Protocol for economic evaluation alongside a cluster-randomised controlled trial of a psychoeducational intervention for the primary prevention of postnatal mental health problems in first-time mothers

Prevention of common mental disorders among women in the perinatal period: a critical mixed-methods review and meta-analysis

Perinatal depression and anxiety account for a high burden of perinatal morbidity and poor psychosocial functioning. There is a growing interest among mental health professionals, to devise interventions to prevent this condition. This review synthesizes evidence for the effectiveness of psychological and psychosocial interventions aimed at the prevention of perinatal depression and anxiety. We also explore qualitative evidence to understand the acceptability and feasibility of these interventions. Using a mixed-methods approach, data from a total of 21 studies were collated to inform the evidence for preventive interventions for perinatal depression and anxiety. Based on their theoretical orientations, these interventions were described by authors as cognitive-behavioral (n = 7); psychoeducational (n = 6); mindfulness (n = 2); and interpersonal psychotherapy (n = 2). These also included psychosocial approaches such as social support (n = 1) and multicomponent interventions (n = 3). For depressive symptoms, these interventions yielded moderate to strong effect sizes in favor of the intervention group [standardized mean difference (SMD) = -0.59; 95% confidence interval (CI) -0.95 to -0.23]. For anxiety symptoms, a strong effect size was estimated in favor of the intervention group (SMD = -1.43, 95% CI -2.22 to -0.65). Preventive interventions significantly reduce the severity of perinatal depressive and anxiety symptoms. These interventions are also acceptable and feasible in many settings.

A complex postnatal mental health intervention: Australian translational formative evaluation

Reducing the burden of postnatal maternal mental health problems is an international public health priority. We developed What Were We Thinking (WWWT), a psychoeducation programme for primary postnatal health care that addresses known but neglected risks. We then demonstrated evidence of its effects in a before-and-after controlled study in preventing maternal postnatal mental health problems among women without a psychiatric history participating in the intervention compared to usual care (AOR 0.43; 95% CI 0.21, 0.89) when conducted by specialist nurses. Testing its effectiveness when implemented in routine primary care requires changes at practitioner, organizational and health system levels. This paper describes a programme of translational formative evaluation to inform the protocol for a cluster RCT. Following the UK Medical Research Council (MRC) Guidance for evaluating complex interventions, we conducted a translational formative evaluation using mixed methods. Collection and analysis of postnatal health service documents, semi-structured interviews, group discussions and an online survey were used to investigate service provision, consumers' needs and expectations, clinicians' attitudes and clinical practice, and the implications for health service delivery. Participants were expectant parents, health care providers, health service managers and government policy makers. Results documented current clinical practice, staff training needs, necessary service modifications to standardize advice to parents and include fathers, key priorities and drivers of government health policy, and informed a model of costs and expected health and social outcomes. Implementation of WWWT into routine postnatal care requires adjustments to clinical practice. Staff training, modifications to service opening hours and economic implications for the health system also need to be considered. The MRC Guidance for developing and evaluating complex interventions is a useful framework for conceptualizing and reporting translational formative evaluation, which is an essential step in the evidence trajectory. The results of the evaluation will inform the protocol for a cluster RCT of WWWT and associated health economic evaluation.

Preventing postnatal maternal mental health problems using a psychoeducational intervention: the cost-effectiveness of What Were We Thinking

OBJECTIVES

Postnatal maternal mental health problems, including depression and anxiety, entail a significant burden globally, and finding cost-effective preventive solutions is a public policy priority. This paper presents a cost-effectiveness analysis of the intervention, What Were We Thinking (WWWT), for the prevention of postnatal maternal mental health problems.

DESIGN

The economic evaluation, including cost-effectiveness and cost-utility analyses, was conducted alongside a cluster-randomised trial.

SETTING

48 Maternal and Child Health Centres in Victoria, Australia.

PARTICIPANTS

Participants were English-speaking first-time mothers attending participating Maternal and Child Health Centres. Full data were collected for 175 participants in the control arm and 184 in the intervention arm.

INTERVENTION

WWWT is a psychoeducational intervention targeted at the partner relationship, management of infant behaviour and parental fatigue.

OUTCOME MEASURES

The evaluation considered public sector plus participant out-of-pocket costs, while outcomes were expressed in the 30-day prevalence of depression, anxiety and adjustment disorders, and quality-adjusted life years (QALYs). Incremental costs and outcomes were estimated using regression analyses to account for relevant sociodemographic, prognostic and clinical characteristics.

RESULTS

The intervention was estimated to cost $A118.16 per participant. The analysis showed no statistically significant difference between the intervention and control groups in costs or outcomes. The incremental cost-effectiveness ratios were $A36 451 per QALY gained and $A152 per percentage-point reduction in 30-day prevalence of depression, anxiety and adjustment disorders. The estimate lies under the unofficial cost-effectiveness threshold of $A55 000 per QALY; however, there was considerable uncertainty surrounding the results, with a 55% probability that WWWT would be considered cost-effective at that threshold.

CONCLUSIONS

The results suggest that, although WWWT shows promise as a preventive intervention for postnatal maternal mental health problems, further research is required to reduce the uncertainty over its cost-effectiveness as there were no statistically significant differences in costs or outcomes.

TRIAL REGISTRATION NUMBER

ACTRN12613000506796; results.

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

OBJECTIVES

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

DESIGN

Cluster-randomised controlled trial.

SETTING

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

PARTICIPANTS

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

INTERVENTION

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION NUMBER

ACTRN12613000506796; Results.

Economic Evaluation Plan (EEP) for A Very Early Rehabilitation Trial (AVERT): An international trial to compare the costs and cost-effectiveness of commencing out of bed standing and walking training (very early mobilization) within 24 h of stroke onset with usual stroke unit care

Rationale

A key objective of A Very Early Rehabilitation Trial is to determine if the intervention, very early mobilisation following stroke, is cost-effective. Resource use data were collected to enable an economic evaluation to be undertaken and a plan for the main economic analyses was written prior to the completion of follow up data collection.

Aim and hypothesis

To report methods used to collect resource use data, pre-specify the main economic evaluation analyses and report other intended exploratory analyses of resource use data.

Sample size estimates

Recruitment to the trial has been completed. A total of 2,104 participants from 56 stroke units across three geographic regions participated in the trial.

Methods and design

Resource use data were collected prospectively alongside the trial using standardised tools. The primary economic evaluation method is a cost-effectiveness analysis to compare resource use over 12 months with health outcomes of the intervention measured against a usual care comparator. A cost-utility analysis is also intended.

Study outcome

The primary outcome in the cost-effectiveness analysis will be favourable outcome (modified Rankin Scale score 0-2) at 12 months. Cost-utility analysis will use health-related quality of life, reported as quality-adjusted life years gained over a 12 month period, as measured by the modified Rankin Scale and the Assessment of Quality of Life.

Discussion

Outcomes of the economic evaluation analysis will inform the cost-effectiveness of very early mobilisation following stroke when compared to usual care. The exploratory analysis will report patterns of resource use in the first year following stroke.

A cluster randomised controlled trial of a brief couple-focused psychoeducational intervention to prevent common postnatal mental disorders among women: study protocol

INTRODUCTION

Postnatal common mental disorders among women are an important public health problem internationally. Interventions to prevent postnatal depression have had limited success. What Were We Thinking (WWWT) is a structured, gender-informed, psychoeducational group programme for parents and their first infant that addresses two modifiable risks to postnatal mental health. This paper describes the protocol for a cluster randomised controlled trial to test the clinical effectiveness and cost-effectiveness of WWWT when implemented in usual primary care.

METHODS AND ANALYSIS

48 maternal and child health (MCH) centres from six diverse Local Government Areas, in Victoria, Australia are randomly allocated to the intervention group (usual care plus WWWT) or the control group (usual care). The required sample size is 184 women in each group. English-speaking primiparous women receiving postpartum healthcare in participating MCH centres complete two computer-assisted telephone interviews: baseline at 4 weeks and outcome at 6 months postpartum. Women attending intervention MCH centres are invited to attend WWWT in addition to usual care. The primary outcome is meeting Diagnostic and Statistical Manual-IV (DSM-IV) diagnostic criteria for major depressive episode; generalised anxiety disorder; panic disorder with or without agoraphobia, agoraphobia with or without panic, social phobia, adult separation anxiety or adjustment disorder with depressed mood, anxiety or mixed depressed mood and anxiety within the past 30 days at 6 months postpartum. Secondary outcomes are self-rated general and emotional health, infant sleep problems, method of infant feeding, quality of mother-infant relationship and intimate partner relationship, and healthcare costs and outcomes.

ETHICS AND DISSEMINATION

Approval to conduct the study has been granted. A comprehensive dissemination plan has been devised.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry ACTRN12613000506796. UTN: U1111-1125-8208.