Uptake of referrals for women with positive perinatal depression screening results and the effectiveness of interventions to increase uptake: a systematic review and meta-analysis

Who decides to follow the referral advice after a positive postpartum depression screening result? Reflections about the role of sociodemographic, health, and psychological factors from psychological consultations - a cross-sectional study

BACKGROUND/OBJECTIVE

Postpartum depression (PPD), a common and severe mental health problem, affects about 13-20 % of new mothers. Despite the psychological intervention's effectiveness, referral uptake rates among affected women are low. In the article, we aim to characterise those new mothers who adhered to referral advice after a positive PPD screening result.

METHOD

9161 women had taken part in a midwife-led PPD screening. Those who scored equal to or more than ten points on the Edinburgh Postnatal Depression Scale (EPDS) were referred for psychological consultations (12 %, n = 1109). We used data gathered during the realization of a PPD prevention programme. The following measures were used: EPDS, a sociodemographic and health data survey, and psychological consultation cards.

RESULTS

We found that only 85 (8 %) of referred mothers later enrolled in psychological consultations. Those mothers who adhered to the referral advice had higher EPDS (total score) and EPDS - 3A anxiety scores than mothers who did not contact a psychologist. Moreover, they had a higher gestational age at birth and, on average, fewer children. More PPD symptoms, C-section experience, self-assessed good financial situation and a postgraduate higher education degree were predictors of seeking help.

CONCLUSION

A mother's decision to follow the referral advice is crucial in mental health prevention and should be treated as an addition to a separate step 2: referral in a 3-step PDD management process, with identification constituting a step 1, and intervention - a step 3.

The use of a nursing implementation framework to enhance the uptake of an evidence-based intervention

BACKGROUND

Evidence-based practices (EBPs) are instrumental in improving patient outcomes and ensuring high-quality nursing care, yet their implementation often encounters substantial barriers. The Iowa Implementation for Sustainability Framework and the Precision Implementation Approach© offer systematic strategies for overcoming barriers and enhancing EBP implementation and sustainability in health care settings.

AIM

This project aimed to use the Iowa Implementation for Sustainability Framework and the Precision Implementation Approach© to support the use of an evidence-based maternal depression intervention within Iowa's Title V Maternal Health Program that serves mothers of young children living in poverty.

METHODS

This practice-based implementation was accomplished in three steps: (1) hold intervention-focused staff meetings, (2) identify barriers to using the intervention, and (3) identify and deliver implementation strategies. Collected data included barriers identified, selected implementation strategies, and evaluation of meeting attendance and impact on confidence.

RESULTS

Four of the monthly virtual staff meetings focused on Listening Visits (LV) use. The 7 strategies comprising our approach to supporting LV use addressed three categories of identified barriers: lack of confidence, logistical issues, and not understanding intervention procedures. In the LV-focused meetings, representation of the 14 maternal health clinics was high, although attendance by individual staff was inconsistent. Post-meeting polls indicated that 40% to 65% of attendees felt more confident using intervention skills.

LINKING EVIDENCE TO ACTION

This practical nursing-implementation framework facilitated EBP adoption, and our well-structured targeted strategies effectively increased staff confidence. Nursing managers and educators should consider using this framework to enhance their organizations' capacity to implement EBPs sustainably.

Registered nurse lactation consultants' experiences supporting maternal mental health: A qualitative descriptive study

BACKGROUND

The province of Nova Scotia has the highest rates of perinatal mental health disorders in Canada, and rates of exclusive breastfeeding fall below the Canadian national average. Exclusive breastfeeding is identified as a protective factor against the development of perinatal mental health disorders. Lactation consultant support is associated with increased rates of exclusive breastfeeding and decreased rates of perinatal mental health disorders. Despite this, little is known regarding the experiences of Registered Nurse Lactation Consultants related to supporting maternal mental health.

OBJECTIVE

To understand the experiences of Registered Nurse Lactation Consultants related to supporting maternal mental health.

DESIGN

A qualitative descriptive design using online semi-structured interviews.

SETTING & PARTICIPANTS

Ten Registered Nurse Lactation Consultants employed in the publicly funded healthcare system in Nova Scotia, Canada, were recruited via purposive sampling.

FINDINGS

Three themes emerged regarding the relational experiences of Registered Nurse Lactation Consultants while supporting maternal mental health; these included (1) Experiences supporting maternal mental health, (2) Providing maternal mental health care, and (3) Mothers need support.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Registered Nurse Lactation Consultants described positive experiences supporting maternal mental health and indicated that lactation consultant appointments were an opportune time to provide screening and support for maternal mental health. Enhancing support for maternal mental health requires collaborative and integrated approaches throughout the perinatal period. Healthcare providers, including Registered Nurse Lactation Consultants, must be provided with the support and resources to provide timely and appropriate support for maternal mental health throughout the perinatal period.

Unmet needs in mental healthcare for women with clinically significant symptoms of perinatal depression and/or anxiety during the COVID-19 pandemic

OBJECTIVE/BACKGROUND

Unmet needs in perinatal mental healthcare are an important public health issue particularly in the context of a stressful life event such as the COVID-19 pandemic but data on the extent of this problem are needed.

AIM

The aim of this study is to determine the (1) proportion of women with clinically significant symptoms of perinatal depression, anxiety or comorbid symptoms of depression and anxiety, receiving mental healthcare overall and by country and (2) factors associated with receiving mental healthcare.

METHOD

Women in the perinatal period (pregnancy or up to 6 months postpartum) participating in the Riseup-PPD-COVID-19 cross-sectional study, reported on sociodemographic, social support health-related factors, and COVID-19 related factors, and on symptoms of depression (Edinburgh Postnatal Depression Scale [EPDS]) and anxiety (Generalised Anxiety Disorder [GAD-7]) using self-report questionnaires. Clinically significant symptoms were defined as EPDS ≥ 13 for depression and GAD-7 ≥ 10 for anxiety. Mental healthcare was defined as self-reported current mental health treatment.

RESULTS

Of the 11 809 participants from 12 countries included in the analysis, 4 379 (37.1%) reported clinically significant symptoms of depression (n = 1 228; 10.4%; EPDS ≥ 13 and GAD-7 ⟨ 10), anxiety (n = 848; 7.2%; GAD-7 ≥ 10 and EPDS ⟨ 13) or comorbid symptoms of depression and anxiety (n = 2 303; 19.5%; EPDS ≥ 13 and GAD-7 ≥ 10). Most women with clinically significant symptoms of depression, anxiety, or comorbid symptoms of depression and anxiety were not receiving mental healthcare (89.0%). Variation in the proportion of women with clinically significant symptoms of depression and/or anxiety reporting mental healthcare was high (4.7% in Turkey to 21.6% in Brazil). Women in the postpartum (vs. pregnancy) were less likely (OR 0.72; 95% CI 0.59-0.88), whereas women with previous mental health problems (vs. no previous mental health problems) (OR 5.56; 95% CI 4.41-7.01), were more likely to receive mental healthcare.

CONCLUSION

There are high unmet needs in mental healthcare for women with clinically significant symptoms of perinatal depression and/or anxiety across countries during the COVID-19 pandemic. Studies beyond the COVID-19 pandemic and covering the whole range of mental health problems in the perinatal period are warranted to understand the gaps in perinatal mental healthcare.

Uptake rate of interventions among women who screened positive for perinatal depression: A systematic review and meta-analysis

BACKGROUND

Perinatal depression is a global public health problem that seriously affects the health of perinatal women. This study evaluated the pooled uptake rate of interventions among women who screened positive for perinatal depression to provide a basis for clinical intervention.

METHODS

We systematically searched four databases (PubMed, Embase, Cochrane Library and Web of Science) from the establishment of the database to May 1, 2023. All included studies were used to derive the pooled uptake rate. We also performed meta-regression and subgroup analysis to explore the potential sources of heterogeneity using STATA 17.0.

RESULTS

Of 15024 retrieved articles, only 41 met the inclusion criteria. The overall uptake rate was 55 % (95 % CI 43-67 %). Meta-regression and subgroup analyses both showed that the uptake rate in high-income countries 57 % (95 % CI 50-65 %) was higher than that in low and middle-income countries 37 % (95 % CI 18-56 %).

LIMITATIONS

First, only English publications were included. Therefore, articles in other languages were likely missed. Second, of the 41 studies included, there were only six randomized controlled trials, with limited quality of evidence. Third, we could not adequately explain the source of heterogeneity because there were too many mediating variables, although further subgroup and sensitivity analysis were performed.

CONCLUSIONS

About a half of women did not receive interventions after screening positive, and the uptake rate of interventions in high-income countries was higher than that in low and middle-income countries.

Current state and practical recommendations on reproductive mental health: a narrative review

Emotional disorders (EDs) are highly prevalent during the reproductive period, including pregnancy, postpartum, and women undergoing fertility treatments. International guidelines are increasingly suggesting the need to evaluate, prevent, and treat EDs in those women. The main aim of this narrative review is to summarize current practice in the field of EDs management during fertility treatments, pregnancy, and the postpartum and to propose a new technology-based model of care that helps to provide psychological care to all women who are in these periods. Four different databases (Pubmed, Scopus, Science Direct, Web of Science) were consulted. Selected keywords were related with infertility, pregnancy, postpartum, EDs, assessment, prevention, treatment, and technologies. We identified 1603 studies and 43 were included in this review. According to these studies, different face-to-face protocols already exist to manage EDs in women undergoing fertility treatments, pregnant or at the postpartum. We noticed an increased interest in developing technology-based solutions to overcome the limitations of traditional mental healthcare services. However, we also detected some issues in the use of technologies (i.e. increased attention to the postpartum or the lack of transdiagnostic approaches). Our results evidenced that there is still a need to develop modern, well-designed, and conceptually-relevant ICT-based programs to be used in women undergoing fertility treatments, pregnant or at the postpartum.

Barriers to access to mental healthcare among women in the perinatal period: a preliminary report

This preliminary study investigates factors related to reduced access to mental healthcare among women in the perinatal period. We enrolled 145 pregnant women followed in OB-GYN services, using the Edinburgh Postnatal Depression Scale as a clinical measure for depression symptoms. We observed low levels of adherence to psychiatric screenings and referrals. Our findings confirm the importance of improving access to mental healthcare for women in the perinatal period.

An Evaluation of the Health Economics of Postnatal Depression Prevention and Treatment Strategies in China: A Cost-Effectiveness Analysis

OBJECTIVE

The primary objectives of this study are to assess the cost-effectiveness of early postnatal screening and prenatal psychological interventions for the prevention and treatment of postpartum depression (PPD) among Chinese pregnant women. Additionally, we aim to explore the most cost-effective prevention and treatment strategies for PPD in China.

METHODS

We used TreeAge 2019 to construct a decision tree model, with the model assuming a simulated queue size of 10,000 people. The model employed Monte Carlo simulation to assess the cost-effectiveness of PPD prevention and treatment strategies. Transfer probabilities were derived from published studies and meta-analyses. Cost and effectiveness data were obtained from published sources and relevant studies. Incremental cost-effectiveness ratios (ICERs) were used to describe the results, with willingness-to-pay (WTP) thresholds set at China's gross domestic product (GDP) per capita.

RESULTS

Compared to the usual care group, the cost per additional quality-adjusted life year (QALY) for the early postnatal screening group and the prenatal psychological interventions is USD 6840.28 and USD 3720.74, respectively. The cure rate of mixed treatments for PPD has the greatest impact on the model, while patient participation in treatment has a minor impact on the cost-effectiveness of prevention and treatment strategies.

CONCLUSION

Both early postnatal screening and prenatal psychological interventions are found to be highly cost-effective strategies for preventing and treating PPD in China. Prenatal psychological interventions for pregnant women are the most cost-effective prevention and treatment strategy. As such, from the perspective of national payers, we recommend that maternal screening for PPD be implemented in China to identify high-risk groups early on and to facilitate effective intervention.

Examining racial/ethnic inequities in treatment participation among perinatal individuals with depression

OBJECTIVE

A cluster randomized controlled trial (RCT) of two interventions for addressing perinatal depression treatment in obstetric settings was conducted. This secondary analysis compared treatment referral and participation among Minoritized perinatal individuals compared to their non-Hispanic white counterparts.

METHODS

Among perinatal individuals with depression symptoms, we examined rates of treatment 1) referral (i.e., offered medications or referred to mental health clinician), 2) initiation (i.e., attended ≥1 mental health visit or reported prescribed antidepressant medication), and 3) sustainment (i.e., attended >1 mental health visit per study month or prescribed antidepressant medication at time of study interviews). We compared non-Hispanic white (NHW) (n = 149) vs. Minoritized perinatal individuals (Black, Asian, Hispanic/Latina, Pacific Islander, Native American, Multiracial, and white Hispanic/Latina n = 157). We calculated adjusted odds ratios (aOR) for each outcome.

RESULTS

Minoritized perinatal individuals across both interventions had significantly lower odds of treatment referral (aOR = 0.48;95% CI = 0.27-0.88) than their NHW counterparts. There were no statistically significant differences in the odds of treatment initiation (aOR = 0.64 95% CI:0.36-1.2) or sustainment (aOR = 0.54;95% CI = 0.28-1.1) by race/ethnicity.

CONCLUSIONS

Perinatal mental healthcare inequities are associated with disparities in treatment referrals. Interventions focusing on referral disparities across race and ethnicity are needed.

Integrating Mental Health In Perinatal Care: Perspectives Of Interprofessional Clinicians

Despite the prevalence of perinatal mental health issues in the United States, gaps in care persist. To address this, perinatal health care settings are asked to focus on patients' mental health by administering standardized screening and, increasingly, by integrating mental health teams in their clinics. Using in-depth interviews and ethnographic observations, I investigated these emerging practices, exploring the experiences of certified nurse-midwives, obstetricians, and mental health clinicians. I found that certified nurse-midwives and obstetricians lack time, resources, and expertise, restricting their ability to address patients' mental health. Integrated mental health clinicians are constrained by the stratified organization of health care and structural deprioritization of mental health. Redesigning perinatal health care and de-siloing mental health training are necessary to increase clinicians' effectiveness and to improve perinatal health outcomes.

Factors Associated With Service Referrals and Uptake in Early Head Start: The Importance of Care Setting

Secondary analysis of the Early Head Start Family and Child Experiences Survey 2018 data set (Baby FACES 2018) explored links between family risk events and referral-making and referral uptake among families receiving Early Head Start (EHS) services. Referrals to both behavioral health and entitlement programs were considered. Results showed that referrals to behavioral health programs were much more likely to be given to families receiving care from home-based care than center-based care, and that referrals were slightly more likely to be given to families who did not have any family risk events. Several factors also moderated the relationship between family risk and referrals, including perceived closeness of the parent/caregiver-EHS staff relationship, family conflict, and caregiver depression. There were no observed effects for referrals to entitlement programs. Caregiver depression weakened the link between family risk and service uptake for entitlement programs.

Athlete mental health help-seeking: A systematic review and meta-analysis of rates, barriers and facilitators

Athletes are vulnerable to a range of mental health symptoms, in part due to stressors within the sport environment. An early intervention framework suggests the benefits of routine screening and referral for mental health, however, greater understanding around athlete help-seeking is needed to support referral uptake. This review examined rates of formal help-seeking behaviour as well as barriers and facilitators to help-seeking in sport settings. Relevant studies were retrieved from SportDiscus, PubMed and PsycInfo, with unpublished studies identified through contacting authors. Help-seeking rates were meta-analysed and barriers and facilitators were meta-synthesised. Twenty-two studies were included. Help-seeking rates were reported in 11 studies (N = 3415) and the pooled proportion of help-seeking was 22.4 % (95 % CI 16.2-30.2, I2 = 95.7 %). Barriers were reported in 13 studies and facilitators in six, highlighting a range of sporting-specific factors, such as stigma in relation to athlete identity and sport culture, fear of deselection, and concerns around confidentiality in sport settings, in addition to lack of awareness, low mental health literacy, and negative attitudes to services. Normalising experiences of mental health in sport settings, including through role models, was a key facilitator to help-seeking. Results provide implications for sport organisations to promote help-seeking and athlete mental health, such as through the use of role models, ensuring clarity around confidentiality, stigma reduction interventions, and fostering team cultures that promote mental health. Findings also support the value of sport staff in facilitating help-seeking, and organisational culture changes to foster wellbeing.

Common mental disorders and perinatal outcomes in Victoria, Australia: A population-based retrospective cohort study

PURPOSE

Common mental disorders (non-psychotic mental health conditions which impact on day-to-day functioning) are increasingly common in childbearing women and may impact significantly on both maternal and neonatal outcomes. Our study examines the associations between common mental disorders and perinatal outcomes.

METHODS

We used routinely collected perinatal data (2009-2016) for this population-based retrospective cohort study (n = 597,522 singleton births). We undertook multiple logistic regression adjusting for key maternal medical conditions and sociodemographic factors to determine associations between maternal common mental disorders and adverse perinatal outcomes with confidence intervals set at 95%.

RESULTS

Women with common mental disorders were more likely to have an induction of labour and caesarean birth, have a postpartum haemorrhage (PPH), and be admitted to the Intensive Care Unit (ICU) than women without common mental disorders. Neonates of women with common mental disorders were more likely to have an Apgar score at five minutes of less than seven (a measure of neonatal wellbeing at birth), be born preterm and low birthweight, be admitted to the Special Care Nursery or Neonatal Intensive Care Unit (SCN/NICU) and have a congenital anomaly than neonates of women without common mental disorders.

CONCLUSION

Common mental disorders during the perinatal period were associated with poorer perinatal outcomes for mothers and their neonates. Strategies that enable early recognition and response to maternal common mental disorders should be developed to mitigate the consequential impact on maternal and infant wellbeing.

Developing and evaluating an interprofessional shared decision-making care model for patients with perinatal depression in maternal care in urban China: a study protocol

BACKGROUND

The majority of patients with perinatal depression (PND) in China do not receive adequate treatment. As forming a therapeutic alliance with patients is crucial for depression treatment, shared decision-making (SDM) shows promise in promoting patients' uptake of evidence-based mental health services, but its impact on patient outcomes and implementation in real-world maternal care remain uncertain. Therefore, this study aims to develop and evaluate an interprofessional shared decision-making (IP-SDM) model for PND to enhance maternal mental health services.

METHODS

This study contains four research phases: feasibility testing (Phase 1), toolkit development (Phase 2), usability evaluation (Phase 3), and effectiveness evaluation (Phase 4). During the development stage, focus group interviews will be conducted with expectant and new mothers, as well as maternal care providers for feasibility testing. A toolkit, including a patient decision aid along with its user guide and training materials, will be developed based on the findings of Phase 1 and syntheses of up-to-date evidence and appraised by the Delphi method. Additionally, a cognitive task analysis will be used for assessing the usability of the toolkit. During the evaluation stage, a prospective randomized controlled trial embedded in a mixed methods design will be used to evaluate the effectiveness and cost-effectiveness of the IP-SDM care model. The study targets to recruit 410 expectant and new mothers who screen positive for depression. They will be randomly assigned to either an intervention group or a control group in a 1:1 ratio. Participants in the intervention group will receive decision aid, decision coaching, and clinical consultation, in addition to usual services, while the control group will receive usual services. The primary outcome is the quality of decision-making process, and the secondary outcomes include SDM, mental health service utilization and costs, depressive symptoms, and health-related quality of life. In-depth interviews will be used to explore the facilitating and hindering factors of SDM.

DISCUSSION

This study will develop an IP-SDM care model for PND that can be implemented in maternal care settings in China. This study will contribute to the understanding of how SDM impacts mental health outcomes and facilitate the integration of mental health services into maternal care.

TRIAL REGISTRATION

ChiCTR2300072559. Registered on 16 June 2023.

Implementation of caregiver depression screening in an urban, community-based asthma clinic: a quality improvement project

OBJECTIVE

Caregiver depressive symptoms are prevalent among children with asthma and associated with greater asthma morbidity. Identifying caregivers with depression and connecting them to appropriate treatment may reduce child asthma morbidity. The goal of this project was to implement a workflow for caregiver depression screening and treatment referral in an urban, community-based, asthma clinic serving under-resourced children.

METHODS

The Model for Improvement with weekly Plan-Do-Study-Act cycles was utilized. A two-item depression screening tool (Patient Health Questionnaire-2; PHQ-2) and an acceptability question using a 5-point Likert scale were added to an existing social needs screening checklist administered to all caregivers during the child's clinic visit. Caregivers with a positive PHQ-2 score (≥3) received the PHQ-9. Positive screens on the PHQ-9 (≥5) received information and referrals by level of risk. PHQ-9 positive caregivers received a follow-up phone call two weeks post-visit to assess connection to support, improvement in depressive symptoms, and satisfaction with resources provided.

RESULTS

The PHQ-2 was completed by 84.4% of caregivers (233/276). Caregivers had a mean age of 33.8 years (SD = 8.3; Range: 18-68) and were predominately female (86.4%), Black (80.4%), and non-Hispanic (78.4%). The majority (72.3%) found the screening acceptable (agree/strongly agree). Nearly one in six caregivers (37/233, 15.9%) reported depressive symptoms (PHQ-2 ≥ 3); 11.6% (27/233) had clinically significant symptoms (PHQ-9 score ≥ 10); and 2.1% (5/233) reported suicidal thoughts. Of those with depressive symptoms, 70.3% (26/37) participated in the follow-up phone call. While 50% (13/26) reported the resources given in clinic were "extremely helpful," no caregivers contacted or used them.

CONCLUSIONS

Caregiver depression screening was successfully integrated into a pediatric asthma clinic serving under-resourced children. While caregivers found screening to be acceptable, it did not facilitate short-term connection to treatment among those with depressive symptoms.

Perinatal Depression Treatment Guidelines for Obstetric Providers

Perinatal depression is the occurrence of depressive symptoms during the antenatal or postnatal period with an annual incidence of 10% to 20%. The consequences of untreated perinatal depression are significant and include negative impacts on maternal health, pregnancy outcomes, and maternal-infant outcomes. The purpose of this article is to provide perinatal pharmacologic and psychological treatment information to help first-line providers more confidently manage depression in the perinatal period. Treatment strategies including medication management using risk versus risk conversations, psychotherapy, and colocated perinatal mental health clinics are discussed.

Perinatal depression and mental health uptake referral rate in an obstetric service

Perinatal depression is an important indicator of mothers' mental health. Studies have been carried out to identify and characterize women at risk of such affective disorder. The aim of this study is to assess mothers' adherence to our perinatal depression screening and eventual follow-up by a multidisciplinary team, including mental health and obstetrics professionals. Ultimately, a risk profile for the uptake rate of referral was described to psychological support. Pregnant women from a maternity of a tertiary center with on-site assessment and treatment (n = 2163) were included in this study. The identification of women at risk for depression was based on a two-question screening and the EPDS scale. Demographic and obstetric data were obtained from medical records. The number of screening evaluations, the uptake referral rate and the compliance to treatment were analyzed. Logistic regression was used to predict a risk profile for adherence. Among 2163 enrolled in the protocol, 10.2% screened positive for depression. Of these, 51.8% accepted referral for mental health assistance. 74.9% were compliant to Psychology appointments and 74.1% to Psychiatry appointments. Women who had a previous history of depression were more likely to accept referral for mental health support. With this study, we were able to understand the behaviour of this population towards the screening protocol we offer. Women with a previous history of depression are more likely to accept mental health assistance.

Barriers and facilitators for referring women with positive perinatal depression screening results in China: a qualitative study

BACKGROUND

Timely screening and referral can improve the outcomes of perinatal depression (PND). However, uptake rates of referral after PND screening are low in China and the reasons are unclear. The aim of this article is to explore the barriers and facilitators for referring women with positive results of PND screening in the Chinese primary maternal health care system.

METHODS

Qualitative data were collected from four primary health centers located in four different provinces of China. Each of the four investigators conducted 30 days of participant observations in the primary health centers from May to August 2020. Data were collected via participant observations and semi-structured in-depth interviews with new mothers who had positive results of PND screening, their family members, and primary health providers. Two investigators analyzed qualitative data independently. A thematic analysis was conducted, and data were framed using the social ecological model.

RESULTS

A total of 870 hours of observation and 46 interviews were carried out. Five themes were identified: individual (new mothers' knowledge of PND, perceived need to seek help), interpersonal (new mothers' attitudes towards providers, family support), institutional (providers' perception of PND, lack of training, time constraints), community (accessibility to mental health services, practical factors), and public policy (policy requirements, stigma).

CONCLUSIONS

The likelihood of new mothers accepting PND referral is related to factors in five areas. Intervention strategies can be developed around these themes and may include educating new mothers and their families about PND, training primary health providers to improve their awareness of condition and indication for referral, building mental health support in routine postpartum home visits, and providing support through mobile technology.

Additional evidence on prevalence and predictors of postpartum depression in China: A study of 300,000 puerperal women covered by a community-based routine screening programme

BACKGROUND

Previous studies on the prevalence and predictors of postpartum depression (PPD) in China were mostly hospital-based with relatively small study samples. Basing on a routine screening programme, this study assessed the prevalence and factors associated with PPD at community level.

METHODS

A cross-sectional study was conducted with all the women who delivered in a hospital and were screened for depression during routine postpartum home visits in Shenzhen between 2015 August and 2017 April. The Edinburgh Postnatal Depression Scale was used as the screening tool with a cut-off score of 10. Predictors of PPD were determined by Chi-square test and stepwise logistic regression.

RESULTS

Approximately 300,000 puerperal women were included in the study with a PPD prevalence of 4.3%. Prenatal anxiety and depression were associated with 4.55 and 3.80 times of PPD risk, respectively. Stressful life events, family history of mental illness, poor economic status, low Apgar scores and birth defects of the infants, bottle and mixed feeding, as well as living with parents-in-low after childbirth were related to moderate risk. Higher gravidity and parity, larger gestation age, prenatal education, and living with the women's own parents were associated with lower risk.

LIMITATIONS

The large sample size might have suggested statistically significant differences which were not practical.

CONCLUSIONS

The prevalence of PPD at community level is significantly lower than the rates detected within hospitals. Prenatal anxiety and depression are the most important predictors of PPD. Integrating depression screening into routine postpartum home visits facilitates achievement of universal coverage.

Protecting the infant-parent relationship: special emphasis on perinatal mood and anxiety disorder screening and treatment in neonatal intensive care unit parents

Perinatal mood and anxiety disorders (PMADs) are common, particularly among parents of infants requiring admission to the neonatal intensive care unit (NICU), yet remain underdiagnosed and undertreated. Undertreated parental mental health disorders can interfere with healthy infant development, compounding abnormal neurodevelopment and psychosocial development that preterm or ill newborns may already face. Interdisciplinary efforts to increase PMAD awareness, screening, and referral uptake may improve family-infant health and developmental outcomes in high-risk infants requiring NICU admission. Therefore, special emphasis on PMAD screening and treatment in NICU parents aligns with the American Academy of Pediatrics mission and should be a focus in neonatal care and included in education, quality improvement, and outcome-based research initiatives.

Suicide and Maternal Mortality

PURPOSE OF REVIEW

Suicide is a leading cause of death in the perinatal period (pregnancy and 1 year postpartum). We review recent findings on prevalence, risk factors, outcomes, and prevention and intervention for suicide during pregnancy and the first year postpartum.

RECENT FINDINGS

Standardization of definitions and ascertainment of maternal deaths have improved identification of perinatal deaths by suicide and risk factors for perinatal suicide. Reports of a protective effect of pregnancy and postpartum on suicide risk may be inflated. Clinicians must be vigilant for risk of suicide among their perinatal patients, especially those with mental health diagnoses or prior suicide attempts. Pregnancy and the year postpartum are a time of increased access to healthcare for many, offering many opportunities to identify and intervene for suicide risk. Universal screening for suicide as part of assessment of depression and anxiety along with improved access to mental health treatments can reduce risk of perinatal suicide.

The effects of a group cognitive behavioral therapy program using video communication for pregnant women with depressed mood in Korea: a pilot study

Purpose: This study presents the development of a group video communication-based cognitive behavioral therapy (CBT) program for depressed pregnant women. It also provides the results of a preliminary test of its effects on their depression, automatic thoughts, and dysfunctional attitudes. Methods: In this quasi-experimental single-group pre- and posttest design study, 13 pregnant women participated in a 4-week, eight-session group CBT program, based on Beck’s cognitive theory and using video communications from November 23, 2020 to January 30, 2021. Pregnant women between 14 and 32 weeks who were members of an online maternity and parenting community and residing in the cities of Changwon and Gimhae, Korea, were invited to voluntarily participate. Trained nurses led CBT sessions of 3–4 participants per group via video communication. Participants were assessed pre- and postintervention with self-report questionnaires for measurement of depression, automatic thought, and dysfunctional attitude after normality test according to the Shapiro-Wilk test of the variables, the data were analyzed using paired t-test and Pearson correlation coefficients.Results: Depression (t=7.90, p<.001), automatic thoughts (t=4.89, p<.001), and dysfunctional attitudes (t=2.42, p=.032) significantly decreased after the 4-week online program. There were statistically significant correlations among the three variables.Conclusion: This program was found to be effective in reducing depression, automatic thoughts, and dysfunctional attitudes. Above findings suggest that a group CBT program using video communication can be an effective therapeutic modality that helps pregnant women at risk for depression remain free from negative emotions related to depression.

Using virtual patient to assess primary health workers competence to detect postpartum depression in Hunan, China

OBJECTIVES

Primary health workers are the first fine to identify postpartum depression, which is important for patients with this disease to get early specialist diagnosis and treatment. The smartphone-based virtual patient is economical, convenient and effective, and has been applied extensively to evaluate the competency to detect postpartum depression, but there is no relevant application in China. This study aims to use virtual patient to assess the current status on the competency of detecting postpartum depression among primary maternal and child health workers in Hunan Province, and to explore potential influencing factors.

METHODS

A total of 222 primary maternal and child health workers from 3 regions with low, medium, and high economic levels in Hunan Province were enrolled, and smartphone-based virtual patients with postpartum depression were used for the assessment from May to July in 2018, and a self-designed questionnaire was used to investigate their demographic characteristics. The competency to detect postpartum depression was measured by 2 indicators: diagnostic accuracy and treatment accuracy. Descriptive statistical methods were used to describe the competency to detect postpartum depression among them and their demographic characteristics. A logistic regression analysis was used to explore the possible influencing factors for the diagnostic accuracy and treatment accuracy.

RESULTS

The diagnostic accuracy rate was 64.0%. There was no significant difference between the demographic characteristics and diagnostic accuracy rate (P>0.05). The treatment accuracy rate was 50.9%. The workers from the middle economic level area were more likely to make the correct treatment than those from the low economic level area (OR= 3.229, 95% CI 1.478 to 7.014).Apart from postpartum depression, the 3 most frequently diagnosed items were bipolar disorder (22.1%, 49/222), secondary depression disorder (13.5%, 30/222), and neurasthenia (5.4%, 12/222). Among the correctly diagnosed health workers, the proportion for correct treatment was 29.6% (42/142), and there was no significant difference between the diagnostic accuracy and treatment accuracy (P>0.05).

CONCLUSIONS

About half of the primary maternal and child health workers in Hunan Province, China have basic competency to detect postpartum depression, but the overall results are not satisfactory. The regional economic level is correlated with the competency of detecting postpartum depression, and the competency of detecting postpartum depression is stronger in more developed areas. Moreover, for the patients who have been identified as postpartum depression, the rate of correct treatment is low, which warrants particular attention in the follow-up training.

Improving access to perinatal mental health services: the value of on-site resources

BACKGROUND

Perinatal mood disorders have both short- and long-term negative consequences for mothers and their babies. National organizations recommend universal screening for postpartum depression. Little is known, however, about screening and referral among women living in underserved areas with limited access to care.

OBJECTIVE

The objective of this report was to evaluate the utilization of mental health services in an urban, inner-city hospital following the implementation of colocated counseling services across 10 county-sponsored clinics that serve a medically underserved population. We further explored antecedents of a positive postpartum depression screen, factors associated with successful referral, and the rate of perinatal mood disorder diagnoses following universal screening. We hypothesized that integrated mental health services would improve referral rates following positive postpartum depression screening compared with historically separated services.

STUDY DESIGN

This was a retrospective cohort study of women undergoing universal postpartum depression screening with deliveries from January 2017 to December 2019 who were compared with a historic cohort from the same population from June 2008 to March 2010. The Edinburgh Postnatal Depression Scale was used to evaluate women at their postpartum visit, and a mental health service referral was offered to women with a score of ≥13. The primary outcome was a comparison of completed referrals between cohorts with and without colocated mental health services following a positive postpartum depression screen. Statistical analysis included chi-square tests with a P value of <.05 being considered significant and adjusted multivariate analyses for perinatal outcomes associated with a positive postpartum screen.

RESULTS

Between January 2017 to December 2019, 25,425 women completed a postpartum depression screen with 978 (4%) of those recording a positive screen. After implementation of colocated mental health counselors, completed perinatal mental health referrals significantly increased when compared with the historic cohort without colocated services (57%; 560 of 978 vs 22%; 238 of 1106; P<.001). Adverse neonatal outcomes, such as stillbirth (adjusted risk ratio, 9.5; 95% confidence interval, 6.35-14.26) and neonatal demise (adjusted risk ratio, 14.3; 95% confidence interval, 6.67-30.46), were most strongly associated with a positive depression screen. There were 122 (21%) women with a positive screen who were diagnosed with a depressive disorder in the peripartum period. There were no specific features associated with those who did or did not complete referral. One-fifth of women were referred for psychiatric evaluation following an initial evaluation, and the referral rate was associated with higher scores on the depression screen (P<.001).

CONCLUSION

Utilization of mental health services following a positive depression screen more than doubled following the implementation of colocated services.

Experiences and perceptions of perinatal depression among new immigrant Chinese parents: a qualitative study

BACKGROUND

Immigrant status, acculturation level, race and ethnicity have been found to contribute to the utilization of mental health services in the perinatal period. This study explored perinatal experiences and perceptions among Chinese immigrant mothers and their spouses, as well as the possible barriers and facilitators that affect their health care utilization.

METHODS

We recruited 13 women ages 18-35 years born in mainland China, living in Rochester, New York, and residing less than 5 years in the United States. Participants primary language was Mandarin Chinese and all had given birth to at least one live infant within the past 7 years. Participants' age was at least 18 years old at the time of delivery. Five spouses also participated. We divided women in two focus groups and held one focus group for men, with data collection including demographic questionnaires and semi-structured focus group questions conducted in December 2014. Data were analyzed following thematic analysis.

RESULTS

Four themes emerged: experiences of perinatal depression; perceptions of perinatal depression; general preventive and coping strategies; and attitudes toward the supportive use social media applications (apps) and text messaging during the perinatal period. Participants had limited knowledge of perinatal depression and had difficulty distinguishing between normal perinatal mood fluctuations and more severe symptoms of depression. They discussed immigrant-related stress, conflicts with parents/in-laws while "doing the month", the perceived gap between the ideal of "perfect moms" and reality, and challenges with parenting as the causes of perinatal depression. Women approved of screening for the condition but were conservative about follow-up interventions. As for the management of perinatal depression, participants preferred to deal with the problem within the family before seeking external help, due to potential stigma as well as Chinese traditional culture. They were receptive to obtaining pertinent health information from anonymous social media apps, preferring these to personal text messages.

CONCLUSION

The recent immigrant Chinese parents to the United States in the study had limited knowledge of perinatal depression and did not make full use of mental health services for support due to language and cultural barriers. Screening for perinatal depression is only the first step. Future research should explore what interventions may serve as an acceptable approach to overcoming these gaps.

Chinese Women's Acceptance and Uptake of Referral after Screening for Perinatal Depression

China recently issued a national plan on perinatal depression (PND) screening. Previous studies elsewhere suggested that uptake of referral after screening for PND is suboptimal, but little is known in China. In this cohort study including 1126 women in Hunan, we identified women at a high risk of PND using the Edinburgh Postpartum Depression Scale (EPDS) over multiple time points. We texted them and offered free consultations with a psychiatrist/psychologist. Among 248 screen-positive women, only three expressed interest and one attended the appointment. We surveyed the women about their reasons for declining referrals and preferred means of care. Of the 161 respondents, 128 (79.5%) indicated that they could cope with the condition without professional assistance and 142 (88.2%) chose their families as the preferred source of help. Only 15 (9.3%) chose professionals as their first option. Implementing a referral policy for screen-positive women would mean approximately one-third of women who gave birth in China would be eligible. Our result argues against referring all screen-positive women for professional services at this time. Interventions should instead build upon the tradition of family support in a more engaged response. These considerations are relevant for the implementation of national screening for PND in China.