Intervening to reduce depression after birth: a systematic review of the randomized trials

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

Background

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

Objectives

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

Search Methods

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

Selection Criteria

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

Data Collection and Analysis

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

Main Results

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

Authors' Conclusions

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

Barriers and facilitators to supporting women with postnatal depression and anxiety: A qualitative study of maternal and child health nurses' experiences

AIMS AND OBJECTIVES

To explore maternal and child health nurses' experiences of supporting women with postnatal depression and anxiety and the factors which impact these.

BACKGROUND

Maternal and child health nurses play a key role in identifying women with postnatal depression and anxiety and facilitating their access to appropriate supports. Understanding how nurses carryout this work, and the conditions which impact their ability to do so, is critical to the development of service delivery frameworks that can facilitate optimal outcomes for women and their families. Despite this, little is known about this subject.

DESIGN

A qualitative descriptive study.

METHODS

Participants were maternal and child health nurses practicing for at least six months and regularly seeing new mothers in Victoria, Australia. Twelve nurses were interviewed. Thematic analysis was conducted to identify patterns across our data. Qualitative content analysis was used to identify issues which were most emphasised by nurses. Reporting complies with the COREQ checklist.

FINDINGS

Three overarching themes were identified. Theme one pertained to steps taken by nurses following the identification of depression or anxiety symptoms and the shared challenges they encountered. Theme two concerned nurses' experiences of supporting women who required acute mental health interventions and the systemic barriers they faced. Finally, theme three related to how the existing service delivery model could be improved to better support nurses in their work.

CONCLUSIONS

The complex system within which nurses operate presents barriers that can impede their ability to respond to women with postnatal mental health issues. There is a need for service delivery frameworks that better support nurses and facilitates equitable access to mental healthcare.

RELEVANCE TO CLINICAL PRACTICE

Facilitating equitable access to all perinatal mental health services and interventions must be at the heart of all future policy, funding and service delivery frameworks.

Holistic community-based group parenting programs for mothers with maternal mental health issues help address a growing public health need for a diversity of vulnerable mothers, children and families: Findings from an action research study

Background

Maternal mental illness is a major growing global concern which can affect parenting with serious negative implications for offspring. Group-based parenting programs for mothers which both enhance the parent-child relationship and address mental health symptoms in a supportive social setting may optimise better outcomes for mothers and children. The Acorn program in South Australia draws on attachment theory to integrate dance play, reflective diary keeping and therapeutic letters in a holistic program for a diversity of vulnerable mothers and children aged 1-36 months. The program seeks to nurture and enhance parental wellbeing and the quality of the parent-child relationship for mothers experiencing identified mental health illnesses that impinge upon their parenting. This study presents the evaluation of the program and its effectiveness.

Methods

Action research approach for continuous monitoring and program improvement engaging Acorn program staff in evaluation data collection and interpretation of pre and post self-completion measures and standardized observations. Additional data was collected through a telephone interview of attending mothers 6-8 months after program completion to address sustainable impacts on parenting and wellbeing.

Results

The program engaged 353 diverse vulnerable mothers with their children. Many had profound overlapping mental health issues including borderline personality disorder (BPD) and depression. The quality of the parent-child interaction, parental confidence, competence and enjoyment were enhanced; mothers' wellbeing, ability to cope and lasting social supports were augmented. This occurred for a number of "most vulnerable" subgroups including single mothers, mothers with BPD, mothers from non-English speaking households and those with lower levels of education or household income. Mothers reported sustained improvements in their wellbeing, parenting, social and family lives, and feeling closer to their child as a result of participating in the program.

Conclusions

Given the high prevalence of maternal mental health issues and substantial potential negative consequences for mothers and offspring, the Acorn parenting program offers an effective means of addressing this pressing public health issue potentially helping large numbers of vulnerable mothers and their children. This has additional gravitas in the shadow of COVID-19 due to expanded numbers of those experiencing greater parental stress, isolation and mental illness.

Appraisal of systematic reviews on interventions for postpartum depression: systematic review

BACKGROUND

Postpartum depression (PPD) is a highly prevalent mental health problem that affects parental health with implications for child health in infancy, childhood, adolescence and beyond. The primary aim of this study was to critically appraise available systematic reviews describing interventions for PPD. The secondary aim was to evaluate the methodological quality of the included systematic reviews and their conclusions.

METHODS

An electronic database search of MEDLINE, Embase, and the Cochrane Library from 2000 to 2020 was conducted to identify systematic reviews that examined an intervention for PPD. A Measurement Tool to Assess Systematic Reviews was utilized to independently score each included systematic review which was then critically appraised to better define the most effective therapeutic options for PPD.

RESULTS

Of the 842 studies identified, 83 met the a priori criteria for inclusion. Based on the systematic reviews with the highest methodological quality, we found that use of antidepressants and telemedicine were the most effective treatments for PPD. Symptoms of PPD were also improved by traditional herbal medicine and aromatherapy. Current evidence for physical exercise and cognitive behavioural therapy in treating PPD remains equivocal. A significant, but weak relationship between AMSTAR score and journal impact factor was observed (p = 0.03, r = 0.24; 95% CI, 0.02 to 0.43) whilst no relationship was found between the number of total citations (p = 0.27, r = 0.12; 95% CI, - 0.09 to 0.34), or source of funding (p = 0.19).

CONCLUSION

Overall the systematic reviews on interventions for PPD are of low-moderate quality and are not improving over time. Antidepressants and telemedicine were the most effective therapeutic interventions for PPD treatment.

A systematic review, evidence synthesis and meta-analysis of quantitative and qualitative studies evaluating the clinical effectiveness, the cost-effectiveness, safety and acceptability of interventions to prevent postnatal depression

BACKGROUND

Postnatal depression (PND) is a major depressive disorder in the year following childbirth, which impacts on women, their infants and their families. A range of interventions has been developed to prevent PND.

OBJECTIVES

To (1) evaluate the clinical effectiveness, cost-effectiveness, acceptability and safety of antenatal and postnatal interventions for pregnant and postnatal women to prevent PND; (2) apply rigorous methods of systematic reviewing of quantitative and qualitative studies, evidence synthesis and decision-analytic modelling to evaluate the preventive impact on women, their infants and their families; and (3) estimate cost-effectiveness.

DATA SOURCES

We searched MEDLINE, EMBASE, Science Citation Index and other databases (from inception to July 2013) in December 2012, and we were updated by electronic alerts until July 2013.

REVIEW METHODS

Two reviewers independently screened titles and abstracts with consensus agreement. We undertook quality assessment. All universal, selective and indicated preventive interventions for pregnant women and women in the first 6 postnatal weeks were included. All outcomes were included, focusing on the Edinburgh Postnatal Depression Scale (EPDS), diagnostic instruments and infant outcomes. The quantitative evidence was synthesised using network meta-analyses (NMAs). A mathematical model was constructed to explore the cost-effectiveness of interventions contained within the NMA for EPDS values.

RESULTS

From 3072 records identified, 122 papers (86 trials) were included in the quantitative review. From 2152 records, 56 papers (44 studies) were included in the qualitative review. The results were inconclusive. The most beneficial interventions appeared to be midwifery redesigned postnatal care [as shown by the mean 12-month EPDS score difference of -1.43 (95% credible interval -4.00 to 1.36)], person-centred approach (PCA)-based and cognitive-behavioural therapy (CBT)-based intervention (universal), interpersonal psychotherapy (IPT)-based intervention and education on preparing for parenting (selective), promoting parent-infant interaction, peer support, IPT-based intervention and PCA-based and CBT-based intervention (indicated). Women valued seeing the same health worker, the involvement of partners and access to several visits from a midwife or health visitor trained in person-centred or cognitive-behavioural approaches. The most cost-effective interventions were estimated to be midwifery redesigned postnatal care (universal), PCA-based intervention (indicated) and IPT-based intervention in the sensitivity analysis (indicated), although there was considerable uncertainty. Expected value of partial perfect information (EVPPI) for efficacy data was in excess of £150M for each population. Given the EVPPI values, future trials assessing the relative efficacies of promising interventions appears to represent value for money.

LIMITATIONS

In the NMAs, some trials were omitted because they could not be connected to the main network of evidence or did not provide EPDS scores. This may have introduced reporting or selection bias. No adjustment was made for the lack of quality of some trials. Although we appraised a very large number of studies, much of the evidence was inconclusive.

CONCLUSIONS

Interventions warrant replication within randomised controlled trials (RCTs). Several interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty.

FUTURE WORK RECOMMENDATIONS

Several interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty. Future research conducting RCTs to establish which interventions are most clinically effective and cost-effective should be considered.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012003273.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Effect of Health Care as the "Home Visiting" on Postpartum Depression: A Controlled Clinical Trial

Background:

Postpartum depression is considered as a major health complication of women after delivery. It is necessary to find an essential approach for the prevention of its serious consequences on mothers’ and infants’ health. The aim of this study was to investigate the effect of home visiting on postpartum depression.

Methods:

The first stage of study was the design of postpartum package. According to the package, a clinical trial was performed for 276 mothers who had delivered in affiliated hospitals of Shahid Beheshti University in 2013 and were divided into two groups, i.e., control group and intervention group. Intervention group received health care by home visiting, and control group had no intervention. Mothers were supposed to fill up Edinburgh Postnatal Depression Scale before and 60 days after delivery, and the results were compared. The data were analyzed by SPSS version 18 software and t-test, Chi-square, and logistic regression test.

Results:

The mean ages of participants were 27.03 ± 5.2 standard deviation (SD) in intervention group and 27.37 ± 5.4 SD in control group. Occurrence of depression was 7.6% in intervention group and 19% in control group, and there was a significant difference between two groups (P < 0.05). The logistic regression results indicate that groups (intervention and control) (P = 0.087, odds ratio [OR] =2.1); planned and unplanned pregnancy (P = 0.028, OR = 2.5) and the infant nutrition (P = 0.025, OR = 2.2) are significantly associated with the postpartum depression.

Conclusions:

Providing postpartum home visiting can influence postpartum depression in a positive way and could improve mothers’ and infants’ health.

Gender-informed, psychoeducational programme for couples to prevent postnatal common mental disorders among primiparous women: cluster randomised controlled trial

OBJECTIVES

Interventions to prevent postpartum common mental disorders (PCMD) among unselected populations of women have had limited success. The aim was to determine whether What Were We Thinking (WWWT) a gender-informed, psychoeducational programme for couples and babies can prevent PCMD among primiparous women 6 months postpartum.

DESIGN

Cluster-randomised controlled trial.

SETTING

48 Maternal and Child Health Centres (MCHCs) from 6 Local Government Areas in Melbourne, Australia were allocated randomly to usual care (24) or usual care plus WWWT (24).

PARTICIPANTS

English-speaking primiparous women receiving primary care at trial MCHCs were recruited to the intervention (204) and control (196) conditions. Of these, 187 (91.7%) and 177 (90.3%) provided complete data.

INTERVENTION

WWWT is a manualised programme comprising primary care from a trained nurse, print materials and a face-to-face seminar.

MAIN OUTCOME MEASURES

Data sources were standardised and study-specific measures collected in blinded computer-assisted telephone interviews at 6 and 26 weeks postpartum. The primary outcome was PCMD assessed by Composite International Diagnostic Interviews and Patient Health Questionnaire (PHQ) Depression and Generalised Anxiety Disorder modules.

RESULTS

In intention-to-treat analyses the adjusted OR (AOR) of PCMD in the intervention compared to the usual care group was 0.78 (95% CI 0.38 to 1.63, ns), but mild to moderate anxiety symptoms (AOR 0.58, 95% CI 0.35 to 0.97) and poor self-rated health (AOR 0.46, 95% CI 0.22 to 0.97) were significantly lower. In a per protocol analysis, comparing the full (three component) intervention and usual care groups, the AOR of PCMD was 0.36, (95% CI 0.14 to 0.95). The WWWT seminar was appraised as salient, comprehensible and useful by >85% participants. No harms were detected.

CONCLUSIONS

WWWT is readily integrated into primary care, enables inclusion of fathers and addresses modifiable risks for PCMD directly. The full intervention appears a promising programme for preventing PCMD, optimising family functioning, and as the first component of a stepped approach to mental healthcare.

TRIAL REGISTRATION NUMBER

ACTRN12613000506796; Results.

New mothers and postpartum depression: a narrative review of peer support intervention studies

Postpartum depression (PPD) is a serious maternal mental health issue that negatively impacts new mothers and their infants. Various interventions have been studied and one that has shown promise is social support delivered by peers. Understanding what previous studies on peer support interventions have found will contribute to the development and implementation of future peer support interventions for women with PPD. To this end, a systematic search and narrative review of studies that investigated peer support interventions for PPD was conducted. Relevant studies were identified using CINAHL, Medline, PsychINFO and the Cochrane Library published between 2000 and 2010. Six studies matching inclusion criteria were reviewed. Each of the studies had specific selection criteria and some used screening tools for recruitment. There were differences regarding the criteria for volunteers. All volunteers participated in some form of training and had support from a co-ordinator. Interventions varied in terms of length and nature of support offered, frequency and mode of delivery. Volunteers reported positively on their experience, although there were some challenges in providing support. Overall findings suggest that interventions should be targeted and take into consideration the age of the mother, any cultural and linguistic differences, the mother's circumstances and her needs. All volunteers should receive training before providing support and be screened for their ability to commit their time. Although the results were mixed, they provide insights into how peer support volunteers can be an innovative part of a team approach to PPD intervention.

Debriefing interventions for the prevention of psychological trauma in women following childbirth

BACKGROUND

Childbirth is a complex life event that can be associated with both positive and negative psychological responses. When giving birth is experienced as particularly traumatic this can have a negative impact on a woman's postnatal emotional well-being. There has been an increasing focus on women's psychological trauma symptoms following childbirth, including the relatively rare phenomenon of post-traumatic stress disorder (PTSD), and the benefit of debriefing interventions to prevent this. In this review we examined the evidence for debriefing as a preventative intervention for psychological trauma following childbirth.

OBJECTIVES

To assess the effects of debriefing interventions compared with standard postnatal care for the prevention of psychological trauma in women following childbirth.

SEARCH METHODS

The trials registers of the Cochrane Depression, Anxiety and Neurosis Group (CCDANCTR-References and CCDANCTR-Studies) and the Cochrane Pregnancy and Childbirth Group were searched up to 4 March 2015. These registers include relevant randomised controlled trials from the following bibliographic databases: the Cochrane Library (all years to date), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). Additional searches were conducted in CENTRAL, MEDLINE, EMBASE, PsycINFO, and Maternity and Infant Care. The reference lists of all included studies were checked for additional published reports and citations of unpublished research. Experts in the field were contacted.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-randomised trials comparing postnatal debriefing interventions with standard postnatal care for the prevention of psychological trauma of women following childbirth. The intervention consisted of at least one debriefing intervention session, which had the purpose of allowing women to describe their experience and to normalise their emotional reaction to that experience.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed trial quality and extracted data. Meta-analysis was conducted where there were more than two trials examining the same outcomes.

MAIN RESULTS

We included seven trials (eight articles) from three countries (UK, Australia and Sweden) that fulfilled the inclusion criteria. The number of women contributing data to each outcome varied from 102 to 1745. Methodological quality was variable and most of the studies were of low quality. The quality of evidence for the prevalence of psychological trauma (primary outcome) and the prevalence of depression symptoms was rated low or very low, based on few studies (ranging from a single study to three studies) with high risk of bias in main domains such as performance bias, random sequence generation, allocation concealment and incomplete outcome data. The quality of evidence for the remaining outcomes (that is prevalence of anxiety, prevalence of fear of childbirth, prevalence of general psychological morbidity, health service utilization and attrition from treatment) was not assessed as data were not available.Among women who had a high level of obstetric intervention during labour and birth, we found no difference between standard postnatal care with debriefing and standard postnatal care without debriefing on psychological trauma symptoms within three months postpartum (RR 0.61; 95% CI 0.28 to 1.31; n = 425) or at three to six months postpartum (RR 0.62; 95% CI 0.27 to 1.42; n = 246). The results were based on two trials, respectively. Among women who experienced a distressing or traumatic birth, there was no evidence of an effect of psychological debriefing on the prevention of PTSD (measured by the MINI-PTSD) at four to six weeks postpartum (RR 1.15; 95% CI 0.66 to 2.01; n = 102) or at six months (RR 0.35; 95% CI 0.10 to 1.23; n = 103). The results were based on one small trial. One trial involving low-risk women who delivered healthy infants at or near term reported no significant difference between the intervention group and the control group in the proportion of women who met the diagnostic criteria for psychological trauma during the year following childbirth (RR 1.06; 95% CI 0.88 to 1.28; n = 1745). We did not find any information about attrition rates.

AUTHORS' CONCLUSIONS

We did not find any high quality evidence to inform practice, with substantial heterogeneity being found between the studies conducted to date. There is little or no evidence to support either a positive or adverse effect of psychological debriefing for the prevention of psychological trauma in women following childbirth. There is no evidence to support routine debriefing for women who perceive giving birth as psychologically traumatic.Future research should provide greater detail of the outcome measures used, and with scales for measuring psychological trauma validated against clinical diagnostic interviews. High rates of obstetric intervention in some birth settings may mean that women require improved emotional care from health professionals to reduce the risk of childbirth being experienced as traumatic. As all included trials excluded women unable to communicate in the native language of the study setting, there is no information on the response of these women to psychological debriefing. No included studies were conducted in low or middle-income countries.

Antenatal mindfulness intervention to reduce depression, anxiety and stress: a pilot randomised controlled trial of the MindBabyBody program in an Australian tertiary maternity hospital

Background

Mindfulness interventions to reduce psychological distress are well-suited to pregnancy, due to their brief and non-pharmacological nature, but there is a need for more robust evidence determining their usefulness. This pilot study was designed to explore the feasibility of a randomised controlled trial of a mindfulness intervention to reduce antenatal depression, anxiety and stress.

Methods

The study was designed in two parts 1) a non-randomised trial targeting women at risk of mental health problems (a selected population) and 2) a randomised controlled trial (RCT) of a universal population. Process evaluation focused on feasibility of recruitment pathways, participant retention, acceptability of study measures, and engagement with mindfulness practices. Measurement of psychological distress was taken pre and post intervention through the Centre for Epidemiologic Studies Depression Scale Revised, the Depression Anxiety and Stress Scale-21, the State-Trait Anxiety Inventory, and the Perceived Stress Scale.

Results

20 women were recruited to the non-randomised trial, and 32 to the RCT. Recruitment through a mailed study brochure at the time of booking-in to the hospital resulted in the largest number of participants in the RCT (16/32; 50%), and resulted in considerably earlier recruitment (50% in first trimester, 50% second trimester) compared to recruitment through the antenatal clinic waiting room (86% in second trimester, 14% third trimester). Over a third of women in the universal population scored above clinical cut-offs for depression and anxiety, indicating a sample with more symptomology than the general population. The most common reason for loss to follow-up was delivery of baby prior to follow-up (n = 9). In the non-randomised study, significant within group improvements to depression and anxiety were observed. In the intervention arm of the RCT there were significant within group improvements to anxiety and mindfulness. No between group differences for the intervention and ‘care as usual’ control group were observed.

Conclusions

This small pilot study provides evidence on the feasibility of an antenatal mindfulness intervention to reduce psychological distress. Major challenges include: finding ways to facilitate recruitment in early pregnancy and engaging younger women and other vulnerable populations.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12613000742774 (31/10/2012).

Therapeutic interventions in perinatal and infant mental health services: a mixed methods inquiry

Perinatal mental health disorders potentially have long-term negative sequelae for women, their infants and their families. Multidisciplinary perinatal and infant mental health (PIMH) services are an emerging specialty in mental health designed to improve mother-infant outcomes. This mixed methods study explored the characteristics of women referred to a specialist PIMH service and the therapeutic interventions that PIMH clinicians use. Women referred to the service were identified with multiple and complex risk factors. Perinatal and infant mental health clinicians use a range of interventions, dependent upon their training, such as family of origin work/genograms, non-directive counseling, and strategies to manage anxiety and depression. Clinicians also emphasized the therapeutic relationship and the interventions they use within an attachment-based framework, which warrants further research.

Improving population-level maternal health: a hard nut to crack? Long term findings and reflections on a 16-community randomised trial in Australia to improve maternal emotional and physical health after birth [ISRCTN03464021]

BACKGROUND

Community level interventions to improve maternal and child health have been supported and well evaluated in resource poor settings, but less so in developed countries. PRISM--Program of Resources, Information and Support for Mothers--was a primary care and community-based cluster-randomised trial in sixteen municipalities in Victoria, Australia, which aimed to reduce depression in mothers and improve their physical health. The aim of this paper is to report the longer term outcomes of PRISM and to reflect on lessons learned from this universal community intervention to improve maternal health.

METHODS

Maternal health outcome data in PRISM were collected by postal questionnaire at six months and two years. At two years, the main outcome measures included the Edinburgh Postnatal Depression Scale (EPDS) and the SF-36. Secondary outcome measures included the Experience of Motherhood Scale (EOM) and the Parenting Stress Index (PSI). A primary intention to treat analysis was conducted, adjusting for the randomisation by cluster.

RESULTS

7,169/18,424 (39%) women responded to the postal questionnaire at two years -3,894 (40%) in the intervention arm and 3,275 (38%) in the comparison arm. Respondents were mostly representative on available population data comparisons. There were no differences in depression prevalence (EPDS≥13) between the intervention and comparison arms (13.4% vs 13.1%; ORadj = 1.06, 95%CI 0.91-1.24). Nor did women's mental health (MCS: 48.6 vs 49.1) or physical health scores (PCS: 49.1 vs 49.0) on the SF-36 differ between the trial arms.

CONCLUSION

Improvement in maternal mental and physical health outcomes at the population level in the early years after childbirth remains a largely unmet challenge. Despite the lack of effectiveness of PRISM intervention strategies, important lessons about systems change, sustained investment and contextual understanding of the workability of intervention strategies can be drawn from the experience of PRISM. Trial Registration. Controlled-Trials.com ISRCTN03464021.

Early life programming as a target for prevention of child and adolescent mental disorders

This paper concerns future policy development and programs of research for the prevention of mental disorders based on research emerging from fetal and early life programming. The current review offers an overview of findings on pregnancy exposures such as maternal mental health, lifestyle factors, and potential teratogenic and neurotoxic exposures on child outcomes. Outcomes of interest are common child and adolescent mental disorders including hyperactive, behavioral and emotional disorders. This literature suggests that the preconception and perinatal periods offer important opportunities for the prevention of deleterious fetal exposures. As such, the perinatal period is a critical period where future mental health prevention efforts should be focused and prevention models developed. Interventions grounded in evidence-based recommendations for the perinatal period could take the form of public health, universal and more targeted interventions. If successful, such interventions are likely to have lifelong effects on (mental) health.

The estimation of utility weights in cost-utility analysis for mental disorders: a systematic review

OBJECTIVE

To systematically review approaches and instruments used to derive utility weights in cost-utility analyses (CUAs) within the field of mental disorders and to identify factors that may have influenced the choice of the approach.

METHODS

We searched the databases DARE (Database of Abstracts of Reviews of Effects), NHS EED (National Health Service Economic Evaluation Database), HTA (Health Technology Assessment), and PubMed for CUAs. Studies were included if they were full economic evaluations and reported quality-adjusted life-years as the health outcome. Study characteristics and instruments used to estimate utility weights were described and a logistic regression analysis was conducted to identify factors associated with the choice of either the direct (e.g. standard gamble) or the preference-based measure (PBM) approach (e.g. EQ-5D).

RESULTS

We identified 227 CUAs with a maximum in 2009, 2010, and 2012. Most CUAs were conducted in depression, dementia, or psychosis, and came from the US or the UK, with the EQ-5D being the most frequently used instrument. The application of the direct approach was significantly associated with depression, psychosis, and model-based studies. The PBM approach was more likely to be used in recent studies, dementia, Europe, and empirical studies. Utility weights used in model-based studies were derived from only a small number of studies.

LIMITATIONS

We only searched four databases and did not evaluate the quality of the included studies.

CONCLUSIONS

Direct instruments and PBMs are used to elicit utility weights in CUAs with different frequencies regarding study type, mental disorder, and country.

Preventing postpartum depression: a meta-analytic review

This meta-analysis assessed the efficacy of a wide range of preventive interventions designed to reduce the severity of postpartum depressive symptoms or decrease the prevalence of postpartum depressive episodes. A systematic review identified 37 randomized or quasi-randomized controlled trials in which an intervention was compared to a control condition. Differences between treatment and control conditions in the level of depressive symptoms and prevalence of depressive episodes by 6 months postpartum were assessed in separate analyses. Depressive symptoms were significantly lower at post-treatment in intervention conditions, with an overall effect size in the small range after exclusion of outliers (Hedges' g=0.18). There was a 27% reduction in the prevalence of depressive episodes in intervention conditions by 6 months postpartum after removal of outliers and correction for publication bias. Later timing of the postpartum assessment was associated with smaller differences between intervention and control conditions in both analyses. Among studies that assessed depressive symptoms using the EPDS, higher levels of depressive symptoms at pre-treatment were associated with smaller differences in depressive symptoms by 6 months postpartum. These findings suggest that interventions designed to prevent postpartum depression effectively reduce levels of postpartum depressive symptoms and decrease risk for postpartum depressive episodes.

Oxytocin and postpartum depression: delivering on what's known and what's not

The role of oxytocin in the treatment of postpartum depression has been a topic of growing interest. This subject carries important implications, given that postpartum depression can have detrimental effects on both the mother and her infant, with lifelong consequences for infant socioemotional and cognitive development. In recent years, oxytocin has received attention for its potential role in many neuropsychiatric conditions beyond its well-described functions in childbirth and lactation. In the present review, we present available data on the clinical characteristics and neuroendocrine foundations of postpartum depression. We outline current treatment modalities and their limitations, and proceed to evaluate the potential role of oxytocin in the treatment of postpartum depression. The aim of the present review is twofold: (a) to bring together evidence from animal and human research concerning the role of oxytocin in postpartum depression, and (b) to highlight areas that deserve further research in order to bring a fuller understanding of oxytocin's therapeutic potential. This article is part of a Special Issue entitled Oxytocin and Social Behav.

Prevention of common mental disorders: what can we learn from those who have gone before and where do we go next?

OBJECTIVE

Prevention strategies have made a major contribution to the considerable successes in reductions in cardiovascular disease and cancer mortality seen in recent decades. However, in the field of psychiatry, similar population-level initiatives in the prevention of common mental disorders, depression and anxiety, are noticeably lacking. This paper aims to provide a brief overview of the existing literature on the topic of the prevention of common mental disorders and a commentary regarding the way forward for prevention research and implementation.

METHODS

This commentary considers what we currently know, what we might learn from the successes and failures of those working in prevention of other high prevalence health conditions, and where we might go from here. Taking cognisance of previous preventive models, this commentary additionally explores new opportunities for preventive approaches to the common mental disorders.

RESULTS

The consensus from a large body of evidence supports the contention that interventions to prevent mental disorders across the lifespan can be both effective and cost-effective. However, funding for research in the area of prevention of common mental disorders is considerably lower than that for research in the areas of treatment, epidemiology and neurobiology. Thus, there is a clear imperative to direct funding towards prevention research to redress this imbalance. Future prevention interventions need to be methodologically rigorous, scalable to the population level and include economic evaluation. Evidence-based knowledge translation strategies should be developed to ensure that all stakeholders recognise preventing mental disorders as an imperative, with appropriate resources directed to this objective.

CONCLUSION

There has been a recent expansion of research into potentially modifiable risk factors for depression, and it is now timely to make a concerted effort to advance the field of prevention of common mental disorders.

Effect of laparoscopic surgery for moderate and severe endometriosis on depression, relationship satisfaction and sexual functioning: comparison of patients with and without bowel resection

STUDY QUESTION

Is there a difference between women with endometriosis who underwent laparoscopic surgery with bowel resection or without bowel resection regarding depressive symptoms, relational adjustment and sexual functioning?

SUMMARY ANSWER

Radical surgery for endometriosis in both groups improved the levels of depression and sexual functioning, but only the bowel resection patients showed improvements in relationship satisfaction. WHAT IS KNOWN ALREADY?: The frequent pain symptoms in endometriosis patients can have an impact on psychological issues, relationships and sexual functioning. There are no data available on depression and relationship adjustment after endometriosis surgery. Sexual dysfunction problems have been described after bowel resection for rectal cancer, but no data are available for endometriosis surgery.

STUDY DESIGN, SIZE, DURATION

This prospective cohort study included 203 consecutive women operated at the Leuven University Fertility Center (LUFC) between 1 September 2006 and 30 September 2008 for moderate (n = 67) or severe (n = 136) endometriosis. The preoperative response rate was respectively 84% in the bowel resection group and 79% in the no bowel resection group.

PARTICIPANTS, SETTING, METHODS

The beck depression inventory (BDI) measured depression, the dyadic adjustment scale (DAS) measured relationship satisfaction and the short sexual functioning scale (SSFS) measured sexual functioning before and 6, 12 and 18 months after women had laparoscopic surgery at the LUFC, a tertiary referral centre for fertility exploration, treatment and surgery.

MAIN RESULTS AND THE ROLE OF CHANCE

Both groups had better post-operative outcomes when compared with the preoperative assessments. Mean BDI and DAS levels were comparable with the normal population. Overall assessment points, the bowel resection patients had better outcomes for DAS (P < 0.05) and SSFS 'arousal' (P < 0.05) than the no bowel resection patients. At 6 months after the operation, when compared with the no bowel resection group, the bowel resection group reported lower mean levels of BDI (P < 0.05), a lower incidence of SSFS 'pain during intercourse' and 'orgasm problems' (P < 0.05), and a lower proportion of patients with severe orgasm problems (P < 0.05). The data show that radical but fertility sparing surgery, with or without bowel resection, for the treatment of endometriosis results in comparable and good psychological outcomes concerning depression levels, relationship satisfaction and sexual functioning.

LIMITATIONS, REASONS FOR CAUTION

Although the initial response rate was good, response dropped over time and was significantly higher for bowel resection patients compared with the no bowel resection patients (P = 0.05). A responder/non-responder analysis for the whole study population showed no significant differences concerning pain problems. This reduces the possible risk of (positive) bias in the results.

WIDER IMPLICATIONS OF THE FINDINGS

Endometriosis is a complex condition and the focus should not be on a one-dimensional end-organ gynaecological outcome, but should take into account the role of psychological factors in pain-related outcome. To this end, more prospective data are needed on sexual functioning and psychological outcomes.

[Qualitative evidence of monitoring by doulas during labor and childbirth]

The objective of this study was to conduct a metasynthesis of evidence of the work of doulas assisting women in labor and during childbirth. Articles between 2000 and 2009 were located in the Medline, PubMed, SciELO, and Lilacs databases using the key search words: doulas, gestation, labor, and alternative therapy. Seven articles were selected for the study and four categories were created: the support provided by doulas; the birth mother's experiences; professional relationship: and opinions and experiences of professionals. The doulas offered physical, emotional, spiritual and social support. Experiments showed that the professionals stimulated the mother/child relationship, oriented towards successful breastfeeding, and contributed to the prevention of post-partum depression. Controversy was observed among professionals regarding acceptance of the role of the doula as a member of the obstetrics team. The doula's care was considered innovative, calming, encouraging, and attended all the needs of the pregnant woman. The conclusion is that qualitative studies on the work of doulas are recent, incipient, but revealing as to the important possibility of humanizing labor and childbirth.

The Role of Exercise in Treating Postpartum Depression: A Review of the Literature

There is now evidence to support the antidepressant effects of exercise in general and in clinical populations. This article reviews the evidence regarding the potential role of exercise, particularly pram walking, as an adjunctive treatment for postpartum depression. Database searches revealed two small randomised controlled trials conducted in Australia which support exercise as a useful treatment for women with postpartum depression. In addition, uncontrolled studies and observational evidence suggest that postpartum women, some of whom were depressed, report benefit from participation in exercise programmes. There are plausible mechanisms by which exercise could have such an effect. Limited evidence supports a relationship between participation in exercise and reduction in postpartum depression. Given the reluctance by some women to use antidepressant medication postpartum and the limited availability of psychological therapies, exercise as a therapeutic possibility deserves further exploration. Further research using well-designed randomised controlled trial methodologies are warranted.

Development of a universal psycho-educational intervention to prevent common postpartum mental disorders in primiparous women: a multiple method approach

BACKGROUND

Prevention of postnatal mental disorders in women is an important component of comprehensive health service delivery because of the substantial potential benefits for population health. However, diverse approaches to prevention of postnatal depression have had limited success, possibly because anxiety and adjustment disorders are also problematic, mental health problems are multifactorially determined, and because relationships amongst psychosocial risk factors are complex and difficult to modify. The aim of this paper is to describe the development of a novel psycho-educational intervention to prevent postnatal mental disorders in mothers of firstborn infants.

METHODS

Data from a variety of sources were synthesised: a literature review summarised epidemiological evidence about neglected modifiable risk factors; clinical research evidence identified successful psychosocial treatments for postnatal mental health problems; consultations with clinicians, health professionals, policy makers and consumers informed the proposed program and psychological and health promotion theories underpinned the proposed mechanisms of effect. The intervention was pilot-tested with small groups of mothers and fathers and their first newborn infants.

RESULTS

What Were We Thinking! is a psycho-educational intervention, designed for universal implementation, that addresses heightened learning needs of parents of first newborns. It re-conceptualises mental health problems in mothers of infants as reflecting unmet needs for adaptations in the intimate partner relationship after the birth of a baby, and skills to promote settled infant behaviour. It addresses these two risk factors in half-day seminars, facilitated by trained maternal and child health nurses using non-psychiatric language, in groups of up to five couples and their four-week old infants in primary care. It is designed to promote confidence and reduce mental disorders by providing skills in sustainable sleep and settling strategies, and the re-negotiation of the unpaid household workload in non-confrontational ways. Materials include a Facilitators' Handbook, creatively designed worksheets for use in seminars, and a book for couples to take home for reference. A website provides an alternative means of access to the intervention.

CONCLUSIONS

What Were We Thinking! is a postnatal mental health intervention which has the potential to contribute to psychologically-informed routine primary postnatal health care and prevent common mental disorders in women.

Adapting and testing telephone-based depression care management intervention for adolescent mothers

This phase 1 clinical trial combined qualitative and quantitative methods to modify a collaborative care, telephone-based, depression care management intervention for adolescent mothers and to determine the acceptability, feasibility, and initial efficacy of the intervention in a sample of adolescent mothers (n = 97) who were recruited from a Teen Parent Program. Outcomes included measures of depressive symptoms, functioning, and use of mental health services. Acceptability of the intervention was demonstrated, but feasibility issues related to the complex life challenges confronting the adolescent mother. Although only four adolescent mothers received mental health treatment, there was a trend for improved depressive symptoms over time. Results of the study provide data for the need of further refinement of the intervention before a large clinical trial is conducted for adolescent mothers with symptoms of depression.

Innovative psycho-educational program to prevent common postpartum mental disorders in primiparous women: a before and after controlled study

BACKGROUND

Universal interventions to prevent postnatal mental disorders in women have had limited success, perhaps because they were insufficiently theorized, not gender-informed and overlooked relevant risk factors. This study aimed to determine whether an innovative brief psycho-educational program for mothers, fathers and first newborns, which addressed salient learning needs about infant behaviour management and adjustment tasks in the intimate partner relationship, prevented postpartum mental health problems in primiparous women.

METHODS

A before and after controlled study was conducted in primary care in seven local government areas in Victoria, Australia. English-speaking couples with one-week old infants were invited consecutively to participate by the maternal and child health nurse at the universal first home visit. Two groups were recruited and followed sequentially: both completed telephone interviews at four weeks and six months postpartum and received standard health care. Intervention group participants were also invited to attend a half-day program with up to five couples and one month old infants, facilitated by trained, supervised nurses. The main outcome was any Composite International Diagnostic Interview (CIDI) diagnosis of Depression or Anxiety or Adjustment Disorder with Depressed Mood, Anxiety, or Mixed Anxiety and Depressed Mood in the first six months postpartum. Factors associated with the outcome were established by logistic regression controlling for potential confounders and analysis was by intention to treat.

RESULTS

In total 399/646 (62%) women were recruited; 210 received only standard care and 189 were also offered the intervention; 364 (91%) were retained at follow up six months postpartum. In women without a psychiatric history (232/364; 64%), 36/125 (29%) were diagnosed with Depression or Anxiety or Adjustment Disorder with Depressed Mood, Anxiety, or Mixed Anxiety and Depressed Mood in the control group, compared with 16/107 (15%) in the intervention group. In those without a psychiatric history, the adjusted odds ratio for diagnosis of a common postpartum mental disorder was 0.43 (95% CI 0.21, 0.89) in the intervention group compared to the control group.

CONCLUSIONS

A universal, brief psycho-educational group program for English-speaking first time parents and babies in primary care reduces de novo postpartum mental disorders in women. A universal approach supplemented by an additional program may improve effectiveness for women with a psychiatric history.

TRIAL REGISTRATION

ACTRN 12605000567628.

Psychotherapy versus the combination of psychotherapy and pharmacotherapy in the treatment of depression: a meta-analysis

BACKGROUND

A large number of studies have shown that psychological treatments have significant effects on depression. Although several studies have examined the relative effects of psychological and combined treatments, this has not been studied satisfactorily in recent statistical meta-analyses.

METHOD

We conducted a meta-analysis of randomized studies in which a psychological treatment was compared to a combined treatment consisting of the same psychological treatment with a pharmacological therapy. For each of these studies we calculated the effect size indicating the difference between the psychological and the combined treatment.

RESULTS

All inclusion criteria were met by 18 studies, with a total of 1,838 subjects. The mean effect size indicating the difference between psychological and combined treatment was 0.35 (95% CI: 0.24 approximately 0.45; P<0.001), with low heterogeneity. Subgroup analyses indicated that the difference between psychological and combined treatments was significantly smaller in studies in which cognitive behavior therapy was examined. We also found a trend (P<0.1) indicating that the difference between psychological and combined treatment was somewhat larger in studies aimed at specific populations (older adults, chronic depression, HIV patients) than in studies with adults, and in studies in which Trycyclic antidepressants or SSRIs were examined, compared to studies in which a medication protocol or another antidepressant was used. At follow-up, no difference between psychological and combined treatments was found.

CONCLUSION

We conclude that combined treatment is more effective than psychological treatment alone. However, it is not clear whether this difference is relevant from a clinical perspective.

The epidemiology of pregnancy outcomes in rural Burkina Faso

OBJECTIVES

To describe levels and causes of pregnancy-related mortality and selected outcomes after pregnancy (OAP) in two districts of Burkina Faso.

METHODS

A household census was conducted in the two study districts, recording household deaths to women aged 12-49 years from 2001 to 2006. Questions on pregnancy outcomes in the last 5 years for resident women of reproductive age were included, and an additional method - direct sisterhood - was added in part of the area. Adult female deaths were followed-up with verbal autopsies (VA) with household members. A probabilistic model for interpreting VA data (InterVA-M) was used to determine distributions of probable causes of death. An OAP survey was conducted among all women with an experience of pregnancy during the prior 12 months. It aimed to document physical and psychological disabilities, economic and social consequences and discomfort that women may suffer as a result of a pregnancy.

RESULTS

The maternal mortality ratio (MMR) was 441 per 100 000 live births (95% CI: 397, 485), significantly higher in Diapaga [519 per 100 000 (95% CI: 454, 584)] than Ouargaye [353 per 100 000 (95% CI: 295, 411)]. MMRs were associated with wealth quintile, age and distance from a health facility. The causes of death showed higher than expected rates of sepsis (30%) and lower rates of haemorrhage (7%). A substantial proportion of all women had difficulty performing day-to-day tasks as a consequence of pregnancy. Women who had experienced stillbirths or Caesarean sections reported symptom-related indicators of poor physical health more frequently than women reporting uncomplicated deliveries, and were also more likely to be depressed.

CONCLUSIONS

Expectations on the levels and causes of pregnancy-related mortality in Burkina Faso may need to be re-examined, and this could have programmatic implications; for example high levels of sepsis could prompt renewed efforts to reach women with skilled attendance at delivery and follow-up during the postpartum period. Further documentation of how complication-induced disabilities affect women and their families is needed. For mortality and morbidity outcomes, demonstrating variation between study districts is important to empower local decision makers with evidence of need at a subnational level.

Seeking help for anxiety and depression after childbirth: results of the Maternal Health Study

Access to treatment for postnatal anxiety and depression is dependant on women seeking help for psychological symptoms. The aim of this paper was to investigate what women themselves say about seeking help for emotional difficulties after childbirth. The Maternal Health Study is a prospective pregnancy cohort study investigating the physical and psychological health of 1,507 nulliparous women during pregnancy and after birth. One thousand, three hundred eighty-five women completed a computer-assisted telephone interview at 9 months postpartum; 8.5% of women reported intense anxiety or panic attacks occasionally or often, and 9.5% reported depressed mood, between 6 and 9 months postpartum. Of those experiencing anxiety symptoms alone 44.4% had spoken to a health professional, compared with 65.5% of women experiencing depressive symptoms alone (RR = 0.68, 95% CI-0.5 to 0.9). Measures of anxiety and depressive symptoms at 9 months postpartum were not validated against diagnostic criteria. Anxiety is a common experience in the perinatal period. More research is needed into this area to determine what levels of anxiety are 'normal' and acceptable to women during this period. Public health campaigns may have been more effective in encouraging women to seek help for depression than anxiety.

Characteristics of effective psychological treatments of depression: a metaregression analysis

Although many meta-analyses have shown that psychological therapies are effective in the treatment of depression, no comprehensive metaregression analysis has been conducted to examine which characteristics of the intervention, target population, and study design are related to the effects. The authors conducted such a metaregression analysis with 83 studies (135 comparisons) in which a psychological treatment was compared with a control condition. The mean effect size of all comparisons was 0.69 (95% confidence interval = 0.60-0.79). In multivariate analyses, several variables were significant: Studies using problem-solving interventions and those aimed at women with postpartum depression or specific populations had higher effect sizes, whereas studies with students as therapists, those in which participants were recruited from clinical populations and through systematic screening, and those using care-as-usual or placebo control groups had lower effect sizes.

Is psychotherapy for depression equally effective in younger and older adults? A meta-regression analysis

BACKGROUND

It is well established that psychotherapy is effective in the treatment of depression in younger as well as in older adults. Whether these psychotherapies are equally effective in younger and older age groups has not been examined in meta-analytic research.

METHODS

We conducted a systematic literature search and included 112 studies with 170 comparisons between a psychotherapy and a control group (with a total of 7,845 participants). Twenty studies with 26 comparisons were aimed at older adults.

RESULTS

We found no indication that psychotherapies were more or less effective for older adults compared to younger adults. The effect sizes of both groups of comparisons did not differ significantly from each other (older adults: d = 0.74; 95% CI: 0.49-0.99; younger adults: d = 0.67; 95% CI: 0.58-0.76). In a multivariate meta-regression analysis, in which we controlled for major characteristics of the participants, the interventions and the study designs, no indication of a difference between psychotherapy in younger and older adults was found.

CONCLUSIONS

There appears to be no significant difference between psychotherapy in younger and older adults, although it is not clear whether this is also true for clinical samples, patients with more severe depression, and the older old.

A systematic review of home-based interventions to prevent and treat postpartum depression

This systematic review evaluated randomized controlled trials assessing home-based psychological interventions to prevent and treat postpartum depression (PPD). Six studies meeting inclusion criteria were identified, five assessing treatments for PPD and one assessing a preventive intervention for PPD. Interventions used cognitive behavioral, psychodynamic, and non-directive counseling approaches. Of the six studies reviewed, four reported statistically significant treatment effects on PPD following the intervention. Each of the three types of psychological interventions were shown to reduce levels of maternal depression. Recommendations for future development and evaluation of home-based psychological interventions for PPD are discussed. These include identification of mediators and moderators of intervention efficacy, exploring strategies for prevention of PPD, and targeting high-risk groups.

Effectiveness of home visits by mental health nurses for Japanese women with post-partum depression

Post-partum depression affects 10-13% of Japanese women, but many do not receive appropriate treatment or support. This intervention study evaluated the effectiveness of home visits by mental health nurses for Japanese women with post-partum depression. Eighteen post-partum women met the inclusion criteria and were randomly allocated into the intervention (n = 9) or control (n = 9) group at 1-2 months after giving birth. The intervention group received four weekly home visits by a mental health nurse. Control group participants received usual care. Two women in the intervention group did not complete the study. Depressive symptoms and quality of life were measured at 1 and 6 weeks' postintervention. In addition, participants completed an open-ended questionnaire on satisfaction and meaning derived from the home visits. Women in the intervention group had significant amelioration of depressive symptoms over time and reported positive benefits from the home visits, but there were no statistically significant differences between groups. Significant differences (P < 0.05) were observed at times 2 and 3 between groups in terms of increased median scores of physical, environmental, and global subscales, and the total average score of the World Health Organization/quality of life assessment instrument. On the psychological subscale, significant differences (P = 0.042) were observed between groups at time 2. The qualitative analysis of comments about home visitation revealed four categories related to 'setting their mind at ease', 'clarifying thoughts', 'improving coping abilities', and 'removing feelings of withdrawal from others'. These results suggest that home visits by mental health nurses can contribute to positive mental health and social changes for women with post-partum depression. A larger trial is warranted to test this approach to care.

Antenatal psychosocial assessment for reducing perinatal mental health morbidity

BACKGROUND

Mental health conditions arising in the perinatal period, including depression, have the potential to impact negatively on not only the woman but also her partner, infant, and family. The capacity for routine, universal antenatal psychosocial assessment, and thus the potential for reduction of morbidity, is very significant.

OBJECTIVES

To evaluate the impact of antenatal psychosocial assessment on perinatal mental health morbidity.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, the Cochrane Depression, Anxiety and Neurosis Group's Trials Register (CCDAN TR-Studies), HSRProj in the National Library of Medicine (USA), and the Current Controlled Trials website: http://www.controlled trials.com/ and the UK National Research Register (last searched March 2008).

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trials for eligibility; they also extracted data from included trials and assessed the trials for potential bias.

MAIN RESULTS

Two trials met criteria for an RCT of antenatal psychosocial assessment. One trial examined the impact of an antenatal tool (ALPHA) on clinician awareness of psychosocial risk, and the capacity of the antenatal ALPHA to predict women with elevated postnatal Edinburgh Depression Scale (EDS) scores, finding a trend towards increased clinician awareness of 'high level' psychosocial risk where the ALPHA intervention had been used (relative risk (RR) 4.61 95% confidence interval (CI) 0.99 to 21.39). No differences between groups were seen for numbers of women with antenatal EDS scores, a score of greater than 9 being identified by ALPHA as of concern for depression (RR 0.69 95% CI 0.35 to 1.38); 139 providers. The other trial reported no differences in EPS scores greater than 12 at 16 weeks postpartum between the intervention (communication about the EDS scores with the woman and her healthcare providers plus a patient information booklet) and the standard care groups (RR 0.86 95% CI 0.61 to 1.21; 371 women).

AUTHORS' CONCLUSIONS

While the use of an antenatal psychosocial assessment may increase the clinician's awareness of psychosocial risk, neither of these small studies provides sufficient evidence that routine antenatal psychosocial assessment by itself leads to improved perinatal mental health outcomes. Further studies with better sample size and statistical power are required to further explore this important public health issue. It will also be important to examine outcomes up to one year postpartum not only for mother, but also infant and family.

The Edinburgh Postnatal Depression Scale detects but does not distinguish anxiety disorders from depression in mothers of infants

Specific screening tests to detect postpartum anxiety are as yet unavailable. The aim of this study was to test the ability of the Edinburgh Postnatal Depression Scale (EPDS) to detect anxiety disorders in women admitted to residential early parenting centres. Consecutive cohorts of English speaking women admitted with their infants to two centres in Melbourne, Australia completed the Composite International Diagnostic Interview and the Edinburgh Postnatal Depression Scale (EPDS). Anxiety and depression diagnoses were compared with EPDS scores. Of the 145 women (78% recruitment rate), 138 (95%) provided complete data of whom 35 (25%) had at least one anxiety disorder. EPDS scores over 12 correctly identified 28 women (44%) as having major depression, either alone or co-morbid with an anxiety disorder but 10 (16%) had only an anxiety disorder and were not depressed. All of the 26 (41%) women with EPDS scores over 12 with neither diagnosis met diagnostic criteria for minor depression or an adjustment disorder. EPDS scores were unable to distinguish between these diagnostic groups. The presumption that EPDS scores over 12 indicate only probable depression is an oversimplification. Current national initiatives recommend that EPDS scores over 12 warrant treatment for depression, which may lead to inappropriate labeling and therapy.

Psychological treatment of depression: a meta-analytic database of randomized studies

BACKGROUND

A large number of randomized controlled studies have clearly demonstrated that psychological interventions are effective in the treatment of depression. The number of studies in this area is increasing rapidly. In this paper, we present a database of controlled and comparative outcome studies on psychological treatments of depression, based on a series of meta-analyses published by our group. The database can be accessed freely through the Internet.

DESCRIPTION

We conducted a comprehensive literature search of the major bibliographical databases (Pubmed; Psycinfo; Embase; Cochrane Central Register of Controlled Trials) and we examined the references of 22 earlier meta-analyses of psychological treatment of depression. We included randomized studies in which the effects of a psychological therapy on adults with depression were compared to a control condition, another psychological intervention, or a combined treatment (psychological plus pharmacological). We conducted nine meta-analyses of subgroups of studies taken from this dataset. The 149 studies included in these 9 meta-analyses are included in the current database. In the 149 included studies, a total of 11,369 patients participated. In the database, we present selected characteristics of each study, including characteristics of the patients (the study population, recruitment method, definition of depression); characteristics of the experimental conditions and interventions (the experimental conditions, N per condition, format, number of sessions); and study characteristics (measurement times, measures used, attrition, type of analysis and country).

CONCLUSION

The data on the 149 included studies are presented in order to give other researchers access to the studies we collected, and to give background information about the meta-analyses we have published using this dataset. The number of studies examining the effects of psychological treatments of depression has increased considerably in the past decades, and this will continue in the future. The database we have presented in this paper can help to integrate the results of these studies in future meta-analyses and systematic reviews on psychological treatments for depression.

Impact of education on women with perinatal depression

OBJECTIVE

To assess the impact that education through participation in a depression screening program has on mental health literacy and help seeking behavior in perinatal women.

METHODS

Responses to a hypothetical case of depression, help seeking behavior, and screening levels for risk of depression using the Edinburgh Postnatal Depression Scale were compared between two groups of postnatal women; one group who had participated in a screening program and the other who had not. Those who participated in the screening program were also asked to evaluate the educational material they had received.

RESULTS

A total of 1309 women, broadly representative of postnatal women, answered one or more questionnaires. Those who had participated in the screening program were better able to recognize depression in a hypothetical case, and also assess their own mental state more appropriately. Those women who had been part of the program and did not score high on the EPDS were less likely to seek help, were more satisfied when they did and tended to benefit more from the educational booklet.

CONCLUSIONS

Participation in a screening program with educational material had significant benefits for mental health literacy and the health service use for perinatal women at risk for depression.

When giving life starts to take the life out of you: women's experiences of depression after childbirth

OBJECTIVE

To capture the missing voices of mothers who are suffering postnatal depression.

DESIGN

Qualitative methodology using in-depth interviews.

SETTING

Melbourne, Victoria, Australia.

PARTICIPANTS

10 women who had been clinically diagnosed and admitted to a large hospital mother and baby unit in Australia.

FINDINGS

Stigma is frequently attached to women who are unhappy after the birth of their child, because they are not coping with the demands of motherhood or do not instantly bond with, and love, their baby. As a result, postnatal depression can be a terrifying and isolating experience for women. It is also a complex illness with varying degrees, reasons for onset and medical treatments.

IMPLICATIONS FOR PRACTICE

In this study, we have captured the emotions and feelings of women first hand, allowing us and health-care practitioners who are treating women to truly understand this debilitating illness. It is hoped that, in making the wider community aware of depression after childbirth, fewer women will suffer in silence.

PRISM (Program of Resources, Information and Support for Mothers): a community-randomised trial to reduce depression and improve women's physical health six months after birth [ISRCTN03464021]

Background

In the year after birth one in six women has a depressive illness, 94% experience at least one major health problem (e.g. back pain, perineal pain, mastitis, urinary or faecal incontinence), 26% experience sexual problems and almost 20% have relationship problems with partners. Women with depression report less practical and emotional support from partners, less social support, more negative life events, and poorer physical health and see factors contributing to depression as lack of support, isolation, exhaustion and physical health problems. Fewer than one in three seek help in primary care despite frequent health care contacts.

Methods

Primary care and community-based strategies embedded in existing services were implemented in a cluster-randomised trial involving 16 rural and metropolitan communities, pair-matched, within the State of Victoria, Australia. Intervention areas were also provided with a community development officer for two years. The primary aim was to reduce the relative risk of depression by 20% in mothers six months after birth and to improve their physical health. Primary outcomes were obtained by postal questionnaires. The analysis was by intention-to-treat, unmatched, adjusting for the correlated nature of the data.

Results

6,248 of 10,144 women (61.6%) in the intervention arm and 5057/ 8,411 (60.1%) in the comparison arm responded at six months, and there was no imbalance in major covariates between the two arms. Women's mental health scores were not significantly different in the intervention arm and the comparison arm (MCS mean score 45.98 and 46.30, mean EPDS score 6.91 and 6.82, EPDS ≥ 13 ('probable depression') 15.7% vs. 14.9%, Odds ratio_adj 1.06 (95%CI 0.91–1.24). Women's physical health scores were not significantly different in intervention and comparison arms (PCS mean scores 52.86 and 52.88).

Conclusion

The combined community and primary care interventions were not effective in reducing depression, or in improving the physical health of mothers six months after birth.

Clinical issues in perinatal mental health: new developments in the detection and treatment of perinatal mood and anxiety disorders

OBJECTIVE

This paper presents evidence of new developments in the detection and treatment of perinatal mood and anxiety disorders that have relevance for clinicians.

METHOD

An electronic search was conducted in MEDLINE, CINAHL, PsychINFO and The Cochrane Library Database for the interval 1995-2005 for papers published in English.

RESULTS

New developments were identified as follows: i) Broadening frames of reference within perinatal mental health. ii) Impact of disorders upon offspring. iii) Identifying women at risk of mental health problems. iv) Prevention and early intervention strategies. v) Treatments.

CONCLUSION

Perinatal mental health is a rapidly expanding field that impacts upon the health and wellbeing of all members of families with infants and young children. An evidence base for best practice is slowly emerging but considerable work is still needed in relation to the identification of women at risk, standardisation of diagnostic procedures, reduction of adverse outcomes for women and infants, prevention, early intervention, and treatment of clinical disorders.

Psychosocial and psychological interventions for prevention of postnatal depression: systematic review

OBJECTIVE

To assess the effects of psychosocial and psychological interventions compared with usual antepartum, intrapartum, or postpartum care on the risk of postnatal depression.

DATA SOURCES

Medline, Embase, CINAHL, Cochrane central register of controlled trials, Cochrane pregnancy and childbirth group trials register, Cochrane depression, anxiety, and neurosis trials register, secondary references and review articles, and experts in the field.

STUDY SELECTION

All published and unpublished randomised controlled trials of preventive psychosocial or psychological interventions in which the primary or secondary aim was a reduction in the risk of postnatal depression. All trials recruited pregnant women or new mothers less than six weeks postpartum. Eligible studies were abstracted, assessed for methodological quality, and pooled with relative risk for categorical data and weighted mean difference for continuous data.

RESULTS

Fifteen trials with 7697 women were included. Although there was no overall statistically significant effect on the prevention of postnatal depression in the meta-analysis of all types of interventions (15 trials, n = 7697; relative risk 0.81, 95% confidence interval 0.65 to 1.02), these results suggest a potential reduction in postnatal depression. The only intervention to have a clear preventive effect was intensive postpartum support provided by a health professional (0.68, 0.55 to 0.84). Identifying women "at risk" assisted in the prevention of postnatal depression (0.67, 0.51 to 0.89). Interventions with only a postnatal component were more beneficial (0.76, 0.58 to 0.98) than interventions that incorporated an antenatal component. In addition, individually based interventions were more effective (0.76, 0.59 to 1.00) than group based interventions (1.03, 0.65 to 1.63).

CONCLUSIONS

Diverse psychosocial or psychological interventions do not significantly reduce the number of women who develop postnatal depression. The most promising intervention is the provision of intensive, professionally based postpartum support.