Web-based education for postpartum depression: conceptual development and impact

A systematic review of screening for perinatal depression and anxiety in community-based settings

Screening for perinatal depression and anxiety in community-based maternal and child health settings may help close the detection and treatment gap among women at higher risk for these conditions. We aim to review perinatal depression and anxiety screening tools, timing, and follow-up processes for positive screens in community-based settings. We conducted a systematic review of the literature to identify papers describing screening and interventions for perinatal depression and anxiety in community-based settings. We identified 49 papers describing 47 studies of perinatal depression or anxiety screening in community-based settings. The Edinburgh Postnatal Depression Scale (EPDS) was the most frequently used screening tool. Referral and referral tracking for those who screened positive for symptoms were inadequately described. Types of training and technical assistance provided for screening varied widely. It is feasible and acceptable to screen for perinatal depression in community settings, but there is a need for systematic research examining which screening tools to use, the ideal frequency of screening, and referral completion rates. There is a lack of information regarding perinatal anxiety screening and a lack of uniformity in training regarding screening in community-based settings. Future studies should compare the efficacy of screening in community-based settings to screening in healthcare settings.

A systematic review of interventions for healthcare professionals to improve screening and referral for perinatal mood and anxiety disorders

Postpartum depression affects approximately 11% of women. However, screening for perinatal mood and anxiety disorders (PMAD) is rare and inconsistent among healthcare professionals. When healthcare professionals screen, they often rely on clinical judgment, rather than validated screening tools. The objective of the current study is to review the types and effectiveness of interventions for healthcare professionals that have been used to increase the number of women screened and referred for PMAD. Preferred Reporting Items for Systematic Reviews and Meta-Analyses was utilized to guide search and reporting strategies. PubMed/Medline, PsychInfo/PsychArticles, Cumulative Index to Nursing, Allied Health Literature (CINAHL), and Health Source: Nursing/Academic Edition databases were used to find studies that implemented an intervention for healthcare professionals to increase screening and referral for PMAD. Twenty-five studies were included in the review. Based on prior quality assessment tools, the quality of each article was assessed using an assessment tool created by the authors. The four main outcome variables were the following: percentage of women screened, percentage of women referred for services, percentage of women screened positive for PMAD, and provider knowledge, attitudes, and/or skills concerning PMAD. The most common intervention type was educational, with others including changes in electronic medical records and standardized patients for training. Study quality and target audience varied among the studies. Interventions demonstrated moderate positive impacts on screening completion rates, referral rates for PMAD, and patient-provider communication. Studies suggested positive receptivity to screening protocols by mothers and providers. Given the prevalence and negative impacts of PMAD on mothers and children, further interventions to improve screening and referral are needed.

Postpartum Depression Screening: A Review for Psychiatrists

LEARNING OBJECTIVES

After participating in this activity, learners should be better able to:• Evaluate the rationale for screening women for postpartum depression• Assess tools for screening for postpartum depression

OBJECTIVE

To perform a qualitative literature review on screening for postpartum depression (PPD), as applicable to the general psychiatrist. Results are classified by instrument, timing, and clinical setting of the screen.

DATA SOURCES

A literature search was conducted using the PubMed database for English-language articles published since January 1987. Of the 2406 citations initially identified, 61 articles remained after application of inclusion and exclusion criteria.

RESULTS

Among numerous screening tools for PPD, the Edinburgh Postnatal Depression Scale is the most widely used. Data suggest that screening for PPD should commence soon after delivery, with subsequent screens at multiple time-points in the postpartum period. Primary care, pediatric, and obstetric settings are all viable locations for screening, but are ineffective without follow-up mental health evaluations. Less data are available to define optimal patterns either for screening in psychiatric settings or for the psychiatrist's role in managing perinatal depression.

CONCLUSIONS

The American Congress of Obstetricians and Gynecologists, American Academy of Pediatrics, and most authors firmly recommend screening for PPD. The Edinburgh Postnatal Depression Scale can be administered in various clinical settings. Screening should occur at multiple time-points throughout the first postpartum year. The psychiatrist's role in early detection and prevention of PPD requires further exploration.

Online prevention of postpartum depression for Spanish- and English-speaking pregnant women: A pilot randomized controlled trial

BACKGROUND

Postpartum depression (PPD) is a maternal mental health problem that affects women from all regions of the world. Unfortunately, even in developed countries, half of the cases go undetected and, consequently, untreated. Individuals from low and middle income countries trend toward underutilization of mental health services, partly due to the limited number of available psychological resources. The primary aims of this pilot randomized controlled trial were to adapt to the Internet the Mothers and Babies Course/Curso Mamás y Bebés, a prevention of PPD intervention, to describe the characteristics of the pregnant women who engaged in the intervention site, and to obtain preliminary data on the efficacy of the Internet intervention to reduce the risk of PPD.

METHODS

Pregnant women, 18 years or older who were interested in using the site for themselves were recruited and randomly assigned to a fully-automated self-help Internet intervention or to an information-only control condition. Randomized participants were invited to complete monthly depression assessments up to six months postpartum. To examine the prevention effects of the Internet intervention, pregnant women who did not meet current criteria for a major depressive episode, who engaged with the study website, and who provided depression data during the postpartum follow-up period were included in the study analyses.

RESULTS

Participants were 111 predominantly Spanish-speaking (82.9%) and Latino/Hispanic (71.3%) pregnant women residing in 23 countries worldwide. The effect of the prevention intervention condition failed to reach significance at the a priori alpha-level. However, the observed coefficient trended in the hypothesized direction (b = -0.514, χ² (1) = 3.43, p = .061; HR = 0.598). The benefits of receiving the e-MB Internet intervention was greater for pregnant women reporting high (vs. low) levels of prenatal depression symptoms (b = -0.605, χ² (1) = 5.20, p =.023).

CONCLUSIONS

This study provides preliminary evidence that Internet interventions are a promising method toward expanding the reach of psychological resources to perinatal women at-risk for PPD.

Keywords to recruit Spanish- and English-speaking participants: evidence from an online postpartum depression randomized controlled trial

Background

One of the advantages of Internet-based research is the ability to efficiently recruit large, diverse samples of international participants. Currently, there is a dearth of information on the behind-the-scenes process to setting up successful online recruitment tools.

Objective

The objective of the study was to examine the comparative impact of Spanish- and English-language keywords for a Google AdWords campaign to recruit pregnant women to an Internet intervention and to describe the characteristics of those who enrolled in the trial.

Methods

Spanish- and English-language Google AdWords campaigns were created to advertise and recruit pregnant women to a Web-based randomized controlled trial for the prevention of postpartum depression, the Mothers and Babies/Mamás y Bebés Internet Project. Search engine users who clicked on the ads in response to keyword queries (eg, pregnancy, depression and pregnancy) were directed to the fully automated study website. Data on the performance of keywords associated with each Google ad reflect Web user queries from February 2009 to June 2012. Demographic information, self-reported depression symptom scores, major depressive episode status, and Internet use data were collected from enrolled participants before randomization in the intervention study.

Results

The Google ads received high exposure (12,983,196 impressions) and interest (176,295 clicks) from a global sample of Web users; 6745 pregnant women consented to participate and 2575 completed enrollment in the intervention study. Keywords that were descriptive of pregnancy and distress or pregnancy and health resulted in higher consent and enrollment rates (ie, high-performing ads). In both languages, broad keywords (eg, pregnancy) had the highest exposure, more consented participants, and greatest cost per consent (up to US $25.77 per consent). The online ads recruited a predominantly Spanish-speaking sample from Latin America of Mestizo racial identity. The English-speaking sample was also diverse with most participants residing in regions of Asia and Africa. Spanish-speaking participants were significantly more likely to be of Latino ethnic background, not married, completed fewer years of formal education, and were more likely to have accessed the Internet for depression information (P<.001).

Conclusions

The Internet is an effective method for reaching an international sample of pregnant women interested in online interventions to manage changes in their mood during the perinatal period. To increase efficiency, Internet advertisements need to be monitored and tailored to reflect the target population’s conceptualization of health issues being studied.

Trial Registration

ClinicalTrials.gov NCT00816725; http://clinicaltrials.gov/show/NCT00816725 (Archived by WebCite at http://www.webcitation.org/6LumonjZP).

Perinatal depression: a review of US legislation and law

Accumulating research documenting the prevalence and negative effects of perinatal depression, together with highly publicized tragic critical incidents of suicide and filicide by mothers with postpartum psychosis, have fueled a continuum of legislation. Specialists in perinatal mental health should recognize how their work influences legislative initiatives and penal codes, and take this into consideration when developing perinatal services and research. Yet, without legal expertise, the status of legislative initiatives can be confusing. To address this shortfall, we assembled an interdisciplinary team of academics specializing in law, as well as perinatal mental health, to summarize these issues. This review presents the relevant federal and state legislation and summarizes the criminal codes that governed the court decisions on cases in which a mother committed filicide because of postpartum psychosis. Moreover, the review aims to help researchers and providers who specialize in perinatal depression understand their role in this legal landscape.

Perinatal depression screening in healthy start: an evaluation of the acceptability of technical assistance consultation

In 2001, Healthy Start was required to screen for maternal depression. To support this mandate, technical assistance (TA) consultations were provided to eleven programs. Participant evaluations assessed TA recipients' views, a foundational level of program evaluation. Staff evaluated TA presentations immediately; and directors assessed its helpfulness in a 6-month and a 5-year follow-up. Staff believed their knowledge increased significantly; the majority rated TA presentations as "useful" to "very useful." Most directors rated TA as "useful" or "very useful" in achieving TA goals, reported having "few" or "no" obstacles in screening, and rated staff as "willing" or "very willing" to screen. A range of educational programs have been developed to assist the implementation of maternal depression screening. The current evaluation indicates that diverse types of programs held positive views of TA consultation and believed it was effective. The success of the method argues for further development.

Web recruitment and internet use and preferences reported by women with postpartum depression after pregnancy complications

Nearly one million women each year have pregnancy complications that cause antepartum and postpartum anxiety and depression. This exploratory study determined 1) feasibility of using social media to recruit women with depressive symptoms following high risk pregnancy, 2) women's barriers to treatment, 3) use of online resources for assistance with PPD, and 4) preferences for internet treatment. Among a national sample of 53 women, nearly 70% had major depression. Common barriers were lack of time and stigma. Over 90% of women would use the internet to learn coping strategies for PPD. Women expressed interest in web-based PPD treatment and identified desired characteristics of an intervention.

Effect of Postpartum Practices of Doing the Month on Chinese Women’s Physical and Psychological Health

The purpose of the study was to describe Chinese women’s postpartum physiological and psychological health and adherence to “doing-the-month” practices. A descriptive repeated measures design was used, with data collected at 3 days and 6 weeks postpartum. The convenience sample consisted of 198 healthy childbearing women with a term birth. Maternal physical health was measured by the Six-Minute Walk (endurance), Chair Stand test (muscle strength), severity of physical symptoms, and physical health subscales of SF36v2. Maternal psychological health was measured by the Edinburgh Postnatal Depression scale. Adherence was measured by the Adherence to Doing-the-Month Practices questionnaire. Aerobic endurance and lower-body muscle strength improved significantly across time ( p < .001) but remained suboptimal for maternal age. Women who delivered by Cesarean section had significantly poorer physical health than those who had a vaginal delivery. Physical functioning significantly increased, but general health and role limitations due to physical health significantly decreased over time. Postpartum physical symptoms decreased in number and severity. Depression increased over time ( p < .001). Adherence to doing the month was negatively correlated with aerobic endurance and positively correlated with depression at 6 weeks ( p < .05). These findings challenge the assumption that practices of doing the month are healthy for Chinese women’s recovery after childbirth. Research-based evidence needs to be integrated into doing-the-month practices. Education of Chinese women and families, whether living at home or abroad, is needed about the adverse health effects of doing the month. Routine screening for postpartum depression is also advised.

Recognizing and treating peripartum depression

BACKGROUND

In this article, we review current data on the prevalence of, risk factors for, and treatment of peripartum depression.

METHOD

Pertinent publications were retrieved by searches in Medline and the Cochrane Library using the key words "peri/pre/post", "partum/partal/natal", "maternal/motherhood/pregnancy", and "depression/affective disorder".

RESULTS

Depression is the most common peripartal disease: The prevalence of depressive disorders is 18.4% during pregnancy and 19.2% in the puerperium. Prepartum depression is associated with preterm birth, low birth weight, and an abnormal fetal heart rate. In the long run, children of depressed mothers have been found to have impaired cognitive and emotional abilities. Risk factors for peripartal depression include prior depression, poor social support, poor quality of intimate relationship, and negative live events. Peripartum depression can be treated effectively with psychotherapy or drug therapy. Current data support the use of antidepressants during pregnancy and breastfeeding. In many places, pregnancy counseling centers offer low-threshold psychosocial assistance. Nonetheless, no more than 20% of the affected women are identified, even though rapid screening would be possible with instruments such as the Edinburgh Postnatal Depression Scale (EPDS) and the two Whooley questions.

CONCLUSION

Peripartum depression is both common and treatable. Screening for depression should become a routine part of both prepartum care by gynecologists and postpartum care by midwives. This will only be possible, however, with expanded availability of ambulatory and inpatient psychotherapy and psychiatric care for the affected women and their children.

Support intervention needs and preferences of fathers affected by postpartum depression

The effect of postpartum depression (PPD) on mothers has been extensively studied. But even though up to 50% of men whose partners suffer from PPD also have depressive symptoms, little is known about the impact of maternal PPD on fathers. Depressive symptoms are likely to decrease fathers' ability to provide maternal support. Children with 2 depressed parents are at significantly greater risk for poor developmental outcomes than those with 1 affected parent. The objective of this Canada-wide exploratory/descriptive study was to describe the support needs and preferences for support of fathers whose partners have had PPD. Qualitative methods and community-based research approaches were used, and one-to-one telephone interviews were conducted between 2009 and 2011 with a total of 40 fathers. Fathers desired support from both formal (professional) and informal (friends and family) sources and noted that ideal support interventions should cover a number of key topics including information on PPD and practical tips on how to cope with their partner's PPD. Fathers reported that the ideal PPD intervention program does not favor any one setup and, to reach the full spectrum of parents, the program must be multitiered, accessible, and as flexible as funding allows.

Disseminating perinatal depression screening as a public health initiative: a train-the-trainer approach

This case report describes the development and implementation of the Train-the-Trainer: Maternal Depression Screening Program (TTT), a novel approach to disseminating perinatal depression screening. We trained screeners according to a standard pyramid scheme of train-the-trainer programs: three experts trained representatives from health care agencies (the TTT trainers), who in turn trained their staff and implemented depression screening at their home agencies. The TTT trainers had little or no prior mental health experience so "enhanced" components were added to ensure thorough instruction. Although TTT was implemented primarily as a services project, we evaluated both the statewide dissemination and the screening rates achieved by TTT programs. Thirty-two social service or health agencies implemented maternal depression screening in 20 counties throughout Iowa; this reached 58.2% of the Iowa population. For the 16 agencies that provided screening data, the average screening rate (number of women screened/number eligible to be screened) for the first 3 months of screening was 73.2%, 80.5% and 79.0%. We compared screening rates of our TTT programs with those of Healthy Start, a program in which screening was established via an intensive consultation model. We found the screening rates in 62.5% of TTT agencies were comparable to those in Healthy Start. Our "enhanced" train-the-trainer method is a promising approach for broadly implementing depression-screening programs in agencies serving pregnant and postpartum women.

The complexity of postpartum mental health and illness: a critical realist study

The complexity of postpartum mental health and illness: a critical realist study Postpartum depression (PPD) is a major public health issue that profoundly impacts the woman, her infant and family. Although it may be linked to hormone changes, no direct hormonal aetiology has been established. A large body of evidence implicates numerous psychosocial predictors of PPD. While a history of depression predicts about 50% of cases of PPD, it remains unclear why some women with a history do not develop depression following childbirth, even taking psychosocial factors into account. The aim of this study was to identify the main mechanisms and factors associated with the presence or absence of PPD in women with a history of depression, and the presence of PPD in women without a history, using a critical realist approach. The findings indicate a number of personal and contextual factors that influence postpartum mental health and illness. In addition, and perhaps most importantly, women who did not develop depression identified goal-oriented actions that were protective. These factors and processes did not exist in isolation and the interplay among them in influencing health was apparent. More research is needed to explore the effects of these mechanisms in different contexts.

Internet use among patients with psychosomatic disorders: what are the health-related demands and needs?

While Internet-based health-related offers for various disorders are increasing, little is known about the way patients with psychosomatic disorders use the Internet. We conducted a questionnaire survey in outpatient clinics at two university hospitals' Departments of Psychosomatic Medicine. Seventy-four percent of N = 274 patients had Internet home access and 60 percent of those patients reported health-related Internet use. Patients expressed the wish for more professional, evidence-based online information and expert-guided treatment. The survey results support the Internet's high potential in future treatment strategies for patients with psychosomatic disorders.

The many faces of depression in primary care

Depression is a serious global health problem. It creates a huge economic burden on society and on families and has serious and pervasive health impacts on the individual and their families. Specialized psychiatric services are often scarce and thus the bulk of care delivery for depression has fallen to primary care providers, including advanced practice nurses and experienced nurses who work in under-serviced regions. These health professionals require advanced knowledge about the many faces that depression can display. This article reviews some of the faces of depression seen by primary care providers in their practices. Considering depression as a heterogeneous spectrum disorder requires attention to both the details of the clinical presentation, as well as contextual factors. Recommendations around engagement and potential interventions will also be discussed, in terms of the client population as well as for the practitioner who may be isolated by geography or discipline.