus and anxiety and depression measures were re-administered at 7 months postpartum. The Parenting Stress Index was also administered at this time. Significant associations were found between maternal 'affectionless control' and prenatal and postnatal symptom measures of anxiety and depression, p values <0.005. Compared to women who reported optimal parenting, women who recalled maternal 'affectionless control' were also six times more likely to be diagnosed with an anxiety disorder during pregnancy (OR = 6.1, 95% CI = 2.17-30.11) and seven times more likely to be diagnosed with postnatal major depression (OR = 6.8, 95% CI = 1.80-25.37). Paternal 'affectionless control' was associated with significantly higher scores on symptom measures of prenatal and postnatal anxiety, p values <0.005. This study suggests that assessing a woman's own parenting history is important in identifying and managing the risk of prenatal and postnatal affective disorders and parenting stress.