Using the internet to screen for postpartum depression

Postpartum Depression Screening Scale: Its Availability for Use

OBJECTIVE

A silent health crisis in the United States is the underdiagnosed and undertreated mental health of women related to childbirth. This discussion paper describes the Postpartum Depression Screening Scale (PDSS) with its scoring and interpretation along with its psychometric testing and translations.

METHOD

In addition to the studies conducted by the instrument developers, databases were searched for studies where other researchers used the PDSS to assess postpartum depressive symptoms. Studies were included that measured the psychometrics of the scale and studies that reported the translation of the PDSS into other languages.

RESULTS

Evidence is presented that the PDSS is a reliable and valid screening scale for use by psychiatric mental health nurses and other health care providers. The scale also has been translated into 14 languages, so it is available to screen non-English speaking mothers.

CONCLUSION

Childbirth is one of the most powerful triggers of psychiatric illness in a woman's life. Postpartum depression is a treatable mental health condition, but first, women need to be screened so they can be identified and referrals made. Screening for this devastating mood disorder in new mothers is an essential role of psychiatric mental health nurses and other clinicians so that treatment can be started as early as possible to avoid harmful consequences.

Effectiveness of the third wave cognitive behavior therapy for peripartum depression treatment-A systematic review

INTRODUCTION

To investigate the effectiveness of third-wave cognitive behavior therapies in the treatment of peripartum depression.

METHOD

A systematic review of the effectiveness of psychological interventions in treating peripartum depression focus on the Third Wave has been conducted. The electronic databases MEDLINE, PsycINFO, Web of Science and Clinical Trials were searched, using a combination of different search terms. Data were independently extracted by two authors and a synthesis of the results was offered. Methodological quality was assessed by three authors, using ROBE-2 and MINORS. Search date was conducted in February 2022 and the search was re-run in November 2022 for new entries.

FINDINGS

Six papers were included and reported, focused on, the effectiveness of Third Wave approach interventions in reducing depressive symptoms. Papers included the following intervention approaches: Behavioral intervention (n = 2), Mindfulness (n = 2), Dialectical Behavior Therapy (n = 1) and Acceptance and Commitment Therapy (n = 1). All six papers were consistent in that interventions lead to a decrease in depression symptoms. However, risk of bias evaluation showed that all were critical low, but one paper was high quality.

CONCLUSION AND IMPLICATIONS FOR PRACTICE AND RESEARCH

Systematic review showed that third-wave approaches are promising in effectiveness to reduce depression symptoms in peripartum women. However, more high-quality studies with follow-up are needed.

Routine E-Screening for Perinatal Mental Health During the COVID-19 Emergency: Beyond the Instrument Cut-Off Points

The COVID-19 pandemic represents a significant risk factor for mental distress in perinatal women. Assessment for mental health issues should therefore be an integral part of safeguarding health at every stage of pregnancy and postpartum. Considering the impact of the COVID-19 pandemic on the planning of healthcare services locally, it is important to employ information-gathering techniques such as seeking feedback from both patients and staff. E-screening conforms to stay-at-home COVID restrictions and can improve the efficiency of mental healthcare. The symptomatologic levels indicated by the cut-off points, as well as the real time concerns expressed by perinatal women through open questions, are valuable on many levels. Future studies are needed not only on the sensitivity of the e-screening routines in the context of daily clinical practice, but also on the deeper meaning of the personal concerns reported in e-screening open questions in both positive and negative screening environments.

The PPD-ACT app in Canada: feasibility and a latent class analysis of participants with postpartum depression recruited to a psychiatric genetics study using a mobile application

BACKGROUND

Postpartum depression (PPD) and postpartum psychosis (PPP) are linked to negative consequences for women and families. Virtual applications present a solution to the challenge of recruiting large samples for genetic PPD/PPP research. This study aimed to evaluate the feasibility of a protocol for enrolling Canadian women with PPD and PPP to a large international psychiatric genetics study using a mobile application (PPD-ACT), and identify clinically distinct subtypes of PPD in the recruited sample.

METHODS

From April 2017-June 2019, Canadian women provided phenotypic data through the PPD-ACT app. Requests for a genetic sample were made from those with a current or past PPD episode based on an Edinburgh Postnatal Depression Scale (EPDS) score > 12 with onset in pregnancy or 0-3 months postpartum, and from those self-reporting lifetime PPP. Latent class analysis (LCA) was used to identify clinically distinct PPD subgroups based on participant responses to the EPDS scale.

RESULTS

We identified 797 PPD cases, 404 of whom submitted DNA. There were 109 PPP cases, with 66 submitting DNA. PPD cases (86.7% White, mean 4.7 +/- 7.0 years since their episode) came from across Canadian provinces/territories. LCA identified two PPD classes clinically distinct by symptom severity: [1] moderate-severity (mean EPDS = 18.5+/- 2.5; 8.6% with suicidality), and [2] severe (mean EPDS = 24.5+/- 2.1; 52.8% with suicidality).

CONCLUSIONS

A mobile application rapidly collected data from individuals with moderate and severe symptoms of PPD, an advantage for genetics where specificity is optimal, as well as from women with a history of PPP, supporting future work using this approach.

Mother-infant bonding screening in a sample of postpartum women: comparison between online vs offline format

AIMS

We aim to study the the reliability and factorial structure of the Postpartum Bonding Questionnaire (PBQ)administered through two different formats, offline (paper-and-pencil) and online. We also compared clinical, obstetrical, reproductive, and psychopathological variables related to poor mother infant bonding (MIB).

METHODS

A cross-sectional study was conducted on 1,269 mothers. The offline group included 812 women who attended a 40-day postpartum clinical appointment. The online group consisted of 457 women recruited during admission for delivery who volunteered to carry out the online protocol 40 days postpartum. All the participants individually completed the PBQ, the Edinburg Postnatal Depression Scale (EPDS) and other clinical and sociodemographic variables.

RESULTS

The 4-factor solution proposed in the PBQ and its Spanish validation showed good model fit for both samples. Online participants reported higher levels of stress, depressive symptoms, and poor bonding, specifically on PBQ scores and the Rejection and Anger subscales. No differences were found in both samples regarding the type of statistical associations between PBQ and sociodemographic, reproductive, obstetric and psychological outcomes.

CONCLUSION

Online assessment may be an appropriate option for detecting possible alterations in MIB due to the reduction of desirability bias, the increased perception of anonymity, and being a more cost-effective method.

Treating postpartum depression in rural veterans using internet delivered CBT: program evaluation of MomMoodBooster

Depression in the postpartum period impacts approximately 13–26% of the general population. This number can be much higher for rural veteran women who face additional barriers to accessing specialized mental health services due to isolation and cultural factors. This study reports on a program evaluation of MomMoodBooster, a coach-supported internet-delivered CBT program for the treatment of maternal depression in veteran women. Repeated measures ANOVA, run with this sample of 326 women, demonstrated an overall positive effect size across outcome measures and engagement with no differences found between rural women and their urban counterparts. Some differences between urban and rural participants were found in total and average time spent with coaches as well as ratings of coach helpfulness, possibly indicating some cultural differences between coaches and rural women that need to be addressed. These results and the results of earlier trials suggest that MomMoodBooster can be a valid and efficacious option for reaching under-served veteran populations with specialized postpartum mental health support and is as effective with rural women as with urban women

Perinatal mental health and psychosocial risk screening in a community maternal and child health setting: evaluation of a digital platform

Background

Screening women for depression and psychosocial risk during the perinatal period is recognised best practice. Screening by current pen and paper methods can be time consuming, and prone to scorer error. The lack of readily available translated versions of screening tools also excludes many women from different cultures.

Aim

To evaluate a perinatal mental health digital screening platform, iCOPE. The trial was conducted in a community maternal and child health setting in Melbourne, Australia.

Method

A descriptive, cohort design was used. All women attending the urban clinic were invited to complete their routine perinatal screening on the digital platform, designed to automate score calculations and produce instant clinical and client reports whilst collecting data in real time. Screening included the Edinburgh Postnatal Depression Scale (EPDS) and psychosocial risk questions in line with current national clinical guidelines. Functionality of iCOPE was assessed according to duration of screening, completion rates, accuracy of reporting and level of engagement by women.

Results

During the trial, 144 screens were performed. The mean screening time was 6.7 min (SD=3.78). Most (65.7% n=94) women took between 3 and 6 min. Mean EPDS score was 7.2 with 16% (n=23) scoring 13 or more. The accuracy of reports was 100% and screening completion rate was 99.3%. Many women (81.3%) requested a copy of their personal report.

Discussion

The iCOPE platform was efficient in terms of screening time, scoring accuracy, and engagement of women. The automated production of tailored client and clinical reports enabled screening outcomes to be instantly communicated to women and health professionals. The collection of data in real time facilitated the monitoring of screening rates and evaluation of outcomes by clinicians and service managers.

Measuring outcomes of digital technology-assisted nursing postpartum: A randomized controlled trial

AIM

To determine if delivering electronic messages from nurses during the first 6 months postpartum is feasible, acceptable and effective in improving mood and decreasing parenting stress.

BACKGROUND

Competing demands during the postpartum hospitalization make focused time for nurses to provide education and support difficult. Unmet needs following discharge may increase the incidence of postpartum depression. Untreated depression negatively affects families, especially for vulnerable women with limited access to health care.

DESIGN

This is a longitudinal cohort study in three phases. Feasibility and acceptability were assessed during Phases 1 & 2. Phase 3 is a randomized controlled trial (RCT) with three conditions.

METHODS

This protocol was approved by the Institutional Review Board of the maternity hospital on 12 May 2015 and reviewed annually. Women are enrolled during the maternity hospitalization, after which randomization occurs. The control group receives usual care. Intervention I participants receive a standardized electronic message four times/week for 6 months postpartum. Intervention II participants receive the messages and the option to request a call from a nurse. Electronic surveys at 3 weeks, 3 months and 6 months postpartum measure depressive symptoms using the Edinburgh Postnatal Depression Scale and parenting stress using the Parenting Stress Index-Short form. Patient satisfaction, nursing time and expertise required are also measured.

DISCUSSION

Phase 1 and 2 have demonstrated the intervention is feasible and acceptable to women. Phase 3 enrolment is completed, and the last follow-up surveys were emailed to participants in February 2018. Results will help inform efforts to continue nursing care after hospital discharge.

Early Childhood Mental Health: Starting Early with the Pregnant Mother

Perinatal mental health has important implications for maternal and child outcomes. Most women with psychiatric disorders during pregnancy go undiagnosed and untreated, despite widespread initiatives for early identification. Universal screening for psychiatric disorders, particularly depression and anxiety, has been implemented in obstetric and primary care settings. However, there is little evidence regarding the effectiveness on psychiatric symptom reduction or prevention of adverse outcomes in children. Recently, comprehensive screening and follow-up programs integrated within obstetric or primary care settings have shown promising results in improving maternal mental health outcomes. Further work is needed to determine best clinical and most cost-effective practices.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Baby Steps - An Online Program Promoting the Well-Being of New Mothers and Fathers: A Study Protocol

BACKGROUND

Parental well-being can be seriously impacted during the challenging perinatal period. Most research and support services focus on perinatal psychopathology, leaving a need for programs that recognize and enhance the strengths and well-being of parents. Furthermore, fathers have received minimal attention and support relative to mothers, despite experiencing perinatal distress. New parents have limited time and energy to invest in program attendance, and web-based programs provide an ideal platform for delivering perinatal well-being programs. Such programs are globally accessible, available at any time, and can be accessed anywhere with an Internet connection.

OBJECTIVE

This paper describes the protocol of a randomized controlled trial investigating the effects on first-time parents' perinatal well-being, comparing two versions of the online program Baby Steps.

METHODS

The clinical trial will randomize 240 primiparous mother-father couples to either (1) Babycare, an online information-only program providing tips on selected childcare issues, or (2) Well-being, an online interactive program including all content from the Babycare program, plus parental well-being-focused content with tools for goal-setting and problem solving. Both programs will be supported by short message service (SMS) texts at two, four, seven, and ten weeks to encourage continued use of the program. Primary outcomes will be measures of perinatal distress and quality of life. Secondary outcomes will be couple relationship satisfaction, parent self-efficacy, and social support. Cost-effectiveness will also be measured for each Baby Steps program.

RESULTS

Participant recruitment commenced March, 2015 and continued until October, 2015. Follow-up data collection has commenced and will be completed May, 2016 with results expected in July, 2016.

CONCLUSIONS

Perinatal distress has substantial impacts on parents and their infants, with potential to affect later childhood adjustment, relationships, and development. This study aims to test the impact of a highly accessible online program to support parental coping, and maximize the well-being of both parents. By including fathers in the program, Baby Steps has the potential to engage and support this often neglected group who can make a substantial contribution to familial well-being.

CLINICALTRIAL

Australian & New Zealand Clinical Trials Registry: ANZCTR12614001256662; https://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx?id=367277 (Archived by WebCite at http://www.webcitation.org/6ibUsjFIL).

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.

Identification of Postpartum Depression in an Online Community

OBJECTIVE

To identify the rate of postpartum depression symptoms in an online community. A secondary purpose was to identify women's experiences when accessing health care services for postpartum depression (PPD).

DESIGN

A quantitative, cross-sectional, survey design.

SETTING

The setting consisted of nine birth clubs from one online community specifically targeted toward new mothers.

PARTICIPANTS

A convenience sample of 469 mostly married (n = 373), White (n = 401) mothers with a mean age of 29.3 (SD = 5.3) years took part in this study. The majority (n = 433) reported living in the United States with access to health insurance coverage.

METHODS

The Edinburgh Postnatal Depression Scale (EPDS) was used to assess depression symptoms. Mothers indicating a previous diagnosis of PPD also completed the Access to Postpartum Depression Care (APDC) questionnaire.

RESULTS

Total EPDS scores ranged from 0 to 27 with a median of 7.0. Sixteen percent of participants (n = 75) scored ≥ 13, indicating a high risk for developing PPD. Of these 75 mothers, 18 (24%) indicated having thoughts of harming themselves sometimes and five (7%) indicated having these thoughts quite often. Additionally, 76 mothers indicating a previous history of PPD also completed the APDC questionnaire. Findings suggested mothers often received care that did not meet their expectations. Barriers to PPD care included insurance limitations and insensitive comments from their health care providers.

CONCLUSIONS

The rate of depression symptoms noted in this Internet-based population is in agreement with published rates. Therefore, findings of this study support further exploration and evaluation of using online platforms for PPD screening.

Magnitude and risk factors for postpartum symptoms: a literature review

BACKGROUND

The prevalence of postpartum depression worldwide varies from 0.5% to 60.8% in the first 12 months postpartum using self-reported questionnaire. This review aims to update the current magnitude of postpartum depression based on self-reported questionnaire and clinical interview and explore its associated factors in developed and developing countries.

METHODS

A literature search conducted between 2005 and 2014 identified 203 studies, of which 191 used self-reported questionnaire in 42 countries and 21 used structured clinical interview in 15 countries. Nine studies used a combination of self-reported questionnaire and clinical interview.

RESULT

The prevalence of postpartum depression varies from 1.9% to 82.1% in developing countries and from 5.2% to 74.0% in developed countries using self-reported questionnaire. Structured clinical interview shows a much lower prevalence range from 0.1% in Finland to 26.3% in India. Antenatal depression and anxiety, previous psychiatric illness, poor marital relationship, stressful life events, negative attitude towards pregnancy, and lack of social support are significant contributors to postpartum depression.

LIMITATION

All studies are included irrespective of the methodological quality, such as small sample size and their inclusion could affect the generalizability of the results.

CONCLUSION

The current prevalence of postpartum depression is much higher than that previously reported, and similar risk factors are documented. A culturally sensitive cut-off score with adequate psychometric properties of the screening instruments should be available. In future studies, examining the physical, biological, and cultural factors in qualitative studies and in those with adequate methodological qualities is recommended.

Translation and factor analysis of structural models of Edinburgh Postnatal Depression Scale in Serbian pregnant and postpartum women - Web-based study

BACKGROUND

The Edinburgh Postnatal Depression Scale (EPDS) is well accepted for detecting symptoms of postnatal depression. The aim of this study was to examine psychometric properties and to evaluate structural models of the Serbian translation of EPDS in pregnant and postpartum women.

METHODS

The original English version of the EPDS was translated into Serbian, and checked by means of back-translation. Data were collected via an anonymous online questionnaire posted on a Serbian website devoted to pregnancy topics. The study sample included 201 women (76 pregnant, 125 postpartum). The internal consistency of the scale was measured by Cronbach's α coefficient. Principal component analysis was used to determine scale dimensions while confirmatory factor analysis was used to evaluate model fit.

FINDINGS

Cronbach α coefficient was 0.84 and 0.83 in pregnant and postpartum women, respectively, which indicated good internal consistency of the Serbian EPDS. Three dimensions of the scale were revealed in both groups of women. Goodness of fit indices described good and excellent model in pregnant and postpartum women, respectively. High level of depression symptoms (score ≥13) was recorded in 27.6% and 24.8% (p>0.05) of pregnant and postpartum women, respectively. Moderate level of depression symptoms (score 10-12) was recorded in 21.1% and 16.8% (p>0.05) of pregnant and postpartum women, respectively.

CONCLUSION

The Serbian translation of the EPDS showed good consistency and good model characteristics in pregnant and postpartum women. However, cut-off values, sensitivity and specificity of the scale should be determined in the further studies with more representative samples of women.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Interformat reliability of digital psychiatric self-report questionnaires: a systematic review

Background

Research on Internet-based interventions typically use digital versions of pen and paper self-report symptom scales. However, adaptation into the digital format could affect the psychometric properties of established self-report scales. Several studies have investigated differences between digital and pen and paper versions of instruments, but no systematic review of the results has yet been done.

Objective

This review aims to assess the interformat reliability of self-report symptom scales used in digital or online psychotherapy research.

Methods

Three databases (MEDLINE, Embase, and PsycINFO) were systematically reviewed for studies investigating the reliability between digital and pen and paper versions of psychiatric symptom scales.

Results

From a total of 1504 publications, 33 were included in the review, and interformat reliability of 40 different symptom scales was assessed. Significant differences in mean total scores between formats were found in 10 of 62 analyses. These differences were found in just a few studies, which indicates that the results were due to study effects and sample effects rather than unreliable instruments. The interformat reliability ranged from r=.35 to r=.99; however, the majority of instruments showed a strong correlation between format scores. The quality of the included studies varied, and several studies had insufficient power to detect small differences between formats.

Conclusions

When digital versions of self-report symptom scales are compared to pen and paper versions, most scales show high interformat reliability. This supports the reliability of results obtained in psychotherapy research on the Internet and the comparability of the results to traditional psychotherapy research. There are, however, some instruments that consistently show low interformat reliability, suggesting that these conclusions cannot be generalized to all questionnaires. Most studies had at least some methodological issues with insufficient statistical power being the most common issue. Future studies should preferably provide information about the transformation of the instrument into digital format and the procedure for data collection in more detail.

Netmums: a phase II randomized controlled trial of a guided Internet behavioural activation treatment for postpartum depression

BACKGROUND

Despite the high prevalence of postnatal depression (PND), few women seek help. Internet interventions may overcome many of the barriers to PND treatment use. We report a phase II evaluation of a 12-session, modular, guided Internet behavioural activation (BA) treatment modified to address postnatal-specific concerns [Netmums Helping With Depression (NetmumsHWD)].

METHOD

To assess feasibility, we measured recruitment and attrition to the trial and examined telephone session support and treatment adherence. We investigated sociodemographic and psychological predictors of treatment adherence. Effectiveness outcomes were estimated with the Edinburgh Postnatal Depression Scale (EPDS), Generalized Anxiety Disorder-7, Work and Social Adjustment Scale, Postnatal Bonding Questionnaire, and Social Provisions Scale.

RESULTS

A total of 249 women were recruited via a UK parenting site, Netmums.com. A total of 83 women meeting DSM-IV criteria for major depressive disorder were randomized to NetmumsHWD (n = 41) or treatment-as-usual (TAU; n = 42). Of the 83 women, 71 (86%) completed the EPDS at post-treatment, and 71% (59/83) at the 6-month follow-up. Women completed an average of eight out of 12 telephone support sessions and five out of 12 modules. Working women and those with less support completed fewer modules. There was a large effect size favouring women who received NetmumsHWD on depression, work and social impairment, and anxiety scores at post-treatment compared with women in the TAU group, and a large effect size on depression at 6 months post-treatment. There were small effect sizes for postnatal bonding and perceived social support.

CONCLUSIONS

A supported, modular, Internet BA programme can be feasibly delivered to postpartum women, offering promise to improve depression, anxiety and functioning.

Online screening and referral for postpartum depression: an exploratory study

The fear and stigma associated with postpartum depression (PPD) is a major challenge in the treatment of this disease. Our goal is to develop innovative methods of screening women for the symptoms of PPD to facilitate referral and treatment. This study explores the efficacy of the Internet in reaching out to postpartum women in the convenience and privacy of their own homes, particularly those in rural and underserved areas. An exploratory study design was used to explore the feasibility and acceptability of online screening for PPD with postpartum women in the first 2-3 months after delivery (N = 18). In the first phase, a focus group was conducted with a small group of postpartum women; the second phase consisted of individual interviews of postpartum women in their homes; and in phase three, 10 women participated in the on-line screening intervention. PPD was measured using an online version of the Edinburgh Postnatal Depression Scale (EPDS) a well-established instrument with reported alpha reliabilities (0.81-0.88) across studies and concurrent validity demonstrated using the gold standard, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for depression interview. Qualitative data collected from all the participants were also analyzed. The sample included women age 18-29; 70 % White/Caucasian, 50 % low income, and the majority living in rural areas. The EPDS scores ranged from 0 to 13 (mean 8.0; SD 4.76). Participants described the online PPD screening process as easy, straightforward and personalized and provided additional suggestions for improvement.

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

BACKGROUND

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

METHODS/DESIGN

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

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01901796.

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).

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

BACKGROUND

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

METHODS/DESIGN

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

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01899534.

Internet-based behavioral activation--treatment for postnatal depression (Netmums): a randomized controlled trial

BACKGROUND

Despite the high prevalence of postnatal depression (PND), few women seek help. The internet may increase timely access to treatment. We report a randomized controlled trial of a minimal intervention internet Behavioral Activation (iBA) treatment modified to address postnatal specific concerns (Postnatal-iBA).

METHODS

Women (n=910) recruited via a popular UK parenting site, Netmums.com, scoring above 12 on the Edinburgh Postnatal Depression Scale (EPDS) were randomly assigned to receive either Postnatal-iBA delivered or treatment-as-usual (TAU). We investigated the feasibility (recruitment, trial and treatment adherence) and effectiveness (depression status EPDS >12) of the intervention.

RESULTS

Recruitment was excellent; 1261 women, 961 of whom met inclusion criteria, signed up to the trial within two 2-week recruitment periods. Thirty-eight percent (343/910) of women completed the 15-week outcome assessment. Of those who completed 15-week assessment, fewer exceeded the depression cutoff in the Postnatal-iBA group (n=66/181) compared to TAU (n=91/162). Assuming all non-respondents remained depressed, the Postnatal-iBA effect was reduced.

LIMITATIONS

The study suffered from high attrition and future trials need to consider strategies for improving outcome completion. Some women reported struggles "keeping up" with the treatment.

CONCLUSIONS

A minimal support, widely accessible internet Behavioral Activation program for PND is feasible to deliver to community populations when embedded within popular parenting sites. For women who provide outcome data, postnatal-iBA offers promise as an effective treatment for PND. The addition of support may reduce women's struggles to keep pace with the treatment.

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.

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

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