A group programme for postnatally distressed women and their partners

The forgotten father in obstetric medicine

The role of fathers prior to conception, during pregnancy, and in the post-partum period has generally not been a key consideration for Obstetric Physicians. However, this view may need challenging. This paper outlines the key importance of fathers in all phases of obstetric medical care. We review the contribution of paternal factors such as genetics, health, and lifestyle to fetal development, pregnancy complications, and maternal and neonatal wellbeing. The role of fathers in complex care decisions during pregnancy is also reviewed. Postpartum, fathers have a substantial role in shaping the future of the family unit through encouraging breastfeeding and creating a supportive environment for motherhood. This review proposes areas for future research and recommends an evidence-based change in practice in obstetric medicine that focuses on recognizing the role of fathers in the pregnancy journey.

First-time fathers' needs and experiences of transition to fatherhood in relation to their mental health and wellbeing: a qualitative systematic review protocol

REVIEW QUESTION/OBJECTIVE

This qualitative review seeks to identify first-time fathers' needs and experiences in relation to their mental health and wellbeing during their transition to fatherhood. This will include resident first-time fathers who are either the biological or non-biological father.The objectives are to explore first-time fathers' experiences in relation to.

Couple comorbidity and correlates of postnatal depressive symptoms in mothers and fathers in the first two weeks following delivery

BACKGROUND

Postnatal depression affects a significant number of parents; however, its co-occurrence in mothers and fathers has not been studied extensively. Identifying predictors and correlates of postnatal depressive symptoms can help develop effective interventions.

METHODS

Questionnaires on several socio-demographic and psychosocial factors were administered to 276 couples within two weeks after birth. Depressive symptoms in mothers and fathers were assessed using the Edinburgh Postnatal Depression Scale (EPDS). After calculating the correlation coefficient between mothers and fathers' EPDS scores, univariate and multivariate linear regression analyses were performed to identify significant correlates of postnatal depressive symptoms in mothers and fathers.

RESULTS

Prevalence of maternal and paternal postnatal depressive symptoms was 15.9% (EPDS>12) and 5.4% (EPDS>10), respectively. There was a moderate positive correlation between mothers and fathers' EPDS scores (r=.30, p<.001). Multivariate analyses indicated that parental stress was the strongest predictor for maternal and paternal postnatal depressive symptoms. Pregnancy- and birth-related distress and partners' EPDS scores were also associated with depressive symptoms in both parents. Relationship satisfaction was only inversely related with fathers' EPDS scores, while mothers' EPDS scores were additionally associated with critical life events, history of childhood violence, and birth-related physiological complaints.

LIMITATIONS

Since information about participation rates (those who declined) is unavailable, we cannot rule out sampling bias. Further, some psychosocial factors were assessed using single items.

CONCLUSION

Since co-occurrence of depressive symptoms in mothers and fathers is high, developing and evaluating postnatal depression interventions for couples may be beneficial. Interventions to reduce parenting stress may help prevent parental postnatal depression.

PROGRESS ON THE PATERNAL BRAIN: THEORY, ANIMAL MODELS, HUMAN BRAIN RESEARCH, AND MENTAL HEALTH IMPLICATIONS

With a secure foundation in basic research across mammalian species in which fathers participate in the raising of young, novel brain-imaging approaches are outlining a set of consistent brain circuits that regulate paternal thoughts and behaviors in humans. The newest experimental paradigms include increasingly realistic baby-stimuli to provoke paternal cognitions and behaviors with coordinated hormone measures to outline brain networks that regulate motivation, reflexive caring, emotion regulation, and social brain networks with differences and similarities to those found in mothers. In this article, on the father brain, we review all brain-imaging studies on PubMed to date on the human father brain and introduce the topic with a selection of theoretical models and foundational neurohormonal research on animal models in support of the human work. We discuss potentially translatable models for the identification and treatment of paternal mood and father-child relational problems, which could improve infant mental health and developmental trajectories with potentially broad public health importance.

Prevention and treatment of postnatal depression

Postnatal depression is a common condition that may have a significant negative impact on both infant and mother, often remaining undiagnosed and untreated. Development of effective means of detection, prevention and treatment of postnatal depression is a major health challenge. The objective of this article is to critically review pharmacological, psychological and psychosocial approaches of prevention and treatment for postnatal depression. There is little evidence of short-term success for preventive interventions and some evidence of short-term success for treatment interventions. No preventive or therapeutic studies, however, have provided evidence for long-term success. There is a need for future research into the prevention and treatment of postnatal depression including the assessment of long-term effects on the child's development as well as feasibility in relation to cost-effectiveness.

Diagnosis, pathophysiology, and management of mood disorders in pregnant and postpartum women

Mood disorders disproportionately affect women across the lifespan. Mood disorders in pregnancy and the postpartum period are common and have profound implications for women and their children. These include obstetric and neonatal complications, impaired mother-infant interactions, and, at the extreme, maternal suicide and infanticide. Because obstetrician-gynecologists are often the first (and sometimes the only) point of contact for young women in the health care system, familiarity with the presentation and treatment of depressive illness in the perinatal period is imperative. The goal of this review is to synthesize essential information on depressive illness in the perinatal period with a focus on its most common and severe presentations, major depressive disorder and bipolar disorder. Accurate diagnosis of unipolar major depressive disorder from bipolar disorder can facilitate the selection of the best possible treatment alternatives. Counseling may be sufficient for perinatal women who have mild to moderate depression, but women who are severely depressed are likely to require antidepressant treatment. Women with bipolar disorder are at high risk for relapse if mood stabilizer medication is discontinued, and they are vulnerable to relapse near the time of delivery. Comanagement of their care with psychiatrists will increase their chances of avoiding a recurrence of illness.

Mums 4 Mums: structured telephone peer-support for women experiencing postnatal depression. Pilot and exploratory RCT of its clinical and cost effectiveness

Background

Postnatal depression (PND) can be experienced by 13% of women who give birth, and such women often exhibit disabling symptoms, which can have a negative effect on the mother and infant relationship, with significant consequences in terms of the child's later capacity for affect regulation. Research has shown that providing support to mothers experiencing PND can help reduce their depressive symptoms and improve their coping strategies. The Mums4Mums study aims to evaluate the impact of telephone peer-support for women experiencing PND.

Methods/Design

The study design adopts the MRC framework for the development and evaluation of complex interventions. Health visitors in Warwickshire and Coventry Primary Care Trusts are screening potential participants at the 8-week postnatal check using either the Edinburgh Postnatal Depression Scale (EPDS > = 10) or the three Whooley questions recommended by NICE (http://guidance.nice.org.uk/CG45). The Mums4Mums telephone support intervention is being delivered by trained peer-supporters over a period of four months. The primary outcome is depressive symptomatology as measured by the Edinburgh Postnatal Depression Scale. Secondary outcomes include mother-child interaction, dyadic adjustment, parenting sense of competence scale, and self-efficacy. Maternal perceptions of the telephone peer-support are being assessed using semi-structured interviews following the completion of the intervention.

Discussion

The proposed study will develop current innovative work in peer-led support interventions and telecare by applying existing expertise to a new domain (i.e. PND), testing the feasibility of a peer-led telephone intervention for mothers living with PND, and developing the relationship between the lay and clinical communities. The intervention will potentially benefit a significant number of patients and support a future application for a larger study to undertake a full evaluation of the clinical and cost effectiveness of telephone based peer-support for PND.

Trial registration

ISRCTN: ISRCTN91450073. The study has received a major funding grant from National Institute for Health Research (NIHR) (UK) - Research for Patient Benefit (RfPB) programme (ref: PB-PG-0407-13232).

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.

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.

Maternal distress: a concept analysis

AIM

This paper is a report of an analysis of the concept of maternal distress.

BACKGROUND

Although not well-developed, the concept of maternal distress has offered an important viewpoint in nursing and midwifery practice since the mid-1990s. Traditionally, understanding of maternal distress has been based on the medical model and dysfunction. The concept of maternal distress needs development so that it describes responses ranging from normal stress responses to those indicating mental health problem/s.

DATA SOURCES

The SCOPUS, CINAHL and Medline databases were searched for the period from 1995 to 2009 using the keywords 'psychological distress', 'emotional distress' and 'maternal distress'.

REVIEW METHODS

Steps from Rodgers' evolutionary concept analysis guided the conduct of this concept analysis.

RESULTS

Four attributes of maternal distress were identified as responses to the transition to motherhood, with the level of each response occurring along a continuum: stress, adapting, functioning and control, and connecting. Antecedents to maternal distress include becoming a mother, role changes, body changes and functioning, increased demands and challenges, losses and gains, birth experiences, and changes to relationships and social context. The consequences of maternal distress are compromised mental health status, maternal role development, quality of life, ability to function, quality of relationships and social engagement. The extent of the impact depends on the level of maternal distress.

CONCLUSION

Clearer interpretation of maternal distress offers a comprehensive approach to understanding maternal emotional health during the transition to motherhood. Acknowledging women's experiences and providing more appropriate support could alleviate some of the struggles and hardships experienced by mothers.

A randomised control trial for the effectiveness of group Interpersonal Psychotherapy for postnatal depression

This study is a randomised controlled trial comparing outcomes from an 8-week Interpersonal Psychotherapy group (IPT-G) for postnatal depression with 'treatment as usual' (TAU), conducted in a routine community setting in the Australian Capital Territory (ACT). Eligible women were recruited and randomly assigned to either IPT-G or TAU conditions. This study compared outcomes on such variables as depressive symptoms, marital adjustment, social support and mother-infant bond at baseline, mid-treatment, end-of-treatment and 3 months follow-up. Participants were also independently assessed using the Hamilton Depression Rating Scale (HAM-D). 50 women completed baseline assessments and were included in the analysis. Comparisons of treatment conditions showed that by end of treatment both the TAU and IPT-G groups significantly improved in terms of mean depression scores, however, the IPT-G women improved significantly more and had continued improvements at 3 months post therapy. Furthermore, women who received IPT-G displayed significant improvement in terms of marital functioning and perceptions of the mother-infant relationship compared to TAU participants. These findings highlight the potential benefits of an interpersonally based treatment, which not only improves outcomes for the mother but also potentially for the couple and the infant when compared to usual care.

Postnatal depression: A global public health perspective

The aim of this paper is to discuss whether or not postnatal depression is a global public health concern. Public health is the study of the morbidity, mortality and the cause and course of disease, at a population rather than an individual level. Public health is also concerned with examining factors that cause health inequalities. Postnatal depression is a mental and emotional condition that can affect women during the first postnatal year. Since the effects of postnatal depression are known to go beyond the mother in that it also affects the partner and the child, it can be deemed a public health problem. Additionally, severe postnatal depression can lead to infanticide as well as maternal death, often by suicide. Furthermore, evidence demonstrates that all countries are faced with the challenge of postnatal depression, but low- to middle-income countries face the greatest burden. The literature revealed various treatment options for this complex condition. However, it also uncovered that not all women are assessed for postnatal depression, nor do all women receive treatment. The emerging picture is that postnatal depression is indeed a public health problem, particularly as the incidence is much higher than the quoted rate of 10%—15%. This paper recommends direction for public health-orientated perinatal mental health research and suggests that service providers should consider the routine assessment of all postnatal women.

Women with postpartum depression: "my husband" stories

BACKGROUND

The research on Postpartum Depression (PPD) to date suggests that there is a knowledge gap regarding women's perception of their partners' role as carer and care activities they perform. Therefore, the purpose of this study was to describe women's understanding of their partners' or husbands' involvement in the midst of PPD.

METHODS

This study used interview data from a larger study of northern and rural Ontario women's stories of help-seeking for PPD. The interpretive description approach was used to illustrate the complexity of women's spousal connections in PPD. Data from a purposive community sample of 27 women who self-identified as having been diagnosed with PPD was used. From the verbatim transcribed interviews a number of data excerpts were identified and labeled as "my husband" stories. Narrative analysis was employed to examine these stories.

RESULTS

During this time of vulnerability, the husbands' physical, emotional and cognitive availability positively contributed to the women's functioning and self-appraisals as wife and mother. Their representations of their husbands' 'doing for' and/or 'being with' promoted their well-being and ultimately protected the family.

CONCLUSION

Given that husbands are perceived to be central in mitigating women's suffering with PPD, the consistent implementation of a triad orientation, that includes woman, child and partner rather than a more traditional and convenient dyadic orientation, is warranted in comprehensive postpartum care. Finally, this study contributes a theoretical understanding of responsive as well as reactive connections between women and family members during the postpartum period.

Tailoring screening protocols for perinatal depression: prevalence of high risk across obstetric services in Western Australia

Given what appears to be an ever-increasing list of concerning consequences of perinatal depression, longitudinal studies have much to offer when considering the timing and efficacy of prevention and intervention strategies. The course of depressive symptomatology across the perinatal period at four obstetric services was investigated utilising Western Australian data collected as part of the beyondblue National Postnatal Depression Program. Pregnant women completed one or two Edinburgh Postnatal Depression Scale (EPDS) assessments during pregnancy and a demographic and psychosocial risk factors questionnaire. One or two EPDS assessments were administered within 12 months postpartum. Prevalence of high risk scores across gestational ages ranged from 14% to 5% during pregnancy and 6% to 9% in the postnatal period. For women who were screened twice, the prevalence of high risk scores appeared earlier and decreased with advancing gestation (p = 0.026). The prevalence of postnatal high risk increased after 12 weeks postpartum (p = 0.029). Screening protocols for depressive symptomatology during pregnancy may need to be fine-tuned across individual hospitals, and take into account gestational ages, in order to be most effective. As depressive symptomatology persists postnatally, screening protocols may need to extend beyond 12 weeks postpartum.

Suffering in silence: a qualitative meta-data-analysis of postpartum depression

In this article, we apply a relational lens to a grounded theory meta-data-analysis of qualitative studies on postpartum depression (PPD) conducted between 1999 and 2005. Women in all studies report feeling that they have failed to live up to cultural standards for a "good mother." Central to this experience is a sense that these negative feelings could not be spoken. The analysis shows how constructions of motherhood and the reactions of others combine with feelings of incompetence to precipitate isolation from others. Women survive depression through support that validates their experience and promotes eventual reconnection with others. Conclusions emphasize the need for persons trained to facilitate relational connection to develop interventions that address the interpersonal contexts of PPD.

Study of a group treatment program for postnatal adjustment difficulties

This study examined the impact of implementation of a structured 8-session psycho-educational and cognitive behavioural therapy skills group for postnatal adjustment. Forty-five women identified as experiencing antenatal adjustment problems attended the 8-week group. Participants completed the Edinburgh Postnatal Depression Scale, Beck Anxiety Inventory, and the Maternal Attitudes Questionnaire prior to and after attendance, as well as a feedback form in the final session. Following attendance, participant scores on measures of depression, anxiety, and attitudes to mothering improved significantly. Further research is needed to contrast the group to a control condition and to determine group effects are maintained over time.

Evidence-based recommendations for depressive symptoms in postpartum women

Postpartum depression is a serious health issue affecting 13% of women from diverse cultures. Despite the well-documented consequences of postpartum depression, it remains difficult to identify, and diverse practices relate to its prevention and treatment. Evidence-based interventions are essential to improve both maternal and infant health outcomes associated with pregnancy. This article describes the development process of an evidence-based practice guideline for postpartum depression and highlights the practice recommendations related to the confirmation, prevention, and treatment of depressive symptoms in postpartum mothers.

Psychosocial and psychological interventions for treating postpartum depression

BACKGROUND

Postpartum depression is a major health issue for many women from diverse cultures. While pharmacological interventions are an effective treatment for depression, mothers are often reluctant to take antidepressant medication due to concerns about breast milk transmission or potential side-effects. It is important that non-pharmacologic interventions be evaluated for use with postpartum women experiencing depressive symptomatology.

OBJECTIVES

Primary: to assess the effects of all psychosocial and psychological interventions compared with usual postpartum care in the reduction of depressive symptomatology.Secondary: to examine (1) the effectiveness of specific types of psychosocial interventions; (2) the effectiveness of specific types of psychological interventions; (3) the effectiveness of specific types of psychosocial interventions versus psychological interventions; (4) the effects of intervention mode (e.g., individual versus group-based interventions); and (5) the effects of sample selection criteria (e.g., targeting women with clinically diagnosed depression versus self-reported depressive symptomatology).

SEARCH STRATEGY

CCDANCTR-Studies and CCDANCTR-References were searched on 1/8/2007, the Cochrane Pregnancy and Childbirth Review Group trials register, CENTRAL, MEDLINE (1966 to 2006), EMBASE (1980 to 2006) and CINAHL (1982 to 2006) using various combinations of the terms 'postpartum/postnatal depression.' Secondary references and experts in the field were used to identify other published or unpublished trials.

SELECTION CRITERIA

All published, unpublished, and ongoing randomised controlled trials and quasi-randomised trials of psychosocial or psychological interventions where the primary or secondary aim was a reduction in depressive symptomatology.

DATA COLLECTION AND ANALYSIS

Both review authors participated in the evaluation of methodological quality and data extraction. Additional information was sought from several trial researchers. Results are presented using relative risk for categorical data and weighted mean difference for continuous data.

MAIN RESULTS

Ten trials met the inclusion criteria, of which nine trials reported outcomes for 956 women. Any psychosocial or psychological intervention, compared to usual postpartum care, was associated with a reduction in the likelihood of continued depression, however measured, at the final assessment within the first year postpartum. Both psychosocial and psychological interventions were effective in reducing depressive symptomatology. Trials selecting participants based on a clinical diagnosis of depression were just as effective in decreasing depressive symptomatology as those that enrolled women who met inclusion criteria based on self-reported depressive symptomatology.

AUTHORS' CONCLUSIONS

Although the methodological quality of the majority of trials was, in general, not strong, the meta-analysis results suggest that psychosocial and psychological interventions are an effective treatment option for women suffering from postpartum depression. The long-term effectiveness remains unclear.

Quality of life, postnatal depression and baby gender

AIMS AND OBJECTIVE

To study the impact of postnatal depression on the quality of life of young French mothers and to evaluate if the gender of their child influences this.

BACKGROUND

Postnatal depression (PND) constitutes a major public health problem considering its high prevalence and consequences upon quality of life and parental skills.

DESIGN

This research is a cross-sectional study during the postnatal period.

METHODS

This study was carried out during a two-month period. Data were collected by interview and questionnaires. The authors compared the prevalence rate of PND and life quality in a cohort of 181 women and measured the short-term impact of the child's birth.

RESULTS

Postnatal depression strongly negatively influences all dimensions of life quality explored through the SF36, e.g. physical functioning (PF), physical Role (RP), bodily pain (BP), mental health (MH), emotional role (RE), social functioning (SF), vitality (VT), general health (GH), standardized physical component (PCS) and standardized mental component (MCS). The baby's gender (having a boy) also significantly reduces quality of life, irrespective of depressive state. There is a relationship between baby gender and PND.

CONCLUSION

This research is the first to show that the birth of a boy reduces several dimensions of the mothers' quality of life.

RELEVANCE TO CLINICAL PRACTICE

The importance of the impairment of quality of life in case of PND, as well as its effects on mother-child interaction, could justify prevention programs and early psychotherapeutic care. Further research needs to explore the effectiveness of programmes targeting the construction of parenting skills as a preventative measure against PND, especially for parents of boys.

Global and relationship-specific perceptions of support and the development of postpartum depressive symptomatology

BACKGROUND

A lack of social support has consistently been demonstrated to be an important modifiable risk factor for postpartum depression. As such, a greater understanding of specific support variables may assist health professionals in the development of effective preventive interventions. The purpose of this paper was two-fold: (1) to determine if women discriminated between global and relationship-specific perceptions of support, and (2) to examine the influence of global and relationship-specific perceptions of support in the immediate postpartum period on the development of depressive symptomatology at 8 weeks postpartum.

METHODS

As part of a longitudinal study, a diverse sample of 594 mothers completed questionnaires that included the Edinburgh Postnatal Depression Scale (EPDS) and global and relationship-specific (e.g., partner, mother, and other women with children) measures of support.

RESULTS

Mothers clearly discriminated between global and relationship-specific perceptions of support and those with depressive symptomatology at 8 weeks had significantly lower perceptions of both global and relationship-specific support at 1-week postpartum. Using discriminant function analysis, four variables, reliable reliance from partner, nurturance from partner, attachment to other women with children, and EPDS score at 1-week postpartum, differentiated between mothers who experienced depressive symptomatology at 8 weeks and those who did not.

CONCLUSION

Relationship-specific interventions may be beneficial if they include strategies that target a positive partner relationship through preceptions of reliable alliance and feeling needed and provide opportunites for interaction with other mothers. Maternal mood at 1 week postpartum was the largest predictor of depressive symptomatology at 8 weeks.

Women's perceptions of partner support and conflict in the development of postpartum depressive symptoms

AIM

This paper reports a study examining the influence of maternal perceptions of conflict and relationship- and postpartum-specific support from the partner on the development of depressive symptoms in the first 8-weeks postpartum.

BACKGROUND

Although the quality of a woman's relationship with her partner has been associated with risk for postpartum depression, few studies have examined which elements of partner-specific support and conflict are determinants of maternal mental health.

METHODS

Self-administered measures of partner support (Social Provisions Checklist, Postpartum Partner Support Scale), partner conflict (Quality of Relationships Inventory), and depression (Edinburgh Postnatal Depression Scale) were mailed postnatally to a population-based sample of 396 mothers between April 2001 to January 2002. Differences in partner support and conflict at 1 and 4-weeks postpartum were examined between those women who met criteria for probable depression (Edinburgh Postnatal Depression Scale > 9) and those who did not meet criteria for probable depression at 8-weeks postpartum.

FINDINGS

Women with depressive symptoms at 8-weeks postpartum had significantly lower perceptions of relationship-specific and postpartum-specific partner support and significantly higher levels of relationship conflict than women with no depressive symptoms. Multiple regression analyses revealed that three variables, perceived social integration, partner encouragement to obtain help when needed, and partner agreed with infant care, significantly explained the variance in Edinburgh Postnatal Depression Scale scores.

CONCLUSIONS

Maternal perceptions of social integration and partner provision of problem-focused informational support and positive feedback are important in determining maternal mental health. Therefore, in the antenatal period healthcare professionals should teach couples appropriate ways to provide feedback and communicate expectations, especially those relating to infant care strategies. The importance of appraisal and emotional support should be highlighted in order to foster maternal feelings of acceptance and being cared for. Partners should also be encouraged to participate actively in household tasks and infant care activities to protect the mother from becoming overwhelmed.

Men's voices: postnatal depression from the perspective of male partners

Postnatal depression (PND) is a serious and debilitating condition that is recognized as being disruptive to women's lives at a time when they are already under stress adapting to the demands that a new baby creates. What has not always been fully acknowledged is that PND is linked with elevated levels of depression in male partners. In this article, the authors report on men's experiences of PND and of participation in a 6-week group treatment program specifically designed for male partners. The men experienced their partners' PND as overwhelming, isolating, stigmatizing, and frustrating. Coping with PND was assisted by participation in the men's group. Men reported lowered levels of depression and stress, and higher levels of social support, as a result of their participation. The men valued highly the opportunity to share experiences with peers, to hear strategies for engaging in their relationship, and to gain factual information.

Group interpersonal psychotherapy for postnatal depression: a pilot study

We conducted a pilot study to assess the potential effectiveness of group interpersonal psychotherapy (IPT-G) as a treatment for postnatal depression (PND). The study was also established to test a treatment manual for IPT-G, assess the acceptability of this format for participants and test a recruitment strategy for a randomised controlled trial. 18 mothers diagnosed with PND participated in 2 individual session and 8 sessions of group IPT. A two-hour psychoeducational session was also held for the partners of the participants. Measures of depressive symptomatology and social adjustment were administered by an independent clinician at baseline, 4 weeks, 8 weeks and 3 months post treatment. Patient satisfaction with the treatment was also evaluated. Severity scores on the BDI, EPDS and the HDRS decreased from pre- to post-treatment. This was maintained at three months follow up. No overall improvement in the Social Adjustment Scale-Self Report was noted, although there was improvement in their relationship with their significant other. The results confirm previous work that IPT-G may improve symptom severity for women suffering from postnatal depression. Limitations included the use of antidepressant therapy by 67% of subjects and the lack of a control group. There is a need for further randomised controlled trials of IPT-G with larger sample sizes to establish its effectiveness as treatment for PND.

Couples' experiences of postnatal depression: a framing analysis of cultural identity, gender and communication

Difficulties in communication have been associated with fathers' perceived lack of support for mothers suffering postnatal depression (PND). This paper investigates why the communication of the experience of PND is so difficult and considers how these difficulties might be linked, in part, to the diagnostic process. The study explores, through in-depth interviews, how six Australian couples talked about the new mothers' experience of mild to moderate PND. Framing analysis revealed discrepancies in the couples' explanations of the mothers' PND. The application of the concept of 'framing' has come to the study of mental health by way of Goffman's work on how experience becomes organised. Goffman used the technique of 'frame analysis' to identify and describe the taken-for-granted sociocultural elements that give meaning to a situation. This study identified that mothers and fathers used different frames, with mothers understanding their postnatal experience primarily from within an 'identity' frame and fathers understanding the mothers' experience primarily through a 'psychological' or 'physical hardship' frame. Implications for health service providers are considered.

Meeting the Challenge of New Fatherhood During the Early Weeks

OBJECTIVE

To explore new/subsequent Australian fathers' perspectives on the experiences, processes, and life changes in the early weeks of fatherhood.

DESIGN

Interpretive study using in-depth interviews and grounded theory analysis techniques, based on a symbolic interactionist framework.

SETTING

Participants were recruited from the postnatal wards of a major public hospital, early discharge program, and early childhood centers in southeast Queensland, Australia.

PARTICIPANTS

Eighteen first-time/subsequent fathers interviewed 6 to 12 weeks after the birth.

RESULTS

Although rewarding, fathers found new or expanding fatherhood to be a significant challenge and time of change. Major themes included making a commitment, taking responsibility, negotiating responsibilities, developing and maintaining relationships, maintaining family integrity, balancing activities, and perceiving the self as father. Work had a major impact on fathers' ability to participate with their family and newborn. To manage, fathers sought to balance the demands of work and home, deal with stressors, manage their time, develop routines, and reprioritize. Fathers developed a sense of themselves as fathers over time, building confidence and deriving satisfaction from their fathering role.

CONCLUSIONS

A range of competing factors affected fathers' ability to participate in the home with their newborn in the early weeks after birth.

A population-based study of exclusive breastfeeding in Icelandic women: is there a relationship with depressive symptoms and parenting stress?

This study investigated whether postpartum depressive symptoms and parenting stress are related to exclusive breastfeeding in mothers at 2-3 months postpartum. Data were collected from 734 Icelandic mothers postpartum. Parenting stress, depressive symptoms, feeding methods and demographical data were assessed by self-administered questionnaires. A high level of maternal education increased the likelihood of exclusive breastfeeding whereas lower maternal education, high levels of depressive symptoms, twins and single motherhood reduced the likelihood of exclusive breastfeeding. It is concluded that depressive symptoms are related to lower levels of exclusive breastfeeding and that exclusive breastfeeding becomes more likely with higher level of maternal education.

Paternal postpartum depression, its relationship to maternal postpartum depression, and implications for family health

BACKGROUND

Much attention has been paid to the problem of postpartum depression in women. However, there is some indication that men also experience depression after the birth of a child, and that paternal depression is linked to maternal depression.

AIMS

The purpose of this integrative review was to examine current knowledge about postpartum depression in fathers. Specific aims were (1) to examine the incidence of paternal depression in the first year after the birth of a child, (2) to identify the characteristics and predictors of paternal postpartum depression, (3) to describe the relationship between maternal and paternal postpartum depression, and (4) to discuss the influence of paternal depression on the family and infant.

METHODS

A literature search from 1980 to 2002 was carried out using the CINAHL, PsychInfo, and Medline electronic databases. Twenty research studies were identified that included incidence rates of paternal depression during the first year postpartum. These were further examined and synthesized regarding onset, severity, duration, and predictors of paternal depressive symptoms, and for information about the relationship between maternal and paternal depression.

FINDINGS

During the first postpartum year, the incidence of paternal depression ranged from 1.2% to 25.5% in community samples, and from 24% to 50% among men whose partners were experiencing postpartum depression. Maternal depression was identified as the strongest predictor of paternal depression during the postpartum period. The implications of parental depression for family health were discussed.

CONCLUSIONS

Postpartum depression in men is a significant problem. The strong correlation of paternal postpartum depression with maternal postpartum depression has important implications for family health and well-being. Consideration of postpartum depression in fathers as well as mothers, and consideration of co-occurrence of depression in couples, is an important next step in research and practice involving childbearing families.

Benefits and risks to mother and infant of drug treatment for postnatal depression

The postnatal period presents a special problem to healthcare providers treating psychiatric disorders in women. Many new mothers who need antidepressant treatment may wish to breastfeed their infants, but are hesitant to do so for fear of passing on possible harmful effects of the medication through their milk. The focus of this article will be on highlighting and interpreting the existing literature on the benefits and risks to mother and infant of drug treatment for postnatal depression, as well as outlining treatment guidelines for the use of antidepressants in breastfeeding mothers. The article will specifically focus on the use of fluoxetine, sertraline, paroxetine, fluvoxamine and citalopram, which are more commonly used and belong to the selective serotonin reuptake inhibitor group of antidepressants. The tricyclic and other newer antidepressant medications will also be discussed. As there are no published controlled studies on the use of antidepressants by breastfeeding women, publications of individual case reports, case series, and pharmacokinetic investigations serve as the basis for the development of treatment guidelines. Results from this growing body of literature are promising in that, with the exception of a few cases, no serious adverse events have been reported in infants exposed to antidepressant medications through breast milk. In addition nonpharmacological treatments consisting of different types of psychotherapies will be discussed. It is critical that healthcare providers evaluate each mother-infant dyad on an individual basis when faced with the decision to prescribe antidepressant medications during the postnatal period.

Mental illness in women who have young children: current literature

Postnatal depression is an illness that has been researched a great deal in recent years. While much is known about the prevalence and contributing factors, it is not clear whether antenatal interventions are successful in preventing postnatal depression. Mother-child relationships where the mother has a mental illness, have been reported to be more negative and may adversely affect the child's development. Many researchers discuss the importance of supporting such families, not only to improve their current situation, but also to help prevent the development of mental health problems in the children.

Postpartum depression: a metasynthesis

Postpartum depression has been described as a dangerous thief that robs mothers of the love and happiness they expected to feel toward their newborn babies. Even though the number of qualitative studies on postpartum depression is increasing, knowledge development will be impeded unless the rich understandings gleaned from these studies are synthesized. Using Noblit and Hare's 1988 approach, the author conducted a metasynthesis of 18 qualitative studies on postpartum depression. Four overarching themes emerged that reflected four perspectives involved in postpartum depression: (a) incongruity between expectations and the reality of motherhood, (b) spiraling downward, (c) pervasive loss, and (d) making gains. Implications for clinical practice and theory development are addressed.

Treatment of depression in women: a summary of the expert consensus guidelines

Women constitute two-thirds of patients suffering from common depressive disorders, making the treatment of depression in women a substantial public health concern. However, high-quality, empirical data on depressive disorders specific to women are limited, and there are no comprehensive evidence-based practice guidelines on the best treatments for these illnesses. To bridge the gap between research evidence and key clinical decisions, the authors developed a survey of expert opinion concerning treatment of four depressive conditions specific to women: premenstrual dysphoric disorder, depression in pregnancy, postpartum depression in a mother choosing to breast-feed, and depression related to perimenopause/menopause. The survey asked about 858 treatment options in 117 clinical situations and included a broad range of pharmacological, psychosocial, and alternative medicine approaches. The survey was sent to 40 national experts on women's mental health issues, 36 (90%) of whom completed it. The options, scored using a modified version of the RAND Corporation's 9-point scale for rating appropriateness of medical decisions, were assigned one of three categorical rankings-first line/preferred choice, second line/alternate choice, third line/usually inappropriate-based on the 95% confidence interval of each item's mean rating. The expert panel reached consensus (defined as a non-random distribution of scores by chi-square "goodness-of-fit" test) on 76% of the options, with greater consensus in situations involving severe symptoms. Guideline tables indicating preferred treatment strategies were then developed for key clinical situations. The authors summarize the expert consensus methodology they used and then, for each of the four key areas, review the treatment literature and summarize the experts' recommendations and how they relate to the research findings. For women with severe symptoms in each area we asked about, the first-line recommendation was antidepressant medication combined with other modalities (generally psychotherapy). These recommendations parallel existing guidelines for severe depression in general populations. For initial treatment of milder symptoms in each situation, the panel was less uniform in recommending antidepressants, and either gave equal endorsement to other treatment modalities (e.g., nutritional or psychobehavioral approaches in PMDD; hormone replacement in perimenopause) or preferred psychotherapy over medication (during conception, pregnancy, or lactation). In all milder cases, however, antidepressants were recommended as at least second-line options. Among antidepressants, selective serotonin reuptake inhibitors (SSRIs) were recommended as first-line treatment in all situations. The specific SSRIs that were preferred depended on the particular clinical situation. Tricyclic antidepressants were highly rated alternatives to SSRIs in pregnancy and lactation. In evaluating many of the treatment options, the experts had to extrapolate beyond controlled data in comparing treatment options with each other or in combination. Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide some direction for addressing common clinical dilemmas in women, and can be used to inform clinicians and educate patients regarding the relative merits of a variety of interventions.

Validation of the Edinburgh Postnatal Depression Scale for men, and comparison of item endorsement with their partners

BACKGROUND

The Edinburgh Postnatal Depression Scale (EPDS) has been validated and used extensively in screening for depression in new mothers, both in English speaking and non-English speaking communities. While some studies have reported the use of the EPDS with fathers, none have validated it for this group, and thus the appropriate cut-off score for screening for depression or anxiety caseness for this population is not known.

METHODS

Couples were recruited antenatally and interviewed at six weeks postpartum. EPDS scores and distress caseness (depression or anxiety disorders) for 208 fathers and 230 mothers were determined using the Diagnostic Interview Schedule.

RESULTS

Analyses of the EPDS for fathers using distress caseness (depression or anxiety disorders) as the criterion shows that a cut-off of 5/6 has optimum receiver operating characteristics. Furthermore acceptable reliability (split-half and internal consistency) and validity (concurrent) coefficients were obtained. For mothers the optimum cut-off screening value to detect distress caseness was 7/8. Item analysis revealed that fathers endorsed seven of the ten items at lower rates to mothers, with the most significant being that referring to crying.

CONCLUSIONS

The EPDS is a reliable and valid measure of mood in fathers. Screening for depression or anxiety disorders in fathers requires a two point lower cut-off than screening for depression or anxiety in mothers, and we recommend this cut-off to be 5/6.

Effects of support group intervention in postnatally distressed women. A controlled study in Taiwan

OBJECTIVE

The symptoms of depression experienced by women during the postnatal period may have profound effects on the lifelong health of both the mother and the child. In this randomized controlled study, we systematically evaluated the effects of weekly supportive group meetings for women with postnatal distress.

METHODS

Sixty postnatally distressed women were randomly assigned to support (n=30) and control (n=30) groups. Women assigned to the support group participated in four supportive group sessions that comprised discussions concerning transition to motherhood, postnatal stress management, communication skills, and life planning.

RESULTS

Subjects who attended the support sessions had significantly decreased scores on the Beck Depression Inventory (BDI) and the Perceived Stress Scale (PSS), and significantly increased scores on the Interpersonal Support Evaluation List (ISEL) as evaluated at the end of the fourth weekly session. In contrast, no significant changes were observed in the control group during this period.

CONCLUSION

This is the first controlled study to provide evidence that participation in support groups for postnatally distressed women provides quantifiable psychosocial benefits.

Migration and motherhood: a response to Barclay and Kent (1998)

A recent paper by Barclay and Kent (1998) raised various issues with regards to motherhood and recent immigration. They expressed reservations with conceptualizing extreme misery in new mothers as depression, and with screening for postnatal distress in women from non-English-speaking backgrounds (NESB). They argued that a common self-report measure for postnatal distress screening, the Edinburgh Postnatal Depression Scale (EPDS), was flawed. They also argued that the concept of postnatal depression implies a medical aetiology and, thus, fails to recognise the socio-cultural aspects experienced by NESB women. We address these issues, by demonstrating that the EPDS is not flawed, and by arguing that screening for postpartum distress results in more NESB women being identified and, consequently, offered a service, than if such screening does not occur. We also disagree with the view that the term 'postnatal depression' necessarily implies any aetiology, and that work by our unit, as well as others around the world, indicates that the psychosocial and cultural aspects related to distress in new immigrant mothers is being recognised and acted upon.