The prevention and psychotherapeutic treatment of postpartum depression

Effectiveness of interpersonal psychotherapy in comparison to other psychological and pharmacological interventions for reducing depressive symptoms in women diagnosed with postpartum depression in low- and middle-income countries: A systematic review

Background

Postpartum depression (PPD) is a condition that can affect any woman regardless of ethnicity, age, party, marital status, income, and type of delivery. This condition is highly prevalent worldwide. PPD, if not treated timely, can affect the maternal-child bond and can have a detrimental impact on the future cognitive, emotional, and behavioral development of the child. Interpersonal psychotherapy (IPT) has been reported as an effective treatment of PPD in previous studies as this focuses on relationship and social support issues. Previous reviews conducted in developed nations have reported the superior efficacy of IPT in comparison to other treatment options. There is no systematic review conducted in low to middle-income countries on the efficacy of IPT on PPD. Therefore it was necessary to undertake a systematic review to assess the effectiveness of IPT in reducing the depression among postpartum women in low and middle-income countries (LMICs).

Objectives

The main aim of this systematic review was to assess the effectiveness of IPT alone or in conjunction with pharmacological therapy and/or other psychological and psychosocial interventions, in reducing depressive symptoms among women diagnosed with PPD residing in LMICs.

Search Methods

The systematic search encompassed several prominent databases and grey literature. Furthermore, experts specializing in the field of IPT were consulted to identify any relevant studies conducted in LMICs that fulfilled the predetermined eligibility criteria. The most recent search update was performed in July 2022.

Selection Criteria

The PICOS criteria were meticulously defined for this review as described. Participants: Postpartum women diagnosed with PPD in LMICs were included. Intervention: IPT either as a standalone treatment or in conjunction with pharmacological therapy was included. Comparison: any form of psychological therapy or pharmacological therapy, whether administered individually or in combination, was considered for comparison. Study designs: experimental and quasi-experimental, factorial designs, and quantitative components (experimental, quasi-experimental, factorial designs) of mixed methods designs were eligible to be included. Studies with single-group study designs and qualitative studies were excluded from the review.

Data Collection and Analysis

Two reviewers from our team conducted a rigorous screening process to determine the eligibility of articles for inclusion. This involved an initial evaluation of titles and abstracts, followed by a comprehensive assessment of the full text of selected articles. In instances where discrepancies arose between the two reviewers, resolution was achieved through discussion or consultation with a third author to establish a consensus. Following the screening process, two team members independently extracted pertinent information and data from the studies that met the inclusion criteria. The treatment effect of the intervention, in comparison to the control group, was subsequently analyzed utilizing the fixed effects model taking into account the small number of studies.

Main Results

A total of 17,588 studies were identified from various databases, and 6493 duplicate studies were removed. Subsequently, 9380 studies underwent independent title and abstract screening resulting in the exclusion of 9040 studies. 345 full texts were thoroughly assessed leading to the exclusion of 341 studies, finally including 4 studies for review. The four included trials were randomized trials and comprised a total sample size of 188 women diagnosed with PPD residing in LMICs. Among these studies, three compared IPT with usual treatment, while one study compared IPT with antidepressant medications (ADMs). In terms of the providers of IPT, in one study, IPT was administered by nurses, while psychologists delivered IPT in another study. In one study, community health workers were responsible for providing IPT. However, in one study, information regarding the specific providers of IPT was not available or reported. The primary outcome measure reported in all four studies was depression, assessed using the Edinburgh Postnatal Depression Scale (EPDS). The geographical distribution of the studies included; one conducted in Zambia, one in Kenya, one in Pakistan, and one in Iran. Out of the four studies, three were included in the meta-analysis, as missing data from one study could not be obtained. Based on the overall treatment effect, it was found that depression scores decreased significantly more in the IPT group compared to other interventions (usual treatment or ADMs) (standardized mean difference [SMD] -0.62, 95% confidence interval [CI] (-1.01, -0.23), Z = 3.13 (p = 0.002), χ 2 = 49.49; df = 2; p < 0.00001; I 2 = 96%; 3 studies, n = 136). Out of the three studies, two studies compared the effectiveness of IPT in reducing depression scores specifically when compared to the usual treatment, and in both studies, depression scores were reduced significantly in the IPT group as compared to the usual treatment group. Only one study directly compared the effectiveness of IPT with ADM, reporting that IPT was more effective than ADM in reducing depression scores among postpartum women. Regarding adverse outcomes, only one study reported suicidal ideation with one participant in the IPT group and two in the ADM group (RR 0.50, 95% CI (0.05, 5.30), p = 0.56, n = 78). The same study reported seven participants in the ADM group had adverse drug reactions as compared to none in the IPT group (RR 15.0, 95% CI (0.89, 254), p = 0.06, n = 78).

Authors' Conclusions

Our comprehensive search yielded a limited number of four studies conducted in such settings. Despite the scarcity of available evidence, the findings collectively suggest that IPT is indeed an effective treatment for reducing PPD when compared to usual treatment and pharmacological therapy. However given the low certainty of evidence, there is a need for further research in the form of well-designed randomized controlled trials with larger sample sizes and a reduced risk of bias. Such studies would greatly contribute to enhancing the strength and reliability of the evidence base regarding the effectiveness of IPT in the context of PPD in LMICs. The knowledge generated from future research endeavors would be highly valuable in guiding the development of more affordable and cost-effective treatment approaches for PPD in resource-limited settings.

Consumer acceptance of using a digital technology to manage postpartum depression

The goal of the study was to evaluate the end user experience using the MamaLift Plus app for 2 weeks to support the treatment of their postpartum depression (PPD). A total of 14 participants completed the study and their experiences are reported in this publication. Participants reported that MamaLift Plus is an acceptable, highly usable, and practical mobile tool to use weekly for the management of their PPD. More research is warranted to evaluate the benefit of digital behavior health interventions, especially in patient populations where mental health care may be limited or harder to access by patients.

Effects of 1-day e-learning education on perinatal psychological support skills among midwives and perinatal healthcare workers in Japan: a randomised controlled study

BACKGROUND

Although midwives are expected to play a key role for psychological support throughout perinatal periods, their educational chances are limited. Versatile teaching strategies such as e-learning may be promising in expanding education. The objective of our study was to clarify the effects of an e-learning educational programme on midwives' empathic communication skills.

METHODS

From April 2019 to September 2019, a randomised controlled trial of a 1-day e-learning educational programme on perinatal psychological issues (both perinatal mental health assessment and empathic communication) was conducted to improve empathic communication skills of midwives and perinatal healthcare workers. Two types of measurements (paper-and-pencil multiple-choice test and video-viewing tests of simulated patient) were used to measure the competency of empathic communication skills.

RESULTS

Participants (N = 115) were randomly allocated to two groups (Intervention: n = 58, Control: n = 57). The intervention group was at a significantly higher level for both post-tests of empathic communication skills compared with the control group. Both intervention and control groups showed improvements in acquiring knowledge about perinatal mental health assessments.

CONCLUSIONS

The results of our study show that a 1-day e-learning programme helped improve the midwives' empathic communications skills. Therefore, an effective 1-day e-learning educational programme of perinatal mental health will expand opportunity to learn about empathic communication skills for midwives and perinatal healthcare workers.

TRIAL REGISTRATIONS

UMIN000036052.

Influence of adjuvant detached mindfulness and stress management training compared to pharmacologic treatment in primiparae with postpartum depression

Ten to 15% of mothers experience postpartum depression (PPD). If untreated, PPD may negatively affect mothers' and infants' mental health in the long term. Accordingly, effective treatments are required. In the present study, we investigated the effect of detached mindfulness (DM) and stress management training (SMT) as adjuvants, compared to pharmacologic treatment only, on symptoms of depression in women with PPD. Forty-five primiparae (mean age: M = 24.5 years) with diagnosed PPD and treated with an SSRI (citalopram; CIT) took part in the study. At baseline, they completed questionnaires covering socio-demographic data and symptoms of depression. Experts rated also symptoms of depression. Next, participants were randomly assigned to one of the following study conditions: adjuvant detached mindfulness (CIT+DM); adjuvant stress management training (CIT+SMT); control condition (CIT). Self- and experts' ratings were completed at the end of the study 8 weeks later, and again at 8 weeks follow-up. Symptoms of depression decreased significantly over time, but more so in the CIT+DM and CIT+SMT group, compared to the control condition. The pattern of results remained stable at follow-up. In primiparae with PPD and treated with a standard SSRI, adjuvant psychotherapeutic interventions led to significant and longer-lasting improvements.

Psychotherapy Training on Psychological Mindedness in a Japanese Nurse Population: Effects and Personality Correlates

Aims and objective: The aim of this study was to determine whether the training would influence the psychological mindedness of nurses and midwives. In addition, we explored the relationship of the change of psychological mindedness before and after the training and the correlation with their personality traits. Background: It is important for perinatal health professionals such as nurses and midwives to acquire intervention skills such as psychotherapy and counselling techniques. We think that one of the essential requisites is psychological mindedness. Method: A total of 45 perinatal health professionals who participated in the postpartum depression prevention programme were distributed a set of questionnaires including the Psychological Mindedness Scale (PMS) and Temperament and Character Inventory (TCI) at the beginning and end of the training. Results: The PMS scores increased significantly after the training. A structured equation modelling suggested that PMS and self-directedness predicted each other whereas PMS predicted low harm avoidance. Conclusion: These findings indicate that the psychological mindedness of nurses and midwives could be advanced by a course of training and that this could be supported by high self-directedness. The harm avoidance trait may be reduced by increased psychological mindedness. Relevance to clinical practice: Nurses and nursing students are apt to psychological skill training in the advancement of psychological mindedness.

Prevention of postnatal depression

Postnatal depression is the most frequent psychiatric disorder seen after childbirth, with a prevalence rate of 10% to 15%. The women at risk need to be identified by a valid and reliable method, either using a screening instrument or an interview schedule.

The preventive strategies need to have enough power to detect a clinically worthwhile effect to be considered useful in clinical practice. Many of the risk factors for developing postnatal depression are present during the pregnancy and immediate post-partum period. The risk factors for postnatal depression include depression or anxiety during pregnancy, experiencing stressful life events during pregnancy or the early puerperium, maternity blues, low levels of social support, past history of depression and poor marital adjustment. The antenatal and postnatal period provides an ideal opportunity to screen women for these risk factors. The women identified to be at risk can be identified, and preventive interventions can be implemented.

Routine clinical practice can be improved to identify some of the women at risk by better communication between health professionals. There are no antenatal screening tools that have been shown to be of benefit in predicting postnatal depression. Edinburgh Postnatal Depression Scale is widely used in the postnatal period to screen for depression. The psychosocial interventions to prevent postnatal depression have not been shown to be beneficial and there is a dearth of psychopharmacological trials to make firm conclusions about their efficacy in preventing postnatal depression. Individualised psychosocial interventions aimed at the at-risk populations and initiated in the postnatal period appear to have some benefit in preventing postnatal depression. The focus of this article will be the risk factors associated with postnatal depression, screening methods and tools to identify those at risk of developing the disorder and the psychosocial, psychological and psychopharmacological interventions to prevent postnatal depression.

Adjusting an Available Online Peer Support Platform in a Program to Supplement the Treatment of Perinatal Depression and Anxiety

BACKGROUND

Perinatal depression and anxiety are common and debilitating conditions. Novel, cost effective services could improve the uptake and the impact of mental health resources among women who suffer from these conditions. E-mental health products are one example of such services. Many publically available e-mental health products exist, but these products lack validation and are not designed to be integrated into existing health care settings.

OBJECTIVE

The objective of the study was to present a program to use 7 Cups of Tea (7Cups), an available technological platform that provides online peer (ie, listener) based emotional support, to supplement treatment for women experiencing perinatal depression or anxiety and to summarize patient's feedback on the resultant program.

METHODS

This study consisted of two stages. First, five clinicians specializing in the treatment of perinatal mood disorders received an overview of 7Cups. They provided feedback on the 7Cups platform and ways it could complement the existing treatment efforts to inform further adjustments. In the second stage, nine women with perinatal depression or anxiety used the platform for a single session and provided feedback.

RESULTS

In response to clinicians' feedback, guidelines for referring patients to use 7Cups as a supplement for treatment were created, and a training program for listeners was developed. Patients found the platform usable and useful and their attitudes toward the trained listeners were positive. Overall, patients noted a need for support outside the scheduled therapy time and believed that freely available online emotional support could help meet this need. Most patients were interested in receiving support from first time mothers and those who suffered in the past from perinatal mood disorders.

CONCLUSIONS

The study results highlight the use of 7Cups as a tool to introduce accessible and available support into existing treatment for women who suffer from perinatal mood disorders. Further research should focus on the benefits accrued from such a service. However, this article highlights how a publicly available eHealth product can be leveraged to create new services in a health care setting.

Can Postpartum Depression Be Managed in Pediatric Primary Care?

BACKGROUND

Postpartum depression is prevalent among women who have had a baby within the last 12 months. Depression can compromise parenting practices, child development, and family stability. Effective treatments are available, but access to mental healthcare is challenging. Routine infant healthcare visits represent the most regular contact mothers have with the healthcare system, making pediatric primary care (PPC) an ideal venue for managing postpartum depression.

METHODS

We conducted a review of the published literature on postpartum depression programs. This was augmented with a Google search of major organizations' websites to identify relevant programs. Programs were included if they focused on clinical care practices, for at-risk or depressed women during the first year postpartum, which were delivered within the primary care setting.

RESULTS

We found that 18 programs focused on depression care for mothers of infants; 12 were developed for PPC. All programs used a screening tool. Psychosocial risk assessments were commonly used to guide care strategies, which included brief counseling, motivating help seeking, engaging social supports, and facilitating referrals. Available outcome data suggest the importance of addressing postpartum depression within primary care and providing staff training and support. The evidence is strongest in family practices and community-based health settings. More outcome data are needed in pediatric practices.

CONCLUSION

Postpartum depression can be managed within PPC. Psychosocial strategies can be integrated as part of anticipatory guidance. Critical supports for primary care clinicians, especially in pediatric practices, are needed to improve access to timely nonstigmatizing care.

MomMoodBooster web-based intervention for postpartum depression: feasibility trial results

Background

Postpartum depression (PPD)—the most common complication of childbirth—is a significant and prevalent public health problem that severely disrupts family interactions and can result in serious lasting consequences to the health of women and the healthy development of infants. These consequences increase in severity when left untreated; most women with PPD do not obtain help due to a range of logistical and attitudinal barriers.

Objective

This pilot study was designed to test the feasibility, acceptability, and potential efficacy of an innovative and interactive guided Web-based intervention for postpartum depression, MomMoodBooster (MMB).

Methods

A sample of 53 women who satisfied eligibility criteria (<9 months postpartum, ≥18 years of age, home Internet access and use of personal email, Edinburgh Postnatal Depression Survey score of 12-20 or Patient Health Questionnaire score from 10-19) were invited to use the MMB program. Assessments occurred at screening/pretest, posttest (3 months following enrollment), and at 6 months follow-up.

Results

All six sessions of the program were completed by 87% (46/53) of participants. Participants were engaged with the program: visit days (mean 15.2, SD 8.7), number of visits (mean 20.1, SD 12.2), total duration of visits in hours (mean 5.1, SD 1.3), and number of sessions viewed out of six (mean 5.6, SD 1.3) all support high usage. Posttest data were collected from 89% of participants (47/53) and 6-month follow-up data were collected from 87% of participants (46/53). At pretest, 55% (29/53) of participants met PHQ-9 criteria for minor or major depression. At posttest, 90% (26/29) no longer met criteria.

Conclusions

These findings support the expanded use and additional testing of the MMB program, including its implementation in a range of clinical and public health settings.

Trial Registration

Clinicaltrials.gov NCT00942721; http://clinicaltrials.gov/ct2/show/NCT00942721 (Archived by WebCite at http://www.webcitation.org/6KjYDvYkQ).

Management of postpartum depression

The mainstays of treatment for peripartum depression are psychotherapy and antidepressant medications. More research is needed to understand which treatments are safe, preferable, and effective. Postpartum depression, now termed peripartum depression by the DSM-V, is one of the most common complications in the postpartum period and has potentially significant negative consequences for mothers and their families. This article highlights common clinical challenges in the treatment of peripartum depression and reviews the evidence for currently available treatment options. Psychotherapy is the first-line treatment option for women with mild to moderate peripartum depression. Antidepressant medication in combination with therapy is recommended for women with moderate to severe depression. Although pooled case reports and small controlled studies have demonstrated undetectable infant serum levels and no short-term adverse events in infants of mothers breastfeeding while taking sertraline (Zoloft) and paroxetine (Paxil), further research is needed including larger samples and long-term follow-up of infants exposed to antidepressants via breastfeeding controlling for maternal depression. Pharmacologic treatment recommendations for women who are lactating must include discussion with the patient regarding the benefits of breastfeeding, risks of antidepressant use during lactation, and risks of untreated illness. There is a growing evidence base for nonpharmacologic interventions including repetitive transcranial magnetic stimulation, which may offer an attractive option for women who wish to continue to breastfeed and are concerned about their infants being exposed to medication. Among severe cases of peripartum depression with psychosis, referral to a psychiatrist or psychiatric advanced practice registered nurse is warranted. Suicidal or homicidal ideation with a desire, intent, or plan to harm oneself or anyone else, including the infant, is a psychiatric emergency, and an evaluation by a mental health professional should be conducted immediately. Peripartum depression treatment research is limited by small sample sizes and few controlled studies. Much work is still needed to better understand which treatments women prefer and are the most effective in ameliorating the symptoms and disease burden associated with peripartum depression.

Psychological management of unipolar depression

OBJECTIVE

To be used in conjunction with 'Pharmacological management of unipolar depression' [Malhi et al. Acta Psychiatr Scand 2013;127(Suppl. 443):6-23] and 'Lifestyle management of unipolar depression' [Berk et al. Acta Psychiatr Scand 2013;127(Suppl. 443):38-54]. To provide clinically relevant recommendations for the use of psychological treatments in depression derived from a literature review.

METHOD

Medical databases including MEDLINE and PubMed were searched for pertinent literature, with an emphasis on recent publications.

RESULTS

Structured psychological treatments such as cognitive behaviour therapy and interpersonal therapy (IPT) have a robust evidence base for efficacy in treating depression, even in severe cases of depression. However, they may not offer benefit as quickly as antidepressants, and maximal efficacy requires well-trained and experienced therapists. These therapies are effective across the lifespan and may be preferred where it is desired to avoid pharmacotherapy. In some instances, combination with pharmacotherapy may enhance outcome. Psychological therapy may have more enduring protective effects than medication and be effective in relapse prevention. Newer structured psychological therapies such as mindfulness-based cognitive therapy and acceptance and commitment therapy lack an extensive outcome literature, but the few published studies yielding positive outcomes suggest they should be considered options for treatment.

CONCLUSION

Cognitive behaviour therapy and IPT can be effective in alleviating acute depression for all levels of severity and in maintaining improvement. Psychological treatments for depression have demonstrated efficacy across the lifespan and may present a preferred treatment option in some groups, for example, children and adolescents and women who are pregnant or postnatal.

Web-Based Intervention for Postpartum Depression: Formative Research and Design of the MomMoodBooster Program

Background

Postpartum depression is a significant public health problem affecting approximately 13% of women. There is strong evidence supporting Cognitive Behavioral Therapy (CBT) for successful psychosocial treatment. This treatment model combines cognitive and behavioral strategies to address pessimism, attributions for failure, low self-esteem, low engagement in pleasant activities, social withdrawal, anxiety, and low social support. Encouraging results have been reported for using Web-based CBT interventions for mental health domains, including the treatment of panic disorder, post-traumatic stress disorder, and complicated grief and depression. To date, however, Web-based interventions have not been used and evaluated specifically for the treatment of postpartum depression.

Objective

We describe the formative work that contributed to the development of our Web-based intervention for helping to ameliorate symptoms of postpartum depression, and the design and key components of the program.

Methods

A total of 17 focus group participants and 22 usability testers, who shared key characteristics with the participants of our planned feasibility study, took part.

The proposed structure and ingredients of the program and mock-ups of selected webpages were presented to focus group participants. At various points, participants were asked a series of thought questions designed to elicit opinions and set the occasion for group discussion. At the end of the session, participants were asked to describe their overall reaction to the proposed features of the program emphasizing candid opinions about what they did not like and features they thought were missing and should be added.

Usability testers were asked to interact with a series of seven different Web-based interactions planned for the program while receiving minimal direction. Each tester was asked to describe her thoughts using a think-aloud technique. They were then asked to consider all that they had learned about the program and complete the System Usability Scale that we adapted slightly to be appropriate for evaluating the proposed website.

Transcripts from the focus groups and usability tests were reviewed by research team members for overarching themes with particular emphasis on suggested changes. A list emerged, and iterative and incremental adjustments were made as a result.

Results

The qualitative and quantitative data gathered in the focus groups and usability sessions reported here suggest that the new mothers involved had largely positive reactions to the major features of the program and that those program features performed well in terms of usability.

Conclusions

An overview of the eventual design, architecture, and key program ingredients of the MomMoodBooster program is provided including innovative features supplementing 6 core CBT sessions, which include a partner’s website, a library, and individual feedback by a personal coach.

Sexual function in the postpartum period: effects of maternal depression and interpersonal psychotherapy treatment

Women's sexual functioning in the postpartum period is understudied given its potential impact on women's mental health and their relationships with their partners. The sexual functioning of women with postpartum depression (PPD) in particular is not well characterized. The goals of this study were to examine factors associated with the sexual functioning of postpartum women and to compare the long-term sexual functioning of depressed postpartum women treated with interpersonal psychotherapy with a group of postpartum women who had never been depressed. Depressed (120) and never depressed (56) postpartum women were enrolled. Self-report questionnaires and clinician-rated measures were completed at initial entry to study, immediately post-treatment, and at 6, 12, and 18 months post-treatment. Analyses revealed significant differences in sexual interest between depressed and never depressed postpartum women (t (171) = 11.82, p <0.001). Although sexual interest improved significantly following treatment for depression (t (104) = -3.18, p < 0.01), those women who fully recovered continued to experience less interest (F (2, 140) = 32.24, p < 0.0001) and less sexual satisfaction through 2 years postpartum than never depressed women. These findings suggest that differences in sexual functioning exist between depressed and never depressed postpartum women, even after depressed women are treated and have recovered from their depression. Clinicians should inquire about changes in sexual functioning when treating women with PPD.

Supportive psychotherapy for perinatal depression: preliminary data for adherence and response

BACKGROUND

We sought to determine patient factors associated with adherence and response to a manualized supportive psychotherapy designed for pregnant and postpartum women with major depressive disorder (MDD).

METHODS

Supportive psychotherapy was provided to all participants in parallel to a placebo-controlled trial of omega-3 fatty acids. The supportive psychotherapy was a six-session, manualized intervention. Clinicians recorded participation and adherence. Symptom rating scales were completed at baseline and every 2 weeks and included the Hamilton Depression Rating Scale (HAM-D) as the primary outcome. N=59 participants were enrolled. Subjects were referred by obstetrical and pediatric health-care providers. Descriptive statistics and general linear models were used to assess the study outcomes.

RESULTS

The mean number of completed sessions was 4.4 out of a full course of 6. There were no significant differences found between omega-3 fatty acid and placebo groups in the parallel assessments. We found significantly lower adherence to the psychotherapy sessions for women who were not married, were unemployed, and those with higher scores on the HAM-D at baseline. Completion of a greater number of psychotherapy sessions, lower baseline depression scores, and postpartum status (compared with pregnant status) were associated with lower final HAM-D scores. Overall, the response rate was 52.9% (> or =50% decrease on HAM-D scores), and the remission rate (final score<8) was 31.4%.

CONCLUSIONS

Study limitations included small sample size, and possible nonspecific and placebo effects. Adherence appears important in response to supportive psychotherapy in women with perinatal MDD, and future efforts to improve adherence in perinatal women with MDD are warranted.

Short-term in-home intervention reduces depressive symptoms in Early Head Start Latina mothers of infants and toddlers

Depressive symptoms may compromise the ability of low-income Latina mothers with limited English language proficiency to parent their infants or toddlers. Eighty Early Head Start Latina mothers with limited English language proficiency were randomized to an advanced practice nurse-delivered, culturally tailored, in-home psychotherapy intervention, or to usual care. Repeated measures regression analysis showed a significantly greater decrease in depressive symptoms for intervention mothers compared to the usual care group at 22 and 26 weeks (4 weeks post intervention). Intervention mothers' reports of their child's aggression diminished significantly from T1 to T4 compared to usual care mothers (p = .03). Self-efficacy appeared to only partially mediate the intervention effect, and maternal health moderated the intervention impact. Results indicate that the intervention reduced depressive symptoms and, compared to previous studies in this population, retention of mothers in both intervention and control conditions was improved.

Alleviating perinatal depressive symptoms and stress: a nurse-community health worker randomized trial

To determine whether a Nurse-Community Health Worker (CHW) home visiting team, in the context of a Medicaid enhanced prenatal/postnatal services (EPS), would demonstrate greater reduction of depressive symptoms and stress and improvement of psychosocial resources (mastery, self-esteem, social support) when compared with usual Community Care (CC) that includes Medicaid EPS delivered by professionals. Greatest program benefits were expected for women who reported low psychosocial resources, high stress, or both at the time of enrollment. Medicaid eligible pregnant women (N = 613) were randomly assigned to either usual CC or the Nurse-CHW team. Mixed effects regression was used to analyze up to five prenatal and postnatal psychosocial assessments. Compared to usual CC, assignment to the Nurse-CHW team resulted in significantly fewer depressive symptoms, and as hypothesized, reductions in depressive symptoms were most pronounced for women with low psychosocial resources, high stress, or both high stress and low resources. Outcomes for mastery and stress approached statistical significance, with the women in the Nurse-CHW group reporting less stress and greater mastery. Women in the Nurse-CHW group with low psychosocial resources reported significantly less perceived stress than women in usual CC. No differences between the groups were found for self-esteem and social support. A Nurse-CHW team approach to EPS demonstrated advantage for alleviating depressive symptoms in Medicaid eligible women compared to CC, especially for women at higher risk.

Psychothérapie interpersonnelle (PTI) et Counseling interpersonnel (CIP) pour le traitement de la dépression post-partum

La dépression périnatale est un trouble prévalent qui comporte un degré élevé de morbidité à la fois chez la mère et chez le nourrisson. De nos jours, on dispose de traitements validés empiriquement pour traiter tant la dépression post-partum que la dépression pendant la grossesse. Parmi ces traitements, la psychothérapie interpersonnelle (PTI) a démontré son efficacité à traiter la dépression post-partum, qu’elle soit légère ou grave. En fait, l’évidence limitée des preuves de l’efficacité de la médication et les préoccupations au sujet de ses effets secondaires ont porté certaines personnes à proposer que la PTI soit la première option retenue pour traiter les femmes souffrant de dépression et qui allaitent. Des préoccupations semblables persistent au sujet de l’usage de médicaments pendant la grossesse. De récentes expériences et recherches cliniques portent à croire que le counseling interpersonnel (CIP) pourrait aussi s’avérer efficace chez certaines femmes en dépression post-partum. Forme abrégée de la PTI, le CIP semble être efficace pour traiter la dépression légère à modérée, et a l’avantage potentiel d’être plus facile à dispenser dans le cadre des soins primaires ou des milieux obstétricaux.

Omega-3 fatty acids and supportive psychotherapy for perinatal depression: a randomized placebo-controlled study

BACKGROUND

Perinatal major depressive disorder (MDD), including antenatal and postpartum depression, is common and has serious consequences. This study was designed to investigate the feasibility, safety, and efficacy of omega-3 fatty acids for perinatal depression in addition to supportive psychotherapy.

METHODS

Perinatal women with MDD were randomized to eicosapentaenoic (EPA) and docosahexaenoic acids (DHA), 1.9g/day, or placebo for 8weeks. A manualized supportive psychotherapy was provided to all subjects. Symptoms were assessed with the Hamilton Rating Scale for Depression (HAM-D) and Edinburgh Postnatal Depression Scale (EPDS) biweekly.

RESULTS

Fifty-nine women enrolled; N = 51 had two data collection points that allowed for evaluation of efficacy. Omega-3 fatty acids were well tolerated. Participants in both groups experienced significant decreases in EPDS and HAM-D scores (p<.0001) from baseline. We did not find a benefit of omega-3 fatty acids over placebo. Dietary omega-3 fatty acid intake was low among participants.

LIMITATIONS

The ability to detect an effect of omega-3 fatty acids may have been limited by sample size, study length, or dose. The benefits of supportive psychotherapy may have limited the ability to detect an effect of omega-3 fatty acids.

CONCLUSIONS

There was no significant difference between omega-3 fatty acids and placebo in this study in which all participants received supportive psychotherapy. The manualized supportive psychotherapy warrants further study. The low intake of dietary omega-3 fatty acids among participants is of concern, in consideration of the widely established health advantages in utero and in infants.

Study of a group treatment program for postnatal adjustment difficulties

This study examined the impact of implementation of a structured 8-session psycho-educational and cognitive behavioural therapy skills group for postnatal adjustment. Forty-five women identified as experiencing antenatal adjustment problems attended the 8-week group. Participants completed the Edinburgh Postnatal Depression Scale, Beck Anxiety Inventory, and the Maternal Attitudes Questionnaire prior to and after attendance, as well as a feedback form in the final session. Following attendance, participant scores on measures of depression, anxiety, and attitudes to mothering improved significantly. Further research is needed to contrast the group to a control condition and to determine group effects are maintained over time.

Patient compliance to psychiatric interventions and course of postpartum mood disorders

OBJECTIVE

Patient compliance to the psychiatric interventions may affect the outcomes of the mothers with postpartum mood disorders. The aim of this study was to assess the course of depressive symptoms of compliant and noncompliant mothers with postpartum mood disorders.

METHOD

One hundred-three mothers were followed with the Edinburgh Postnatal Depression Scale (EPDS) during 12-month follow-up period. Mothers with an EPDS score of 12 or higher were consulted with a psychiatrist. "Noncompliant patient" term was defined in this study for the patients who refused psychiatric consultation or treatment suggestions. Outcomes of the depressive symptoms were followed up according to the EPDS scores. Response rate based EPDS scoring was defined.

RESULTS

A total of 35 (34%) mothers received a higher EPDS score; 28 (27.2%), who accepted the consultation, were diagnosed with postpartum mood disorder. Twenty-three mothers (10 mothers with major depressive disorder and 13 mothers with adjustment disorder) complied with treatment suggestions, and all of them responded to the treatment. EPDS scores was more likely to decrease in these compliant mothers (p = 0.010). However, of the noncompliant mothers (n = 12), only 50% responded to treatment; moreover, the drop out rate was quite high (58.3%).

CONCLUSIONS

This study reveals that noncompliance to psychiatric interventions may lead to a much less favorable course in depressive symptoms, and to a tendency in drop-outs from visits. Health professionals can give advice to the mothers about postpartum mood disorders and could assist them in getting better outcome.

Stepped care treatment of postpartum depression: a primary care-based management model

BACKGROUND AND PURPOSE

Postpartum depression (PPD), the most prevalent serious postpartum complication, is a devastating illness that negatively impacts not only the mother, but also her infant, other family members, and work performance. There is an extensive body of research addressing systems-based quality improvement efforts for treatment of depression in primary care populations; however, little of this research has been directed toward postpartum populations. This paper presents a health care systems-based quality improvement model for the treatment of PPD derived from research outcomes in general primary care populations.

METHODS

OVID/MEDLINE and PsychINFO searches were performed using the following terms: depression, postpartum depression, mass screening, collaborative care, stepped care, psychotherapy, cognitive-behavioral therapy, interpersonal therapy, and education as keywords.

MAIN FINDINGS

The PPD management model described herein includes screening and diagnosis, initiation of active treatment, and use of collaborative care, which includes primary care visits, case manager follow-up, and more intensive care, through specialty consultation or referral, for complicated or difficult cases.

CONCLUSION

Stepped care, a form of collaborative depression treatment, is proposed as a practical, cost-effective method for improving PPD diagnosis and clinical outcomes.

Supporting the mental health of mothers raising children in poverty: how do we target them for intervention studies?

Poverty increases maternal stress by heightening exposure to negative life events, job loss, chronic strains, poor housing, dangerous neighborhoods, and conflict with partners, culminating in crippling depressive symptoms, the most prevalent mental health threat. Depressive symptoms interfere with the provision of the strong maternal support needed to counter the hardships of poverty, thus placing infants and toddlers at risk for delayed language, social, and emotional development. Initial clinical trials in high-risk mothers have shown promise, and successive tests of interventions will be strengthened if mothers who have mental health risks can be accurately targeted for inclusion. This article reports on a sequential, data-driven process by which high-risk mothers were targeted for intervention in two trials currently in progress to reduce depressive symptoms. An iterative process of using data to identify at-risk mothers and validate the presence of risk factors helped hone the recruitment and design of the intervention trials. This report also offers guidance for further study.

Patient choice of treatment for postpartum depression: a pilot study

OBJECTIVE

The lack of systematic efficacy research makes the selection of optimal treatment for postpartum depression (PPD) difficult. Moreover, the treatment decisions for women with PPD who are breastfeeding are heavily influenced by their concerns about infant exposure to antidepressant medication. The objective of this pilot trial was to examine the clinical characteristics of women with PPD associated with treatment selection.

METHOD

This open pilot trial offered 23 women with PPD one of 3 treatment options: sertraline, interpersonal psychotherapy (IPT), or their combination administered in an outpatient mental health setting over 12 weeks. Baseline and treatment outcome measures included the Hamilton Rating Scale for Depression (HRSD), the Beck Depression Inventory (BDI) and the Edinburgh Postnatal Depression Scale (EPDS).

RESULTS

Completers across all 3 treatment groups (n = 18) experienced significant clinical improvement with each of the 3 treatment modalities on the HRSD (p < 0.001), BDI (p < 0.001) and EPDS (p < 0.001). There were trends for women with a prior depression to more frequently choose sertraline as a treatment (alone or with IPT, p = 0.07), and for women who were breastfeeding to choose sertraline (alone or with IPT, p = 0.10) less frequently.

CONCLUSION

In this small sample of women with PPD, most women chose IPT with or without sertraline. A larger randomized study could further confirm the suggested predictors of treatment selection identified in this study: previous depression and breastfeeding status.

Postpartum depression in women with epilepsy versus women without epilepsy

The goal of this study was to determine if there is a significant difference in the rate of postpartum depression among patients with epilepsy and healthy controls. All patients were recruited from the Epilepsy Center and the Department of Obstetrics and Gynecology, University of Milan, St. Paolo Hospital (Milan, Italy). Thirty-five pregnant women with epilepsy and an equal number of pregnant women without epilepsy were assessed with the Edinburgh Postnatal Depression Scale (EPDS), a clinical interview used to screen for postpartum depression (PPD), and a sociodemographic questionnaire. The rate of PPD in patients with epilepsy was statistically significantly higher than that of the controls (P<0.05). PPD was present in 29% of the patients with epilepsy and 11% of the controls. In conclusion, it is very important to point out that in our pilot study, the rate of PPD was higher among women with epilepsy than among women without epilepsy. In this regard, women at higher PPD risk can be identified earlier and treated as soon as possible to alleviate their symptoms and improve their quality of life.

Evaluation of a web-based course for community nurses on postpartum emotional distress

The purpose of this multicentre and quasi-experimental study is to evaluate the effect of a web-based course for community nurses in Iceland with regard to outcome of postpartum emotional distress. A sample of six community health centres was selected and equally divided into an experimental and a control group. All nurses at the experimental centres attended a web-based course focusing on evidence-based interventions for postpartum emotional distress. All new mothers were screened 9 weeks postpartum using the Edinburgh Postpartum Depression Scale (EPDS). If they scored 12 points or more they were eligible for the study. Mothers answered the EPDS at three different points in time, (9, 15 and 24 weeks postpartum) and the Parent Stress Index: Short Form (PSI/SF) at two times (9 and 15 weeks). Results showed no significant difference in the rate of depressive symptoms between study centres at 9 weeks. At 15 and 24 weeks there was, however, a significant difference between mothers at the experimental and control centres. Nurses at the experimental centres documented significantly more evidence-based interventions than did nurses at the control centres, and they had more frequent contact with new mothers suffering from postpartum emotional distress. There was no significant variation in PSI scores between the groups at any time. More women at the experimental centres were on antidepressants compared to the control centres. Of the total of 32 women eligible for the study, 10 declined participation. The findings are limited by small sample size and a probable confounding effect of antidepressants with the nursing interventions. Findings indicate that the web-based transfer of knowledge to nurses on evidence-based interventions for postpartum emotional distress has a positive effect on distressed women in the postpartum period and warrants further study.

Multicentre prospective study of perinatal depression in Japan: incidence and correlates of antenatal and postnatal depression

A multicentre study on the epidemiology of perinatal depression was conducted among Japanese women expecting the first baby (N = 290). The incidence rate of the onset of the DSM-III-R Major Depressive Episode during pregnancy (antenatal depression) and within 3 months after delivery (postnatal depression) were 5.6% and 5.0%, respectively. Women with antenatal depression were characterised by young age and negative attitude towards the current pregnancy, whereas women with postnatal depression were characterised by poor accommodation, dissatisfaction with sex of the newborn baby and with the emotional undermining. Antenatal depression was a major risk factor for postnatal depression.

Group interpersonal psychotherapy for postnatal depression: a pilot study

We conducted a pilot study to assess the potential effectiveness of group interpersonal psychotherapy (IPT-G) as a treatment for postnatal depression (PND). The study was also established to test a treatment manual for IPT-G, assess the acceptability of this format for participants and test a recruitment strategy for a randomised controlled trial. 18 mothers diagnosed with PND participated in 2 individual session and 8 sessions of group IPT. A two-hour psychoeducational session was also held for the partners of the participants. Measures of depressive symptomatology and social adjustment were administered by an independent clinician at baseline, 4 weeks, 8 weeks and 3 months post treatment. Patient satisfaction with the treatment was also evaluated. Severity scores on the BDI, EPDS and the HDRS decreased from pre- to post-treatment. This was maintained at three months follow up. No overall improvement in the Social Adjustment Scale-Self Report was noted, although there was improvement in their relationship with their significant other. The results confirm previous work that IPT-G may improve symptom severity for women suffering from postnatal depression. Limitations included the use of antidepressant therapy by 67% of subjects and the lack of a control group. There is a need for further randomised controlled trials of IPT-G with larger sample sizes to establish its effectiveness as treatment for PND.

Social skill in self-assertive strategies of toddlers with depressed and nondepressed mothers

The authors examined the effects of maternal depression on the skillfulness of toddlers' self-assertive strategies in interactions with their mother and with a female examiner. The participants were 110 mothers and their 26-month-old toddlers. Of these mothers, 57 had experienced an episode of clinical depression sometime since their child's birth, and 53 had had no history of depression. Toddlers exposed to maternal depression demonstrated significantly less social skill in their self-assertive strategies and more defiance when interacting with their mothers than did toddlers who were never exposed to maternal depression. The chronicity and severity of toddlers' exposure to maternal depression did not account for more pronounced differences in toddlers' skill in self-assertion toward mothers; however, toddlers exposed to more chronic courses of depression demonstrated less skill in their self-assertion toward the examiner. Toddlers who were exposed to maternal depression with a comorbid anxiety disorder did not exhibit less skill in their self-assertion toward mothers than did toddlers in either the depression-only or nondepressed groups. These findings suggest that exposure to maternal depression may interfere with toddlers' development of socially competent self-assertion strategies and may pose risks for future problems in the mother-toddler relationship.