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

Postpartum depressive symptoms in the context of high social adversity and reproductive health threats: a population-based study

Background

Postpartum depression is an important but neglected public health issue in low- and middle-income countries. The aim of this study was to assess postpartum depressive (PPD) symptoms and associated factors in a rural Ethiopian setting characterized by high social adversity and reproductive health threats. We hypothesized that infant gender preference would be associated with PPD symptoms.

Methods

A cross-sectional, population-based study was conducted in Sodo district, southern Ethiopia, between March and June 2014. A total of 3147 postpartum women (one to 12 months after delivery) were recruited and interviewed in their homes. The questionnaire included demographic, reproductive health and psychosocial factors in addition to a culturally validated measure of depressive symptoms, the Patient Health Questionnaire. Scores of 5 or more were indicative of high levels of PPD symptoms.

Results

The prevalence of high PPD symptoms was 12.2%, with 95% confidence interval (CI) between 11.1 and 13.4. Of these, 12.0% of the study participants had suicidal ideation. Preference of the husband for a boy baby was associated with PPD symptoms in univariate analysis (crude odds ratio 1.43: 95% CI 1.04, 1.91) but became non-significant after adjusting for confounders. In the final multivariable analysis, rural residence [adjusted odds ratio (aOR) 2.56: 95% CI 2.56, 4.19], grand multiparity (aOR 2.00: 1.22, 3.26), perinatal complications (aOR: 2.55: 1.89, 3.44), a past history of abortion (aOR 1.50: 1.07, 2.11), experiencing hunger in the preceding 1 month (aOR 2.38: 1.75, 3.23), lower perceived wealth (aOR 2.11: 1.19, 3.76), poor marital relationship (aOR 2.47: 1.79, 3.42), and one or more stressful events in the preceding 6 months (aOR 2.36: 1.82, 3.06) were associated significantly with high PPD symptoms.

Conclusion

PPD symptoms affected more than one in 10 women in this Ethiopian community setting. Social adversity and reproductive health threats were associated with poorer mental health. Interventions focusing on poor rural women with low access to care are necessary. This research can serve as an entry point for the adaptation of a psychosocial intervention.

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.

Prevalence and course of anxiety disorders (and symptom levels) in men across the perinatal period: A systematic review

BACKGROUND

Men's experiences of anxiety within the perinatal period can adversely impact themselves, their partner and infant. However, we know little about the prevalence and course of men's anxiety across the perinatal period. The current review is one of the first to systematically review the published literature.

METHODS

Five databases (PubMed, PsycINFO, Cochrane, SCOPUS, and Web of Science) were searched to identify relevant papers published prior to April 2015. The literature search identified articles with data for expectant fathers (prenatal period) and/or fathers of an infant aged between 0 and 1 (postnatal period). The following data were extracted: (a) anxiety disorder prevalence (diagnostic clinical interviews), (b) 'high' anxiety symptom prevalence (above thresholds/cut-points on anxiety symptom scales) and (c) mean anxiety levels (anxiety symptom scales). Initially, 537 unique papers were identified. Subsequently, 43 papers met criteria for inclusion in the review.

RESULTS

Prevalence rates for 'any' anxiety disorder (as defined by either diagnostic clinical interviews or above cut-points on symptom scales) ranged between 4.1% and 16.0% during the prenatal period and 2.4-18.0% during the postnatal period. The data reviewed suggest the course of anxiety across the perinatal period is fairly stable with potential decreases postpartum.

LIMITATIONS

Wide variation in study measurement and methodology makes synthesis of individual findings difficult. Anxiety is highly comorbid with depression, and thus measures of mixed anxiety/depression might better capture the overall burden of mental illness.

CONCLUSIONS

Anxiety disorders are common for men during the perinatal period. Both partners should be included in discussions and interventions focused on obstetric care and parent mental health during the perinatal period.

Early postnatal demoralisation among primiparous women in the community: measurement, prevalence and associated factors

Background

Demoralisation is a psychological state occurring in stressful life situations where a person feels unable to respond effectively to their circumstances, characterised by feelings of distress, subjective incompetence, helplessness and hopelessness. The period after the birth of a first baby is a time of great changes and disruptions to many aspects of the mother's physical, psychological and social functioning. This can lead to feelings of distress, a sense of incompetence and helplessness. This study aimed to examine: (1) the psychometric properties of the Demoralisation Scale in a community setting; (2) the prevalence of demoralisation symptoms among primiparous women in the community; and (3) factors that are uniquely associated with demoralisation in the early postnatal period.

Methods

Primiparous women attending community maternal health centres (n = 400) were recruited and administered the study's questionnaires through a telephone interview.

Results

The Demoralisation Scale was found to be a reliable and valid tool among women in the community who had recently given birth. Higher levels of demoralisation were independently associated with lower confidence on going home from the hospital after birth, lower rating of mother's self-rated global health, more than 3 h of infant crying and fussing in the last 24 h, and a controlling partner, after symptoms of depression and anxiety, and vulnerable personality characteristics were controlled for.

Conclusions

The relevance of demoralisation to postnatal health practitioners in the community is in helping them to better understand women's experiences and to intervene in a way that is more meaningful and less stigmatising to women.