Perinatal Depression and Risk of Suicidal Behavior

The screening accuracy of the Edinburgh Postnatal Depression Scale (EPDS) to detect perinatal depression with and without the self-harm item in pregnant and postpartum women

BACKGROUND

This study aims to examine whether the Edinburgh Postnatal Depression Scale (EPDS), excluding the self-harm item (EPDS-9), performs as effectively as the full EPDS in identifying depression among perinatal women.

METHODS

A total of 3571 pregnant women and 3850 postpartum women participated in this observational study. Participants who scored ≥ 9 on the EPDS underwent further diagnostic evaluations by a clinical psychologist and/or psychiatrist.

RESULTS

The EPDS-9 and full EPDS demonstrated a near-perfect correlation in both the antepartum (r = 0.996) and postpartum (r = 0.998) cohorts. EPDS-9 showed exceptional precision in identifying depression as screened by the full EPDS at cutoff points ranging 9-14, with areas under the curve ≥0.998. The sensitivity of EPDS-9 and full EPDS to detect depression that requires psychotropic medications was poor. The highest accuracy for both versions was at a cutoff score of 9: sensitivity of 0.579 for the full EPDS and 0.526 for the EPDS-9. At the cutoff point of 9, EPDS-9 performed adequately in predicting the response of the participants to the self-harm item.

CONCLUSION

The EPDS-9 represents a solid and effective replacement for the full EPDS in clinical settings. If the presence of suicidal thoughts needs to be assessed, specialized scales should be used.

The effect of music intervention on depression in perinatal women: A systematic review

Objective

Perinatal depression has become a global public health problem, which not only harms the health of mothers and their offspring, but also increases the socio-economic burden, so early intervention is urgent. Music intervention is a low-cost and safe intervention method. This study endeavored to systematically integrate and quantitatively evaluate the effectiveness of music intervention for perinatal depression.

Methods

PubMed, Embase, Web of Science and Cochrane Library were searched systematically. The search period was up to September 1, 2024. The included studies were summarized and analyzed.

Results

A total of 1375 articles were obtained through preliminary search, and 13 of them were finally included. The effect of music intervention on perinatal depression was better than that of the control group (SMD = -0.53, 95%CI (-0.81, -0.26), p ＜ 0.05). Music intervention had no significant effect on alleviating anxiety (SMD = -0.47, 95%CI (-0.63, -0.31), p ＞ 0.05). However, the heterogeneity of the included studies was significant.

Conclusions

This study indicated that music intervention had a significant effect on alleviating perinatal depression, but the effect on anxiety was not significant. However, the results were highly heterogeneous, and large-scale, multi-center, and long-term studies are needed in the future to confirm this.

Mental disorders during pregnancy and postpartum in Bangladesh: A narrative review

Background and Aims

Bangladesh has made significant progress in declining maternal mortality in recent decades. However, the available evidence on the various maternal mental disorders in the country has not been comprehensively and critically reviewed to date. This narrative review aimed to assess the mental disorders and associated factors during pregnancy and postpartum in Bangladesh.

Methods

A thorough search was performed in PubMed, Scopus, Google, Google Scholar, and BanglaJOL with search terms at the end of January 2024 to identify the original articles published on psychiatric morbidities during pregnancy and postpartum.

Results

This review included 28 empirical studies published between 2007 and 2023 with a sample size ranging from 100 to 39,434. Two studies were published before 2010, 16 studies were published between 2011 and 2020, and 10 studies were published between 2021 and 2023. No countrywide study was noted, the Bangla Edinburgh Postnatal Depression Scale (EPDS-B) was used in 57% of studies, suicidal behavior was assessed in three studies, postpartum depression (PPD) was featured in 16 studies, and three qualitative studies were noted. The prevalence of PPD ranged from 9% to 51.7%. About 46% of mothers had positive scores for common mental disorders. The prevalence of mental disorders was 14.2%; among them mood disorders were present at 6.1% and psychoses were noted at 4.5%.

Conclusions

There are wide variations in the prevalence of maternal mental disorders in Bangladesh from study to study; a lower prevalence was noted when diagnostic tools were used even though no nationwide study with confirmatory diagnostic tools was noted. Studies with nationwide distribution and diagnostic tools are warranted to understand the problem precisely.

Suicide Mortality During the Perinatal Period

Importance

The US has the highest maternal mortality rate among developed countries. The Centers for Disease Control and Prevention deems nearly all of these deaths preventable, especially those attributable to mental health conditions. Coordination between US health care and social service systems could help further characterize circumstances and risks associated with perinatal suicide mortality.

Objective

To examine contextual and individual precipitating circumstances and risks associated with perinatal suicide.

Design, Setting, and Participants

This cross-sectional observational study used a convergent mixed methods design to explore factors contributing to maternal suicides and deaths of undetermined intent (hereinafter, undetermined deaths) identified in National Violent Death Reporting System (NVDRS) data for January 1, 2003, to December 31, 2021. Analyses included decedents who were aged 10 to 50 years and pregnant or post partum at death (collectively, the perinatal group) and demographically matched female decedents who were not pregnant or recently pregnant (nonperinatal group) at death. Analyses were performed between December 2022 and December 2023.

Exposures

Pregnancy status at death (perinatal or nonperinatal).

Main Outcomes and Measures

The main outcomes included contributing circumstances associated with suicides and undetermined deaths cited in coroner, medical examiner, or law enforcement case narratives. The study examined quantitative differences between groups using a matched analysis and characterized key themes of salient suicide circumstances using qualitative content analysis.

Results

This study included 1150 perinatal decedents identified in the NVDRS: 456 (39.6%) were pregnant at death, 203 (17.7%) were pregnant within 42 days of death, and 491 (42.7%) were pregnant within 43 to 365 days before death, yielding 694 postpartum decedents. The nonperinatal comparison group included 17 655 female decedents aged 10 to 50 years. The mean (SD) age was 29.1 (7.4) years for perinatal decedents and 35.8 (10.8) years for nonperinatal decedents. Compared with matched nonperinatal decedents, perinatal decedents had higher odds of the following identified contributing circumstances: intimate partner problems (IPPs) (odds ratio [OR], 1.45 [95% CI, 1.23-1.72]), recent argument (OR, 1.33 [95% CI, 1.09-1.61]), depressed mood (OR, 1.39 [95% CI, 1.19-1.63]), substance abuse or other abuse (OR, 1.21 [95% CI, 1.03-1.42]), physical health problems (OR, 1.37 [95% CI, 1.09-1.72]), and death of a family member or friend (OR, 1.47 [95% CI, 1.06-2.02]). The findings of the qualitative analysis emphasized the importance of mental health and identified 128 decedents (12.4%) with postpartum depression.

Conclusions and Relevance

This study provides insights into complex factors surrounding maternal suicide, and it highlights opportunities for further research to understand long-term consequences of perinatal mental health. These findings also underscore the need for targeted evidence-based interventions and effective policies targeting mental health, substance use, and IPPs to prevent maternal suicide and enhance maternal health outcomes.

Stratifying Risk for Postpartum Depression at Time of Hospital Discharge

Objective

Postpartum depression (PPD) represents a major contributor to postpartum morbidity and mortality. Beyond efforts at routine screening, risk stratification models could enable more targeted interventions in settings with limited resources. Thus, we aimed to develop and estimate the performance of a generalizable risk stratification model for PPD in patients without a history of depression using information collected as part of routine clinical care.

Methods

We performed a retrospective cohort study of all individuals who delivered between 2017 and 2022 in one of two large academic medical centers and six community hospitals. An elastic net model was constructed and externally validated to predict PPD using sociodemographic factors, medical history, and prenatal depression screening information, all of which was known before discharge from the delivery hospitalization.

Results

The cohort included 29,168 individuals; 2,703 (9.3%) met at least one criterion for postpartum depression in the 6 months following delivery. In the external validation data, the model had good discrimination and remained well-calibrated: area under the receiver operating characteristic curve 0.721 (95% CI: 0.707-0.734), Brier calibration score 0.088 (95% CI: 0.084 - 0.092). At a specificity of 90%, the positive predictive value was 28.0% (95% CI: 26.0-30.1%), and the negative predictive value was 92.2% (95% CI: 91.8-92.7%).

Conclusions

These findings demonstrate that a simple machine-learning model can be used to stratify the risk for PPD before delivery hospitalization discharge. This tool could help identify patients within a practice at the highest risk and facilitate individualized postpartum care planning regarding the prevention of, screening for, and management of PPD at the start of the postpartum period and potentially the onset of symptoms.

Antenatal depression among pregnant mothers in Afghanistan: A cross-sectional study

BACKGROUND

Approximately one in five pregnant women experience antenatal depression globally. The purpose of the present study was to estimate the prevalence of antenatal depression and explore its relationship between various demographic variables, recent sexual engagement, and recent adverse life events among pregnant Afghan women.

METHODS

A cross-sectional survey study was carried out between January, 2023 and April 2023 among 460 women aged 15-45 years who were recruited using convenience sampling from Herat province (Afghanistan). Logistic regression models were utilized to explore the relationship between antenatal depression and socio-demographic characteristics among the participants.

RESULTS

The prevalence of antenatal depression symptoms was 78.5%. Multiple regression analysis indicated that antenatal depression was significantly associated with (i) being aged 30-45 years (AOR: 4.216, 95% CI: 1.868-9.515, p = .001), (ii) being of low economic status (AOR:2.102, 95% CI: 1.051-4.202, p = .036), (iii) not being employed (AOR: 2.445, 95% CI:1.189-5.025, p = .015), (iv) not having had sex during the past seven days (AOR: 2.335, 95% CI: 1.427-3.822, p = .001), and (v) not experiencing a traumatic event during the past month (AOR:0.263, 95% CI: 0.139-0.495, p < .001).

CONCLUSION

The present study provides insight into the factors associated with the high prevalence of antenatal depression among pregnant Afghan women (e.g., demographic variables, recent adverse life events, and recent sexual engagement). It highlights the urgency of addressing antenatal depression in Afghanistan and provides a foundation for future research and interventions aimed at improving the mental health and well-being of pregnant women in the Afghan context.

Perinatal depression and risk of mortality: nationwide, register based study in Sweden

OBJECTIVE

To determine whether women with perinatal depression are at an increased risk of death compared with women who did not develop the disorder, and compared with full sisters.

DESIGN

Nationwide, register based study.

SETTING

Swedish national registers, 1 January 2001 to 31 December 2018.

PARTICIPANTS

86 551 women with a first ever diagnosis of perinatal depression ascertained through specialised care and use of antidepressants, and 865 510 women who did not have perinatal depression were identified and matched based on age and calendar year at delivery. To address familial confounding factors, comparisons were made between 270 586 full sisters (women with perinatal depression (n=24 473) and full sisters who did not have this disorder (n=246 113)), who gave at least one singleton birth during the study period.

MAIN OUTCOME MEASURES

Primary outcome was death due to any cause. Secondary outcome was cause specific deaths (ie, unnatural and natural causes). Multivariable Cox regression was used to estimate hazard ratios of mortality comparing women with perinatal depression to unaffected women and sisters, taking into account several confounders. The temporal patterns of perinatal depression and differences between antepartum and postpartum onset of perinatal depression were also studied.

RESULTS

522 deaths (0.82 per 1000 person years) were reported among women with perinatal depression diagnosed at a median age of 31.0 years (interquartile range 27.0 to 35.0) over up to 18 years of follow-up. Compared with women who did not have perinatal depression, women with perinatal depression were associated with an increased risk of death (adjusted hazard ratio 2.11 (95% confidence interval 1.86 to 2.40)); similar associations were reported among women who had and did not have pre-existing psychiatric disorder. Risk of death seemed to be increased for postpartum than for antepartum depression (hazard ratio 2.71 (95% confidence interval 2.26 to 3.26) v 1.62 (1.34 to 1.94)). A similar association was noted for perinatal depression in the sibling comparison (2.12 (1.16 to 3.88)). The association was most pronounced within the first year after perinatal depression but remained up to 18 years after start of follow up. An increased risk was associated with both unnatural and natural causes of death among women with perinatal depression (4.28 (3.44 to 5.32) v (1.38 (1.16 to 1.64)), with the strongest association noted for suicide (6.34 (4.62 to 8.71)), although suicide was rare (0.23 per 1000 person years).

CONCLUSIONS

Even when accounting for familial factors, women with clinically diagnosed perinatal depression were associated with an increased risk of death, particularly during the first year after diagnosis and because of suicide. Women who are affected, their families, and health professionals should be aware of these severe health hazards after perinatal depression.

The cost-effectiveness of zuranolone versus selective serotonin reuptake inhibitors for the treatment of postpartum depression in the United States

AIMS

The objective of this research is to evaluate the cost-effectiveness of zuranolone, the first oral treatment indicated for postpartum depression (PPD) in adults approved by the United States Food and Drug Administration.

METHODS

Zuranolone and selective serotonin reuptake inhibitor (SSRI) trial-based efficacy was derived from an indirect treatment comparison. Long-term efficacy outcomes were based on a large longitudinal cohort study. Maternal health utility values were derived from trial-based, short-form 6-D responses. Other inputs were derived from literature and economic data from the US Bureau of Labor Statistics. We estimated costs (2023 US dollars) and quality-adjusted life-years (QALYs) for patients with PPD treated with zuranolone (14-day dosing) or SSRIs (chronic dosing). The indirect costs and QALYs of the children and partners were also estimated.

RESULTS

The incremental cost-effectiveness ratio for zuranolone versus SSRIs was $94,741 per QALY gained over an 11-year time horizon. Maternal total direct medical costs averaged $84,318 in the zuranolone arm, compared to $86,365 in the SSRI arm. Zuranolone-treated adults averaged 6.178 QALYs compared to 6.116 QALYs for the SSRI arm. Costs and utilities for the child and partner were also included in the base case. Drug and administration costs for zuranolone averaged $15,902, compared to $30 for SSRIs over the studied time horizon. Results were sensitive to the model time horizon.

LIMITATIONS

As head-to-head trials were not available to permit direct comparison, efficacy inputs were derived from an indirect treatment comparison which can be confounded by cross-trial differences. The data used are reflective of a general PPD population rather than marginalized individuals who may be at a greater risk for adverse PPD outcomes. The model likely excludes unmeasured effects for patient, child, and partner.

CONCLUSIONS

This economic model's results suggest that zuranolone is a more cost-effective therapy compared to SSRIs for treating adults with PPD.