Development of a screening and recruitment registry to facilitate perinatal depression research in obstetrics settings in the USA

Mental Health Diagnoses on the Mini International Psychiatric Interview Are Associated With Higher Scores on the Edinburgh Postnatal Depression Scale

OBJECTIVE

To understand if Mini International Psychiatric Interview (MINI) scores in pregnancy are associated with higher scores on the Edinburgh Postnatal Depression Scale (EPDS).

DESIGN

Cross-sectional pilot study of participants who completed the EPDS during pregnancy and were then invited to complete the MINI.

SETTING/LOCAL PROBLEM

An urban outpatient clinic at an academic medical setting from November 2020 to June 2021.

PARTICIPANTS

Convenience sample of 20 pregnant people.

INTERVENTION/MEASUREMENTS

Analysis of variance was used to examine differences based on EPDS scores and MINI symptom burden. Nonparametric tests (Mann-Whitney U or Kruskal-Wallis test) were used if assumptions were violated. Descriptive statistics were used to describe sample characteristics.

RESULTS

Nine participants screened 9 or higher on the EPDS and completed the MINI. There were no significant differences in demographic variables by EPDS score. There were significant differences between demographic variables, including employment status (p = .003) and type of health insurance (p = .019), between participants who met criteria for at least one diagnosis on the MINI and those who did not. Participants with public health insurance met the criteria for four more diagnoses compared to people with private insurance. Participants not employed full-time had nearly five more diagnoses compared to those employed full-time. Higher EPDS scores were correlated with all measured MINI symptoms or diagnoses. Higher EPDS scores were significantly correlated with and showed a moderate to strong positive correlation to suicidality and antisocial personality disorder.

CONCLUSION

Pregnant individuals who score 9 or higher on the EPDS may also have other severe mental health diagnoses. Recognizing perinatal mood and anxiety disorders in this population can inform the development of screening protocols and interventions during pregnancy to improve maternal access to mental health treatment and symptom reduction.

Optimizing Social-Emotional-Communication Development in Infants of Mothers With Depression: Protocol for a Randomized Controlled Trial of a Mobile Intervention Targeting Depression and Responsive Parenting

BACKGROUND

Postpartum depression interferes with maternal engagement in interventions that are effective in improving infant social-emotional and social-communication outcomes. There is an absence of integrated interventions with demonstrated effectiveness in both reducing maternal depression and promoting parent-mediated practices that optimize infant social-emotional and social-communication competencies. Interventions targeting maternal depression are often separate from parent-mediated interventions. To address the life course needs of depressed mothers and their infants, we need brief, accessible, and integrated interventions that target both maternal depression and specific parent practices shown to improve infant social-emotional and social-communication trajectories.

OBJECTIVE

The aim of this study is to evaluate the efficacy of a mobile internet intervention, Mom and Baby Net, with remote coaching to improve maternal mood and promote parent practices that optimize infant social-emotional and social-communication development.

METHODS

This is a two-arm, randomized controlled intent-to-treat trial. Primary outcomes include maternal depression symptoms and observed parent and infant behaviors. Outcomes are measured via direct observational assessments and standardized questionnaires. The sample is being recruited from the urban core of a large southern city in the United States. Study enrollment was initiated in 2017 and concluded in 2020. Participants are biological mothers with elevated depression symptoms, aged 18 years or older, and who have custody of an infant less than 12 months of age. Exclusion criteria at the time of screening include maternal homelessness or shelter residence, inpatient mental health or substance abuse treatment, or maternal or infant treatment of a major mental or physical illness that would hinder meaningful study participation.

RESULTS

The start date of this grant-funded randomized controlled trial (RCT) was September 1, 2016. Data collection is ongoing. Following the institutional review board (IRB)-approved pilot work, the RCT was approved by the IRB on November 17, 2017. Recruitment was initiated immediately following IRB approval. Between February 15, 2018, and March 11, 2021, we successfully recruited a sample of 184 women and their infants into the RCT. The sample is predominantly African American and socioeconomically disadvantaged.

CONCLUSIONS

Data collection is scheduled to be concluded in March 2022. We anticipate that relative to the attention control condition, which is focused on education around maternal depression and infant developmental milestones with matching technology and coaching structure, mothers in the Mom and Baby Net intervention will experience greater reductions in depression and gains in sensitive and responsive parent practices and that their infants will demonstrate greater gains in social-emotional and social-communication behavior.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03464630; https://clinicaltrials.gov/ct2/show/NCT03464630.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/31072.

Case Report: Implementation of a Multi-Component Behavioral Health Integration Program in Obstetrics for Perinatal Behavioral Health

Despite growing research and policy attention, perinatal behavioral health conditions (i.e., mental health and substance use disorders) remain prevalent, burdensome for families, and largely untreated in the US. Researchers have documented an array of barriers to accurate detection, linkage with effective treatment, and improved outcomes for perinatal women with behavioral health disorders. It is clear that a multi-component approach that integrates evidence-based detection and management of perinatal behavioral health in the context of obstetrics care can be effective. This paper presents the initial development of a clinical quality improvement program that includes evidence-based components of behavioral health integration in obstetrics in the state of Florida in the US. The FL BH Impact (Improving Maternal and Pediatric Access, Care and Treatment for Behavioral Health) program, guided by the RE-AIM model for program implementation, has been developed over the past 2 years. Program components, initial implementation, and preliminary findings are presented. Following the implementation phase, the program has enrolled 12 obstetrics practices and 122 obstetrics providers in program engagement and training activities. The primary program component allows for obstetrics clinician telephone access to a statewide listing of behavioral health referral resources for patients and access to consultation with psychiatry. Since program implementation, the program has received a total of 122 calls to this line, with an expected increasing trajectory of calls over time. Results suggest this program is feasible to implement across a large geographic area. Challenges to implementation and future directions are discussed. These types of multi-component approaches to improved management and outcomes for perinatal behavioral health are promising and must be expanded and sustained in the US.

Minding the Gatekeepers: Referral and Recruitment of Postpartum Mothers with Depression into a Randomized Controlled Trial of a Mobile Internet Parenting Intervention to Improve Mood and Optimize Infant Social Communication Outcomes

Mothers in the United States (U.S.) who are of non-dominant culture and socioeconomically disadvantaged experience depression during postpartum at a rate 3 to 4 times higher than mothers in the general population, but these mothers are least likely to receive services for improving mood. Little research has focused on recruiting these mothers into clinical intervention trials. The purpose of this article is to report on a study that provided a unique context within which to view the differential success of three referral approaches (i.e., community agency staff referral, research staff referral, and maternal self-referral). It also enabled a preliminary examination of whether the different strategies yielded samples that differed with regard to risk factors for adverse maternal and child outcomes. The examination took place within a clinical trial of a mobile intervention for improving maternal mood and increasing parent practices that promote infant social communication development. The sample was recruited within the urban core of a large southern city in the U.S. and was comprised primarily of mothers of non-dominant culture, who were experiencing severe socioeconomic disadvantage. Results showed that mothers self-referred at more than 3.5 times the rate that they were referred by either community agency staff or research staff. Moreover, compared to women referred by research staff, women who self-referred and those who were referred by community gatekeepers were as likely to eventually consent to study participation and initiate the intervention. Results are discussed with regard to implications for optimizing referral into clinical intervention trials.

The impact of intimate partner violence on the trajectory of perinatal depression: a cohort study in a Chinese sample

Abstract.

AIMS

Intimate partner violence (IPV) is an important risk factor for perinatal depression (PND). But IPV's impact on the natural prognosis of PND symptoms is not well understood. We tested two hypotheses: (1) pregnant women with IPV experiences will exhibit more severe PND symptoms than women without IPV experience; (2) IPV experience will impede the recovery prognosis of PND. We also explored the contribution of IPV to PND comparing with other risk factors.

METHOD

The sample is comprised of 813 pregnant women followed through perinatal period in Hunan, China. We assessed IPV experience using items from the Short Form of the Revised Conflict Tactics Scale (CTS2S), and PND symptoms via the Edinburgh Postnatal Depression Scale (EPSD). We conducted Linear Mixed-effects Model to compare the trajectories of PND symptoms between victims and non-victims and a multistage Generalised Estimating Equations Model to explore salient factors on the trajectory of PND symptoms.

RESULTS

There were 90 participants (11.07%) who reported IPV experience in the past 12 months. With respect to physical, psychological and sexual violence, the prevalence was 4.55% (37/813), 9.23% (75/813) and 2.34% (19/813). Victims reported more severe PND symptoms (t = 5.30, p < 0.01) and slower decreasing slope of trajectories (t = 28.89, p < 0.01). The PND trajectory was associated with IPV experience (OR = 3.78; 95% CI 1.39-10.26), social support (OR = 0.93; 95% CI 0.88-0.97), positive coping strategies (OR = 0.85; 95% CI 0.80-0.91), negative coping strategies (OR = 1.25; 95% CI 1.14-1.37) and monthly income of $0.15-$298.36 (compared to no income, OR = 0.0075; 95% CI 0.00052-0.11).

CONCLUSIONS

The findings suggest the reported prevalence of IPV is lower in Hunan than most of the previous studies during perinatal period in other provinces of China, and IPV victimisation is associated with increased severity and slowed prognosis of PND symptoms. Future studies that screen for victimisation and establish its explicit mechanism to the poorer prognosis of PND symptoms would benefit the prevention and treatment of PND.

Using behaviour change theory to inform an innovative digital recruitment strategy in a mental health research setting

Recruitment in mental health research is challenging, as some disorders such as depression or schizophrenia may involve vulnerable participants that lack motivation as part of their illness. A mental health diagnosis can be stigmatising, so privacy and access to hospital-based patient cohorts is carefully controlled. Our team describe a pragmatic portal recruitment process for facilitating timely recruitment into multiple research studies focusing on mental health. Three factors were analysed; evaluating the success and impact of this novel recruitment process; identification of patterns in recruitment to better target participants; and provision of metrics of the different media formats engaged. A web-based recruitment portal was developed by the research team in collaboration with the South Australian Health and Medical Research Institute (SAHMRI) Consumer & Carer Research Advisory Group. A comprehensive marketing campaign was then undertaken to direct participants towards the portal. Recruitment insights from the dates and times of registration across a two-year period is provided. In total, 933 potential participants registered with the recruitment portal across a two-year period at a cost of approximately $10,000. The advertisement campaign linked to the portal page enabled 506 participants to register in just one week. The area of research was self-selected by the potential participants, then eligibility was followed up with telephone and face to face interviews. Of the total 933 people who registered 706 (76%) expressed an interest in the target clinical depression study, 119 (13%) opted to be clinical controls, and the remainder chose one of the alternative studies. 240 (26%) of those who registered were excluded through telephone interviews because they fell outside of the strict eligibility criterion. We learnt that 77% (n = 723/933) of participants were recruited within seven days of promotional events, providing an interesting pattern of recruitment that may assist future recruitment design.

Relationship Between Depression and/or Anxiety and Hospital Readmission Among Women After Childbirth

OBJECTIVE

To examine the relationship between depression and/or anxiety and any psychiatric diagnosis and readmission after childbirth.

DESIGN

Cross-sectional analysis of administrative data from patient discharge records.

SETTING

Urban academic medical center in the northeastern United States.

PARTICIPANTS

Women admitted for childbirth (N = 17,905).

METHODS

Differences among participants with and without depression and/or anxiety present on admission were compared using t tests and chi-square tests. Risk-adjusted logistic regression models were used to examine the effects of depression and/or anxiety and any psychiatric diagnosis on 7-, 30-, 60-, 90-, and 180-day readmissions after childbirth.

RESULTS

Significant differences were noted between participants with (n = 1,169) and without (n = 16,736) depression and/or anxiety. Participants with these diagnoses had a higher mean age and a longer mean length of stay during hospitalization for childbirth. A greater proportion of these participants were White, were single, had cesarean births, and were discharged with home health services. The presence of depression and/or anxiety was not significantly associated with readmission. The effect of having any psychiatric diagnosis was significantly associated with a greater risk of readmission at 7 (odds ratio [OR] = 1.51, p = .100), 30 (OR = 1.45, p = .030), 60 (OR = 1.45, p = .026), 90 (OR = 1.56, p = .004), and 180 days (OR =1.74, p < .001) following discharge after childbirth.

CONCLUSION

In this sample, women with a psychiatric diagnosis, but not depression and/or anxiety alone, were at increased risk for readmission after childbirth.

The dynamic course of peripartum depression across pregnancy and childbirth

OBJECTIVE

Peripartum depression (PPD) pertaining to depression in pregnancy and postpartum is one of the most common complications around childbirth with enduring adverse effects on mother and child health. Although psychiatric symptoms may improve or worsen over time, relatively little is known about the course of PPD symptoms and possible fluctuations.

METHODS

We applied a person-centered approach to examine PPD symptom patterns across pregnancy and childbirth. 824 women were assessed at three time points: first trimester (T1), third trimester (T2), and again at eight weeks (T3) postpartum. We assessed PPD symptoms, maternal mental health history, and childbirth variables.

RESULTS

Growth mixture modeling (GMM) analysis revealed four discrete PPD symptom trajectory classes including chronic PPD (1.1%), delayed (10.2%), recovered (7.2%), and resilient (81.5%). Delivery complications were associated with chronic PPD but also with the recovered PPD trajectory class. History of mental health disorders was associated with chronic PPD and the delayed PPD class.

CONCLUSION

The findings underscore that significant changes in a woman's depression level can occur across pregnancy and childbirth. While a minority of women experience chronic PDD, for others depression symptoms appear to significantly alleviate over time, suggesting a form of recovery. Our findings support a personalized medicine approach based on the woman's symptom trajectory. Future research is warranted to identify the mechanisms underlying modifications in PPD symptoms severity and those implicated in recovery.

Temporal trends of co-diagnosis of depression and/or anxiety among female maternal and non-maternal hospitalizations: Results from Nationwide Inpatient Sample 2004-2013

Perinatal depression/anxiety is considered the most underdiagnosed pregnancy complication in the US and is associated with poor maternal and fetal outcomes. However, despite its prevalence, most women who present with depressive symptoms are not screened and do not receive adequate treatment. We examined the clinical co-diagnosis of depression and/or anxiety among maternal and non-maternal hospitalizations among females aged 14-49 from the Nationwide Inpatient Sample (NIS) between 2004 and 2013 (n = 83,472,775). Meta-regression was used to determine annual change and presence of temporal trends. Survey logistic regression was used to examine the association with sociodemographic factors. Rates of diagnosis of depression and/or anxiety disorders demonstrated a temporal increase from 2004-2013, and this increase was mainly driven by non-maternal hospitalizations compared to maternal. Furthermore, non-maternal hospitalizations demonstrated a greater prevalence of depression and/or anxiety diagnoses compared to maternal hospitalizations over the same time period (21•7% versus 2•8%). Among all female hospitalizations, whites were roughly twice as likely as minorities to have a diagnosis of depression and/or anxiety. These results add to the evidence suggestive of the underdiagnosed depression/anxiety present among women of reproductive age, particularly pregnant women and minorities, and underscore the critical role of obstetricians in treating both physical and mental health.

Perinatal depression: A clinical update

Perinatal depression is a common condition with significant adverse maternal, fetal, neonatal, and early childhood outcomes. The perinatal period is an opportune time to screen, diagnose, and treat depression. Improved recognition of perinatal depression, particularly among low-income women, can lead to improved perinatal health outcomes.

A Collaborative, Network-Based Approach to Advance Women's Depression Research in the United States: Preliminary Findings

OBJECTIVE

Translation of women's mental health research has yet to impact overall prevalence and burden of Mood Disorders in the United States. The lack of standard measures and methodological coordination across studies has contributed to the slow impact of research on outcomes. The primary aims of this project were to demonstrate the process by which multiple investigators, sites, and settings administered a standard women's mental health questionnaire within a new Women's Depression Network. Information on the prevalence of mental health and service use across sites is provided.

METHODS

A standard women's mental health questionnaire was developed and administered across seven different women's health sites in the United States. Validated measures of depression and anxiety were included (Patient Health Questionnaire Depression Scale [PHQ-9] and Generalized Anxiety Disorder Scale [GAD-7]). Administration of the questionnaire was embedded into existing clinical or research activities at each site.

RESULTS

Data from 1,316 women were collected from seven sites over 12 months. A total of 14% and 15% of the women scored at or above the cutoff on the PHQ-9 and GAD-7 respectively. Just over half of the women screening positive for either depression or anxiety reported current treatment use.

CONCLUSIONS

Findings suggest that coordination and administration of a standard women's mental health questionnaire is feasible across multiple settings and sites. Results highlight a low percentage of treatment use across various settings. The infrastructure developed for this study sets the stage for hypothesis-driven studies that can facilitate coordinated, network-based research that has the potential to accelerate advances in the field.

Implementation of depression screening in antenatal clinics through tablet computers: results of a feasibility study

Background

Mobile devices may facilitate depression screening in the waiting area of antenatal clinics. This can present implementation challenges, of which we focused on survey layout and technology deployment.

Methods

We assessed the feasibility of using tablet computers to administer a socio-demographic survey, the Whooley questions and the Edinburgh Postnatal Depression Scale (EPDS) to 530 pregnant women attending National Health Service (NHS) antenatal clinics across England. We randomised participants to one of two layout versions of these surveys: (i) a scrolling layout where each survey was presented on a single screen; or (ii) a paging layout where only one question appeared on the screen at any given time.

Results

Overall, 85.10% of eligible pregnant women agreed to take part. Of these, 90.95% completed the study procedures. Approximately 23% of participants answered Yes to at least one Whooley question, and approximately 13% of them scored 10 points of more on the EPDS. We observed no association between survey layout and the responses given to the Whooley questions, the median EPDS scores, the number of participants at increased risk of self-harm, and the number of participants asking for technical assistance. However, we observed a difference in the number of participants at each EPDS scoring interval (p = 0.008), which provide an indication of a woman’s risk of depression. A scrolling layout resulted in faster completion times (median = 4 min 46 s) than a paging layout (median = 5 min 33 s) (p = 0.024). However, the clinical significance of this difference (47.5 s) is yet to be determined.

Conclusions

Tablet computers can be used for depression screening in the waiting area of antenatal clinics. This requires the careful consideration of clinical workflows, and technology-related issues such as connectivity and security. An association between survey layout and EPDS scoring intervals needs to be explored further to determine if it corresponds to a survey layout effect. Future research needs to evaluate the effect of this type of antenatal depression screening on clinical outcomes and clinic workflows.

Trial registration

This study was registered in ClinicalTrials.gov under the identifier NCT02516982 on 20 July 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-017-0459-8) contains supplementary material, which is available to authorized users.

Different patterns of depressive symptoms during pregnancy

Recently, the US Preventive Services Task Force has advocated to screen pregnant and postpartum women for depression. However, we questioned the meaning of a single elevated depression score: does it represent just one episode of depression or do these symptoms persist throughout the entire pregnancy? This study assessed depressive symptoms at each trimester in a cohort of 1813 pregnant women and evaluated whether women with different patterns of depressive symptoms showed other characteristics. Depending on the trimester, elevated depression scores were prevalent in 10-15% of the pregnant women. Up to 4% reported persistent symptoms of depression throughout pregnancy. Different patterns of depressive symptoms were observed, for which persistent symptoms were related to other characteristics than incidentally elevated symptoms. Besides a previous history of mental health problems as best overall predictor, incidentally elevated depression scores were related to major life events. Furthermore, persistently depressive symptoms were related to unplanned pregnancy and multiparity. An EDS assessment at 12 weeks of gestation including three additional items (history of mental health problems, unplanned pregnancy and multiparity) enabled us to identify 83% of the women with persistent depressive symptoms. A depression screening strategy in pregnant women should take into account the potential chronicity of depressive symptoms by repeated assessments in order to offer an intervention to the most vulnerable women.

Tablet computers for implementing NICE antenatal mental health guidelines: protocol of a feasibility study

INTRODUCTION

Depression is one of the most common mental health disorders that may affect women during pregnancy. The prompt identification of this disorder, and the provision of treatment, may help to reduce the likelihood of post-partum depression, prevent severe forms of the disease, and reduce its intergenerational impact. Despite women's repeated encounters with health services throughout their antenatal care, depression often goes undiagnosed. This is one area where mobile health could prove useful. We will assess the feasibility of using tablets to incorporate depression screening into antenatal pathways. We will also assess if survey layout could affect the quality of the data collected through these devices.

METHODS AND ANALYSIS

We will test the feasibility of using iPad Airs for the administration of the Whooley questions and the Edinburgh Postnatal Depression Scale (EPDS) to pregnant women attending antenatal clinics in England. We will assess the impact of survey layout on the quality of the responses given to these screening scales using a parallel, randomised controlled study design. We will calculate the positive predictive value, the negative predictive value and the false omission rate of the Whooley questions in comparison with the EPDS. We will calculate differences in data equivalence, time needed to complete the surveys, break-off rates, data completeness and requests for help between the 2 experimental groups: using all questions in one screen and navigation by vertical scrolling, or a single question per screen and navigation by multiple pages.

ETHICS AND DISSEMINATION

This study has been approved by the National Research Ethics Service Committee South East Coast--Surrey. Our findings will be disseminated through academic peer-reviewed publications, conferences and discussion with peers.