Mid-pregnancy allopregnanolone levels and trajectories of perinatal depressive symptoms

Perinatal depression is a major cause of disability for individuals giving birth worldwide, with detrimental effects on short- and long-term parental and child outcomes. There is emerging evidence that the neuroactive steroid hormone allopregnanolone is implicated in the pathophysiology and course of perinatal mood symptoms. However, no study thus far has examined allopregnanolone levels whilst making use of longitudinal data on depressive symptom trajectories throughout the perinatal period. The present study investigated levels of allopregnanolone at gestational week 17 of 252 participants in relation to perinatal depressive symptom trajectories, with a secondary aim of exploring the role of history of depression as an effect modifier. Four perinatal depressive symptom trajectories were investigated: controls (no depressive symptoms throughout perinatal period) (N=161), antepartum (depressive symptoms prenatally with postpartum remission) (N=31), postpartum-onset (no depressive symptoms during pregnancy, development of depressive symptoms postpartum) (N=23), and persistent (depressive symptoms throughout the perinatal period) (N=37). Results show that for every one nmol/l increase in allopregnanolone, there was 7% higher odds for persistent depressive symptoms (OR 1.07, 95% CI 1.01-1.14) compared to controls. No association was seen for antepartum and postpartum-onset depressive symptoms. History of depression did not modify the association between allopregnanolone and perinatal depressive symptom trajectories. These results show the role of allopregnanolone for persistent depressive symptoms and strengthen the hypothesis of differences in pathophysiology among the trajectories.

Discrimination and perinatal depressive symptoms: The protective role of social support and resilience

BACKGROUND

Discrimination is an important social determinant of perinatal depression; however, evidence is limited regarding modifiable social and psychological factors that may moderate this association. We examined whether social support and resilience could protect against the adverse effects of discrimination on perinatal depressive symptoms.

METHODS

Pregnant people (N = 589) receiving Expect With Me group prenatal care in Nashville, TN and Detroit, MI completed surveys during third trimester of pregnancy and six months postpartum. Linear regression models tested the association between discrimination and depressive symptoms, and the moderating effects of social support and resilience, during pregnancy and postpartum.

RESULTS

The sample was predominantly Black (60.6 %), Hispanic (15.8 %) and publicly insured (71 %). In multivariable analyses, discrimination was positively associated with depressive symptoms during pregnancy (B = 4.44, SE = 0.37, p ≤0.001) and postpartum (B = 3.78, SE = 0.36, p < 0.001). Higher social support and resilience were associated with less depressive symptoms during pregnancy (B = -0.49, SE = 0.08, p < 0.001 and B = -0.67, SE = 0.10, p < 0.001, respectively) and postpartum (B = -0.32, SE = 0.07, p < 0.001 and B = -0.56, SE = 0.08, p < 0.001, respectively). Social support was protective against discrimination (pregnancy interaction B = -0.23, SE = 0.09, p = 0.011; postpartum interaction B = -0.35, SE = 0.07, p < 0.001). There was no interaction between discrimination and resilience at either time.

LIMITATIONS

The study relied on self-reported measures and only included pregnant people who received group prenatal care in two urban regions, limiting generalizability.

CONCLUSIONS

Social support and resilience may protect against perinatal depressive symptoms. Social support may also buffer the adverse effects of discrimination on perinatal depressive symptoms, particularly during the postpartum period.

Racial and ethnic disparities in access to community-based perinatal mental health programs: results from a cross-sectional survey

BACKGROUND

Perinatal mental health is a major public health problem that disproportionately affects people from racial and ethnic minority groups. Community-based perinatal mental health programs, such as peer support groups, are essential tools for the prevention and treatment of perinatal depression. Yet, little is known about racial and ethnic disparities in accessibility and utilization of community-based perinatal mental health programs.

METHODS

We conducted a cross-sectional study using an online survey with program administrators representing perinatal mental health community-based services and support programs throughout New Jersey. Descriptive analysis and mapping software was used to analyze the data.

RESULTS

Thirty-three program administrators completed the survey. Results showed substantial racial and ethnic disparities in availability and utilization of community-based programs. In the majority of programs, Black, Hispanic, and Asian individuals made up less than 10% of total annual participants and less than 10% of facilitators. There were also geographic disparities in program accessibility and language availability across counties. Program administrators identified mental health stigma, lack of support from family, fear of disclosure of mental health challenges, social determinants, lack of language-concordant options in programs, and limited awareness of programs in the community as significant barriers to participation of racial and ethnic minorities. Strategies to address barriers included adding language options, improving program outreach, and increasing diversity of facilitators.

CONCLUSIONS

This study provides new evidence on racial and ethnic disparities in access to community-based perinatal mental health programs. Efforts to build the resources and capacities of community-based programs to identify equity gaps, increase diversity of staff, and address barriers to participation is critical to reducing racial and ethnic inequities in perinatal mental health.

Economic costs of perinatal depression and anxiety in a lower middle income country: Pakistan

BACKGROUND

Women's mental health during the perinatal period is a major public health problem in Pakistan. Many challenges and competing priorities prevent progress to address the large treatment gap. Aim To quantify the long-term impacts of untreated perinatal depression and anxiety in economic terms, thus highlighting its overall burden based on country-specific evidence.

METHODS

Cost estimates were generated for a hypothetical cohort of women giving birth in 2017, and their children. Women and children experiencing adverse events linked to perinatal mental health problems were modelled over 40 years. Costs assigned to adverse events included were those linked to losses in quantity and quality-of-life, productivity, and healthcare-related expenditure. Present values were derived using a discount rate of 3 %. Data were taken from published cohort studies, as well as from sources of population, economic and health indicators.

RESULTS

The total costs were $16.5 billion for the cohort and $2680 per woman giving birth. The by far largest proportion referred to quality-of-life losses ($15.8 billion). Productivity losses and out-of-pocket expenditure made up only a small proportion of the costs, due to low wages and market prices. When the costs of maternal suicide were included, total costs increased to $16.6 billion.

LIMITATIONS

Important evidence gaps prevented the inclusion of all cost consequences linked to perinatal mental health problems.

CONCLUSIONS

Total national costs are much higher compared with those in other, higher middle-income countries, reflecting the excessive disease burden. This study is an important first step to inform resource allocations.

Food insecurity and perinatal depression among pregnant women in BUNMAP Cohort in Ethiopia: a structural equation modeling

OBJECTIVE

To assess the effect of food insecurity on perinatal depression in rural Ethiopia.

DESIGN

We used a prospective cohort in which food insecurity was considered as primary exposure and perinatal depression as an outcome. Food insecurity at baseline (in the period of 8 - 24 weeks of pregnancy) was measured using the Household Food Insecurity Access Scale (HFIAS), and perinatal depression at follow-up (in 32-36 weeks of pregnancy) was measured using a patient health questionnaire (PHQ-9). We used multivariable regression to assess the effect of food insecurity on the prevalence of perinatal depression. We explored food insecurity's direct and indirect impacts on perinatal depression using structural equation modelling (SEM).

SETTING

This paper used data from the BUNMAP cohort established under the Butajira Health and Demographic Surveillance Site (BHDSS).

PARTICIPANTS

755 pregnant women.

RESULTS

Among the study participants, 50% were food-insecure, and about one-third were depressed at 32-36 follow-up. In SEM, higher values of baseline food insecurity, depressive symptoms, and state-trait anxiety (STA) were positively and significantly associated with perinatal depression. The direct impact of food insecurity on perinatal depression accounts for 42% of the total effect, and the rest accounted for the indirect effect through baseline depression (42%) and state-trait anxiety (16%).

CONCLUSION

The significant effect of food insecurity at baseline on perinatal depression and the indirect effect of baseline food insecurity through baseline anxiety and depression in the current study implies the importance of tailored interventions for pregnant women that consider food insecurity and psychosocial problems.

"Association between perinatal mood disorders of parents and child health outcomes"

PURPOSE

Perinatal mood disorders affect both parents, impacting their children negatively. Little is known on the association between parental perinatal mood disorders and pediatric outcomes in Japan considering relevant covariates. Our objective was to investigate the association between paternal and maternal perinatal mood disorders and adverse physical and psychological child outcomes by the age of 36 months, adjusting for covariates such as the child's sex, age of parent at child's birth, perinatal mood disorders of the other parent, and perinatal antidepressant use.

METHODS

We identified parents in the JMDC Claims Database in Japan from 2012 to 2020. Perinatal mood disorders were defined using International Classification of Diseases, 10th codes for mood disorders during the perinatal period combined with psychiatric treatment codes. We evaluated the association between parental perinatal mood disorders and pediatric adverse outcomes by the age of 36 months using Cox proportional hazard models adjusted for the covariates.

RESULTS

Of the 116,423 father-mother-child triads, 2.8% of fathers and 2.3% of mothers had perinatal mood disorders. Paternal perinatal mood disorders were not significantly associated with adverse child outcomes. After adjusting for paternal perinatal mood disorders and antidepressant use, maternal perinatal mood disorders were associated with delayed motor development, language development disorders, autism spectrum disorders, and behavioral and emotional disorders (adjusted hazard ratio [95% confidence interval]: 1.65 [1.01-2.69], 2.26 [1.36-3.75], 4.16 [2.64-6.55], and 6.12 [1.35-27.81], respectively).

CONCLUSIONS

Paternal perinatal mood disorders were not associated with adverse child outcomes in this population. Maternal perinatal mood disorders were associated with multiple child outcomes.

Perinatal depression and infant and toddler neurodevelopment: A systematic review and meta-analysis

Many studies have focused on the effect of perinatal depression on neurodevelopment among children and adolescents. However, only a few studies have explored this relationship in infants and toddlers with inconsistent results. We performed a systematic review and meta-analysis to evaluate the association between perinatal depression and infant and toddler neurodevelopment during the first two postnatal years. Twenty-three studies were included in this meta-analysis. Perinatal depression was associated with poorer cognitive (Cohen's d = -0.19, SE= 0.06, 95% CI = -0.30 to -0.08), language (Cohen's d = -0.24, SE = 0.09, 95% CI = -0.40 to -0.07), and motor (Cohen's d = -0.15, SE = 0.05, 95% CI = -0.26 to -0.05) development. Subgroup analyses showed that the types of maternal depression (prenatal depression vs. postnatal depression), the method of measuring maternal depression (rating scale vs. diagnostic interview), and the time interval between assessment of exposure and outcome had an impact on the observed effect about neurodevelopment of infants and toddlers. In addition, the results of our study pointed to a stronger significant association between prenatal depression and cognitive, language, and motor delays in infants and toddlers, whereas the association between postnatal depression and cognitive, language, and motor delays in infants and toddlers was not statistically significant. In conclusion, this study provided convincing evidence that the perinatal window is a sensitive period for offspring neurodevelopment.

Perinatal depression trajectories and child development at one year: a study in China

BACKGROUND

The objective of the current study was to investigate the correlation between trajectories of maternal perinatal depression (PND) spanning from early pregnancy to one year postpartum and developmental delays observed in one-year-old children.

METHODS

The dataset under examination encompassed 880 women who took part in a mother-child birth study conducted in China. Latent class growth analysis (LCGA) was employed to identify patterns in Edinburgh Postnatal Depression Scale (EPDS) scores of women, spanning from early pregnancy to one year postpartum. To assess the neurodevelopment of one-year-old children, a Chinese version of the Bayley Scale of Infant Development (BSID-CR) was employed. Logistic regression was employed to explore the association between PND trajectories and developmental delays in children, with appropriate covariate adjustments.

RESULTS

The trajectories of maternal PND identified in this study included a minimal-stable symptom group (n = 155), low-stable symptom group (n = 411), mild-stable symptom group (n = 251), and moderate-stable symptom group (n = 63). Logistic regression analysis revealed that mothers falling into the moderate-stable symptom group exhibited a notably heightened risk of having a child with psychomotor developmental delays at the age of one year.

CONCLUSIONS

The findings drawn from a representative sample in China provide compelling empirical evidence that bolsters the association between maternal PND and the probability of psychomotor developmental delays in children. It is imperative to develop tailored intervention strategies and meticulously design mother-infant interactive intervention programs for women with PND.

Generating EQ-5D-3L health utility scores from the Edinburgh Postnatal Depression Scale: a perinatal mapping study

BACKGROUND

Perinatal depression (PND) describes depression experienced by parents during pregnancy or in the first year after a baby is born. The EQ-5D instrument (a generic measure of health status) is not often collected in perinatal research, however disease-specific measures, such as the Edinburgh Postnatal Depression Scale (EPDS) are widely used. Mapping can be used to estimate generic health utility index values from disease-specific measures like the EPDS.

OBJECTIVE

To develop a mapping algorithm to estimate EQ-5D utility index values from the EPDS.

METHODS

Patient-level data from the BaBY PaNDA study (English observational cohort study) provided 1068 observations with paired EPDS and EQ-5D (3-level version; EQ-5D-3L) responses. We compared the performance of six alternative regression model types, each with four specifications of covariates (EPDS score and age: base, squared, and cubed). Model performance (ability to predict utility values) was assessed by ranking mean error, mean absolute error, and root mean square error. Algorithm performance in 3 external datasets was also evaluated.

RESULTS

There was moderate correlation between EPDS score and utility values (coefficient:  - 0.42). The best performing model type was a two-part model, followed by ordinary least squared. Inclusion of squared and cubed covariates improved model performance. Based on graphs of observed and predicted utility values, the algorithm performed better when utility was above 0.6.

CONCLUSIONS

This direct mapping algorithm allows the estimation of health utility values from EPDS scores. The algorithm has good external validity but is likely to perform better in samples with higher health status.

Perinatal depression and its associated risk factors during the COVID-19 pandemic in low- and middle-income countries: a systematic review and meta-analysis

PURPOSE

Perinatal depression significantly impacts maternal and child health, with further complexities arising during the COVID-19 pandemic. This review is the first to comprehensively synthesize evidence on the prevalence of perinatal depression and its associated risk factors in Low- and Middle-Income Countries (LMICs) during the pandemic period.

METHODS

The study protocol was registered in PROSPERO (CRD42022326991). This review followed the Joanna Briggs Institute (JBI) guideline for prevalence studies. A comprehensive literature search was conducted in six databases: PubMed, Scopus, Web of Science, PsycInfo, CINAHL, and ProQuest. Pooled prevalence estimates were computed for both prenatal and postnatal depression. Identified risk factors were summarized narratively.

RESULTS

A total of 5169 studies were screened, out of which 58 were included in the narrative review and 48 [prenatal (n = 36) and postnatal (n = 17)] were included in the meta-analysis. The pooled depression prevalence for prenatal women was 23% (95% CI: 19-27%), and for the postnatal women was 23% (95% CI: 18-30%). Maternal age, education, perceived fear of COVID-19 infection, week of pregnancy, pregnancy complications, and social and family support were identified as associated risk factors for depression.

CONCLUSIONS

Our review demonstrates an increased prevalence of perinatal depression during the COVID-19 pandemic in LMICs. It sheds light on the significant burden faced by pregnant and postnatal women and emphasizes the necessity for targeted interventions during the ongoing and potential future crisis.

Chronic non-discriminatory social defeat stress during the perinatal period induces depressive-like outcomes in female mice

Depression is more prevalent in women than in men. Perinatal stress is one of the main risk factors for depression in women. However, there is no suitable female model for perinatal depression that uses the social defeat stress (SDS) paradigm. The standard chronic SDS protocol, which is the most useful method for developing a depression-like model, is effective only in male mice. Thus, this study aimed to characterize a novel SDS method for producing a perinatal depression-like model mouse. We induced chronic SDS in perinatal female mice, wherein chronic non-discriminatory SDS (ND-SDS) was used to induce substantial stress in female mice. The female mice were placed in aggressive ICR mouse cages with sentinel male mice under ND-SDS conditions. Stressed female mice subjected to ND-SDS during the perinatal period efficiently exhibited stress-susceptible phenotypes, such as a social avoidance phenotype and anhedonic behavior, whereas stressed female mice subjected to SDS did not show depressive-like behaviors. These results indicate that chronic ND-SDS in perinatal females could be used to develop a female perinatal depression-like model that can be used to study women's health.

Addressing the challenges of integrating care for perinatal depression in primary care in Nigeria

PURPOSE

This report provides the results of a task-shared approach for integrating care for perinatal depression (PND) within primary maternal and child healthcare (PMCH), including the factors that may facilitate or impede the process.

METHODS

This hybrid implementation-effectiveness study guided by the Replicating Effective Programmes framework was conducted in 27 PMCH clinics in Ibadan, Nigeria. The primary implementation outcome was change in the identification rates of PND by primary health care workers (PHCW) while the primary effectiveness outcome was the difference in symptom remission (EPDS score ≤ 5) 6 months postpartum. Outcome measures were compared between two cohorts of pregnant women, one recruited before and the other after training PHCW to identify and treat PND. Barriers and facilitators were explored in qualitative interviews.

RESULTS

Identification of PND improved from 1.4% before to 17.4% after training; post-training rate was significantly higher in clinics where PHCW routinely screened using the 2-item patient health questionnaire (24.8%) compared to non-screening clinics (5.6%). At 6-months postpartum, 60% of cohort one experienced remission from depression, compared to 56.5% cohort two [OR-0.9 (95%CI-0.6, 1.3) p = 0.58]. Identified facilitators for successful integration included existence of policy specifying mental health as a component of PHC, use of screening to aid identification and supportive supervision, while barriers included language and cultural attitudes towards mental health and human resource constraints. PHCW were able to make adaptations to address these barriers.

CONCLUSIONS

Successful implementation of task-shared care for perinatal depression requires addressing staff shortages and adopting strategies that can improve identification by non-specialist providers.

TRIAL REGISTRATION

This study was retrospectively registered 03 Dec 2019. https://doi.org/10.1186/ISRCTN94230307 .

Are midwives trained to recognise perinatal depression symptoms? Results of MAMA (MAternal Mood Assessment) cross-sectional survey in Italy

PURPOSE

To assess the knowledge, clinical experience, and attitudes of Italian midwives toward perinatal depression (PND) and to explore how these factors impact the quality of care.

METHODS

We conducted a cross-sectional online survey among 152 midwives employed in public hospitals across Italy. The questionnaire covered a range of topics, including demographic data, professional experience, knowledge of PND symptoms, risk factors, and clinical management, as well as communication skills and personal experiences with PND cases.

RESULTS

A concerning 76.3% of midwives displayed inadequate knowledge of PND based on current scientific literature. Those with a more comprehensive understanding were notably more confident in their practice, expressing significantly fewer apprehensions about communicating with mothers (25.8% vs 74.2%) and lesser concerns about the mothers' future well-being (38.9% vs 62.95%). The survey results also emphasised the midwives' call for specialised guidelines and formal training in PND management and underscored the value of communication skills, continuity of care, and family engagement in supporting affected mothers.

CONCLUSION

This inaugural study sheds light on the current state of knowledge and attitudes among Italian midwives regarding PND. It pinpoints crucial areas for educational enhancement and practice improvement, suggesting that elevated levels of midwife expertise in PND could significantly elevate the standard of care and expedite early diagnosis and treatment.

Virtual(ly) no support: Associations between virtual support group participation and peripartum mental health outcomes during the COVID-19 pandemic

OBJECTIVE

This study examined associations between participation in virtual support groups for peripartum women and mental health outcomes at follow-up approximately 8 months later.

METHODS

This cross-sectional online survey study assessed 383 women from the Perinatal Experiences and COVID-19 Effects (PEACE) study. Initial participants (T1) were re-contacted (T2) and self-reported mental health symptoms of depression (CES-D), anxiety (GAD-7), and COVID-related grief were assessed at both time points. Participants reported involvement in virtual support groups and their perception of the effectiveness of social media in addressing feelings of loneliness.

RESULTS

The majority (62%) of respondents participated in a virtual support group, 99% of whom used informal social media-based groups (e.g. Facebook groups). At initial evaluation, virtual group participants reported higher levels of depressive symptoms (p=0.008) and COVID grief (p=0.004), but not higher levels of anxiety. Across the cohort, self-reported depressive, anxiety, and grief symptoms did not change significantly at follow-up in paired analysis, and virtual group participants did not demonstrate improvement in mental health symptoms.

CONCLUSIONS

Participation in virtual support groups did not seem to improve mental health outcomes for peripartum women, and most women found social media engagement minimally effective at addressing loneliness.

The predictive effect of mid-pregnancy sleep disorders on perinatal depression within women with or without depression in early pregnancy: A prospective cohort study

BACKGROUND

To investigate the relationship between depression in early pregnancy and sleep quality in mid-pregnancy, and explore whether sleep disorders independently predicts depression across the perinatal period within women with or without depression in early pregnancy.

METHODS

Data were collected at 7 time points from 12 weeks of pregnancy to 6 weeks postpartum. Multiple logistic regression and survival analysis were used to explore the relationship between sleep quality in mid-pregnancy and perinatal depression within women with or without depression in early pregnancy.

RESULTS

390 women were included. Women with depression in early pregnancy were more likely to have sleep disorders and perinatal depression. Women with sleep disorders had a higher risk of perinatal depression compared to women without sleep disorders in mid-pregnancy. Stratified analysis based on whether depressed at 12 weeks of pregnancy found that among women without depression, those with sleep disorders in mid-pregnancy were more likely to have subsequent perinatal depression and appeared earlier; whereas, among women with depression, mid-pregnancy sleep disorders was not a predictor of subsequent perinatal depression.

LIMITATION

High rates of missed visits may lead to sample bias, with depression and sleep quality being assessed by self-report.

CONCLUSIONS

Women with depression in early pregnancy are more likely to have sleep disorders in mid-pregnancy. There is a strong correlation between sleep quality in mid-pregnancy and perinatal depression among women without depression in early pregnancy. Routine screening and intervention for sleep disorders should be a priority in perinatal care to reduce the incidence of perinatal depression.

Comprehensive Sex-Stratified Genetic Analysis of 28 Blood Biomarkers and Depression Reveals a Significant Association between Depression and Low Levels of Total Protein in Females

Introduction

Major depression (MD) is more common amongst women than men, and MD episodes have been associated with fluctuations in reproductive hormones amongst women. To investigate biological underpinnings of heterogeneity in MD, the associations between depression, stratified by sex and including perinatal depression (PND), and blood biomarkers, using UK Biobank (UKB) data, were evaluated, and extended to include the association of depression with biomarker polygenic scores (PGS), generated as proxy for each biomarker.

Method

Using female (N = 39,761) and male (N = 38,821) UKB participants, lifetime MD and PND were tested for association with 28 blood biomarkers. A GWAS was conducted for each biomarker and genetic correlations with depression subgroups were estimated. Using independent data from the Australian Genetics of Depression Study, PGS were constructed for each biomarker, and tested for association with depression status (n [female cases/controls] = 9,006/6,442; n [male cases/controls] = 3,106/6,222). Regions of significant local genetic correlation between depression subgroups and biomarkers highlighted by the PGS analysis were identified.

Results

Depression in females was significantly associated with levels of twelve biomarkers, including total protein (OR = 0.90, CI = [0.86, 0.94], p = 3.9 × 10-6) and vitamin D (OR = 0.94, CI = [0.90, 0.97], p = 2.6 × 10-4), and PND with five biomarker levels, also including total protein (OR = 0.88, CI = [0.81, 0.96], p = 4.7 × 10-3). Depression in males was significantly associated with levels of eleven biomarkers. In the independent Australian Genetics of Depression Study, PGS analysis found significant associations for female depression and PND with total protein (female depression: OR = 0.93, CI = [0.88, 0.98], p = 3.6 × 10-3; PND: OR = 0.91, CI = [0.86, 0.96], p = 1.1 × 10-3), as well as with vitamin D (female depression: OR = 0.93, CI = [0.89, 0.97], p = 2.0 × 10-3; PND: OR = 0.92, CI = [0.87, 0.97], p = 1.4 × 10-3). The male depression sample did not report any significant results, and the point estimate of total protein (OR = 0.98, CI = [0.92-1.04], p = 4.7 × 10-1) did not indicate any association. Local genetic correlation analysis highlighted significant genetic correlation between PND and total protein, located in 5q13.3 (rG = 0.68, CI = [0.33, 1.0], p = 3.6 × 10-4).

Discussion and Conclusion

Multiple lines of evidence from genetic analysis highlight an association between total serum protein levels and depression in females. Further research involving prospective measurement of total protein and depressive symptoms is warranted.

Prospective analysis of factors associated with perinatal depression

BACKGROUND

Perinatal depression is a significant public health problem that has adverse effects on both mothers and infants. Little research has been conducted on how depressive symptoms change throughout the perinatal period, especially in the Middle East. This study examines changes in depressive symptoms from pregnancy to the postnatal period, and what explains these changes.

METHODS

This prospective study recruited 306 Omani women in the third trimester of pregnancy and followed them up two to eight weeks after delivery. The Edinburgh Postnatal Depression Scale (EPDS), with a cut-off of ≥12, was used to assess depressive symptoms in both the antenatal and postnatal periods. Independent t-tests, one-way ANOVA, Tukey's honestly significant difference test and Chi-square tests were used to analyse the data.

RESULTS

The prevalence of depressive symptoms was 27.12 % (n = 83) during late pregnancy and 29.30 % (n = 81) during the postnatal period. Four groups of women were identified based on the EPDS scores: 1) antenatal depression group (8.82 %; n = 27); 2) ante- and postnatal depression group (14.38 %; n = 44); 3) postnatal depression group (12.09 %; n = 37); and 4) non-depression group (54.90 %; n = 168). Depressive symptoms were associated with low birth weight babies (d = 0.50), which confirms the negative effects of depression on perinatal health outcomes. When compared to the non-depression group, the three depressed groups had higher antenatal Perceived Stress Scale (PSS) scores (ds > 0.52), while the non-depression group had higher antenatal and postnatal Maternity Social Support Scale (MSSS) scores (ds > 0.63), and better relationships with the mother-in-law antenatally (d= 0.57).

CONCLUSION

The present study of this Middle Eastern cohort shows that there were distinct groups of women experiencing perinatal depressive symptoms, influenced by various psychosocial and obstetric factors, which were comparable to those identified in more regularly studied populations. However, this study also identified other novel factors, such as the quality of family relationships. There is a need for additional research into the factors associated with these groups in order to develop appropriate interventions.

Long noncoding RNA NONHSAG045500 regulates serotonin transporter to ameliorate depressive-like behavior via the cAMP-PKA-CREB signaling pathway in a model of perinatal depression

OBJECTIVE

Perinatal depression (PND) is the most common complication of childbirth and negatively affects the mother. Long noncoding RNA (lncRNA) NONHSAG045500 inhibits the expression of 5-hydroxytryptamine (5-HT) transporter (i.e. serotonin transporter [SERT]) and produces an antidepressant effect. This study aimed to identify a link between the lncRNA NONHSAG045500 and the pathogenesis of PND.

METHODS

Female C57BL/6 J mice were divided into normal control group (control group, n = 15), chronic unpredictable stress (CUS) model group (PND group, n = 15), lncRNA NONHSAG045500-overexpressed group (LNC group, sublingual intravenous injection of NONHSAG045500 overexpression cells for 7 days, n = 15), and escitalopram treatment group (i.e. the selective serotonin reuptake inhibitor [SSRI] group, with escitalopram administered from the 10th day after pregnancy to the 10th day after delivery, n = 15). Control group mice were conceived normally, whereas, in the other groups, a CUS model was established before mice were conceived. Depressive-like behaviour was assessed via sucrose preference, forced swimming, and open-field tests. The expression levels of 5-HT, SERT, and cAMP-PKA-CREB pathway-related proteins in the prefrontal cortex were detected on the 10th day after delivery.

RESULTS

Mice in the PND group exhibited significant depressive-like behaviours compared with those in the control group, indicating that the PND model was successfully established. The expression of lncRNA NONHSAG045500 was markedly decreased in the PND group compared with that in the control group. After treatment, both LNC and SSRI groups showed a significant improvement in depression-like behaviour, and the expression of 5-HT in the prefrontal cortex was increased in these groups compared with that in the PND group. In addition, the LNC group displayed lower expression of SERT and higher expression of cAMP, PKA, and CREB when in comparison to PND group.

CONCLUSION

NONHSAG045500 mediates the development of PND mainly by activating the cAMP-PKA-CREB pathway, increasing the level of 5-HT, and decreasing the expression of SERT.

Association of serum folate levels during pregnancy and prenatal depression

OBJECTIVE

To evaluate the association between serum folate levels during pregnancy and prenatal depression and the extent to which obesity may modify this relationship.

METHODS

This secondary data analysis leveraged data from a previous study of pregnant Kaiser Permanente Northern California participants who completed a survey and provided a serum sample between 2011 and 2013. Serum folate was assessed using the Center for Disease Control's Total Folate Serum/Whole Blood Microbiological Assay Method. A score of 15 or greater on the Center for Epidemiologic Studies Depression Scale was defined as prenatal depression. We used Poisson regression to estimate risk of prenatal depression given prenatal serum folate status (low/medium tertiles vs. high tertile) in the full sample and in subsamples of women with pre-pregnancy body mass index in the (a) normal range and (b) overweight/obese range.

RESULTS

Of the sample, 13% had prenatal depression. Combined low/medium folate tertiles was associated with prenatal depression (adjusted relative risk [aRR] = 1.97, 95% confidence interval [CI]: 0.93-4.18), although results did not reach statistical significance. This relationship was stronger among women with overweight/obesity than women with normal weight (aRR: 2.61, 95% CI: 1.01-6.71 and aRR: 1.50, 95% CI: 0.34-6.66, respectively).

CONCLUSION

Results suggest an association between lower pregnancy folate levels and prenatal depression that may be stronger among women with overweight or obesity. Future studies need to clarify the temporal sequence of these associations.

Judicial interface with perinatal depression in India: an empirical analysis and thematic review of published judgments

In the absence of health law policies focused on perinatal depression (PND) in India, it has primarily remained a biomedical research matter instead of being understood from the human rights perspective. Also, the interplay between PND and the Indian justice delivery system remains unexplored. Hence, it is imperative to understand the medico-legal milieu of PND through the lens of judicial interface with the facet of PND. Most popular Indian electronic legal databases were used to identify the judgments pronounced by the Indian Courts where the PND quotient was involved. The text of the resultant judgments was individually read to evaluate if if the subject claim were affected by PND quotient to fit the inclusion criteria. Using the inductive and latent thematic approach, the different emergent themes from the subject claims of every single judgment were used for developing codes. Myriad themes emerged out of the analysis, which helped identify how PND vastly impacts the justice delivery system in varied types of cases in India. Obliviousness and lack of awareness in Indian judiciary regarding PND, and its consequences was largely observed. Human rights violations were discerned owing to absence of perinatal mental health (PMH) services. This policy gap, in turn, results in absence of data regarding women affected by PND and about administered treatment (if any) for managing PND, and reduced empathy by the law enforcement agencies. The resultant themes depict the urgent and multidimensional benefits of introducing policies for PMH services, which will help create awareness about the human rights dimension of PND amongst the law enforcement agencies including the Indian judiciary, and police.

Cascade training for scaling up care for perinatal depression in primary care in Nigeria

BACKGROUND

Task-shared care is a demonstrated approach for integrating mental health into maternal and child healthcare (MCH) services. Training and continued support for frontline providers is key to the success of task sharing initiatives. In most settings this is provided by mental health specialists. However, in resource constrained settings where specialists are in short supply, there is a need to explore alternative models for providing training and supportive supervision to frontline maternal care providers. This paper reports on the impact of a cascade training (train-the-trainers) approach in improving the knowledge and attitudes of primary healthcare workers (PHCW) to perinatal depression.

METHODS

Senior primary health care providers selected from across participating local government areas were trained to provide training to other PHCWs. The training sessions facilitated by these trainers were observed and rated for fidelity by specialist trainers, while the trainees provided their impression of and satisfaction with the training sessions using predesigned assessment forms. Training outcomes assessed included knowledge of depression (using mhGAP training questions and knowledge of depression questionnaire) and attitude towards providing care for depression (revised depression attitude questionnaire (R-DAQ)) measured pre and post training as well as six months after training.

RESULTS

Trainees were 198 PHCWs (94.4% female), who routinely provide MCH services in 28 selected primary care clinics and had between 6- and 34-years' experience. Training was provided by 11 trained trainers who were general physicians or senior nurses. Training sessions were rated high in fidelity and on training style. Sessions were rated excellent by 77.8% of the trainees with the trainers described as knowledgeable, effective and engaging. Knowledge of depression mean score improved from a pre-training level of 12.3 ± 3.5 to 15.4 ± 3.7, immediately post-training and 14.7 ± 3.2, six months post-training (both comparisons: p < 0.001). The proportion of PHCW workers endorsing statements indicative of positive attitudes on the professional confidence and the generalist perspective modules of the R-DAQ also increased with training.

CONCLUSION

Our findings suggest that cascade training can be an effective model for rapidly providing training and upskilling frontline PHCWs to deliver care for women with perinatal depression in resource limited settings.

TRIAL REGISTRATION

This study was retrospectively registered 03 December 2019. https://doi.org/10.1186/ISRCTN 94,230,307.

Disentangling the trajectories of maternal depressive symptoms and partnership problems in the transition to parenthood and their impact on child adjustment difficulties

Maternal perinatal depression (PND) and partnership problems have been identified to influence the development of later child adjustment difficulties. However, PND and partnership problems are closely linked which makes it difficult to draw conclusions about the exact transmission pathways. The aim of the present study was to investigate to what extent PND symptoms and partnership problems influence each other longitudinally and to examine the influence of their trajectories on child adjustment difficulties at the age of three. Analyses were based on publicly available data from the German family panel "pairfam". N = 354 mothers were surveyed on depressive symptoms and partnership problems annually from pregnancy (T0) until child age three (T4). Child adjustment difficulties were assessed at age three. Results of latent change score modeling showed that partnership problems predicted change in PND symptoms at T0 and T3 while PND symptoms did not predict change in partnership problems. Child adjustment difficulties at age three were predicted by PND symptoms, but not by partnership problems. Partnership problems predicted externalizing, but not internalizing symptoms. Results underline the effects of family factors for the development of child adjustment difficulties and emphasize the importance of early interventions from pregnancy onwards.

Prenatal and postpartum depression diagnosis in a large health system: prevalence and disparities

BACKGROUND/OBJECTIVES/INTRODUCTION

Depression during pregnancy or postpartum carries the same risks as general depression as well as additional risks specific to pregnancy, infant health and maternal well-being. The purpose of this study is to document the prevalence of depression symptoms and diagnosis during pregnancy and in the first 3 months postpartum among a cohort of women receiving prenatal care in a large health system. Secondarily, we examine variability in screening results and diagnosis by race, ethnicity, language, economic status and other maternal characteristics during pregnancy and postpartum.

PATIENTS/MATERIALS AND METHODS

A retrospective study with two cohorts of patients screened for depression during pregnancy and postpartum. Out of 7807 patients with at least three prenatal care visits and a delivery in 2016, 6725 were screened for depression (87%) at least once during pregnancy or postpartum. Another 259 were excluded because of missing race data. The final sample consisted of 6523 prenatal care patients who were screened for depression; 4914 were screened for depression in pregnancy, 4619 were screened postpartum (0-3 months). There were 3010 screened during both periods who are present in both the pregnancy and postpartum cohorts. Depression screening results are from the Patient Health Questionnaire (PHQ-9) and diagnosis of depression was measured using ICD codes. For patients screened more than once during either time period, the highest score is used for analysis.

RESULTS

Approximately, 11% of women had a positive depression screen as indicated by an elevated PHQ-9 score (>10) during pregnancy (11.3%) or postpartum (10.7%). Prevalence of depression diagnosis was similar in the two periods: 12.6% during pregnancy and 13.0% postpartum. A diagnosis of depression during pregnancy was most prevalent among women who were age 24 and younger (19.7%), single (20.5%), publicly insured (17.8%), multiracial (24.1%) or Native American (23.8%), and among women with a history of depression in the past year (58.9%). Among women with a positive depression screen, Black women were less than half as likely as White women to receive a diagnosis in adjusted models (AOR 0.40, CI: 0.23-0.71, p = .002). This difference was not present postpartum.

CONCLUSIONS

Depression symptoms and diagnoses differ by maternal characteristics during pregnancy with some groups at substantially higher risk. Efforts to examine disparities in screening and diagnosis are needed to identify reasons for variability in prenatal depression diagnosis between Black and White women.Key messagesWomen who were young, single, have public insurance, and women who identify as multiracial or non-Hispanic (NH) Native American were most likely to have a positive depression screen or a diagnosis for depression.After adjustment for confounders, NH Black women with a positive depression screen were about half as likely to have a diagnosis of depression during pregnancy as NH White women.Awareness of the differing prevalence of depression risk screening results, diagnoses and potential for variation in diagnosis may identify opportunities to improve equity in the delivery of essential mental health care to all patients.

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.

The Role of Peer Providers to Scale Up Psychological Treatments for Perinatal Populations Worldwide

PURPOSE OF REVIEW

Psychological treatments remain largely inaccessible to perinatal populations despite their robust effectiveness. This gap is partly due to the limited number of available treatment providers. In this review, we critically evaluate recent literature on task-sharing to peer providers and propose future directions.

RECENT FINDINGS

There is a growing evidence base demonstrating that peer providers can effectively deliver psychological treatments for perinatal populations, as well as engage in processes critical to quality assurance, such as measurement-based peer supervision. Findings have also highlighted some benefits of peers over licensed healthcare providers, such as enhanced collaborative relationships, reduced stigma, provision of social comparisons, and increased accessibility. Peer providers may be one solution to improve access to psychological treatments for perinatal populations. However, there is a need to address clinical, professional, and health-system level barriers to effectively leverage this cadre of treatment providers.

An Intervention to Improve Mental Health and HIV Care Engagement Among Perinatal Women in Malawi: A Pilot Randomized Controlled Trial

Perinatal depression (PND) is common and an important barrier to engagement in HIV care for women living with HIV (WLHIV). Accordingly, we adapted and enhanced The Friendship Bench, an evidence-based counseling intervention, for perinatal WLHIV. In a pilot randomized trial (NCT04143009), we evaluated the feasibility, acceptability, fidelity, and preliminary efficacy of the Enhanced Friendship Bench (EFB) intervention to improve PND and engagement in HIV care outcomes. Eighty pregnant WLHIV who screened positive for PND symptoms on the Self-Report Questionnaire (≥ 8) were enrolled, randomized 1:1 to EFB or usual care, and followed through 6 months postpartum. Overall, 100% of intervention participants were satisfied with the intervention and 93% found it beneficial to their overall health. Of 82 counseling sessions assessed for fidelity, 83% met or exceeded the fidelity threshold. At 6 months postpartum, intervention participants had improved depression remission (59% versus 36%, RD 23%, 95% CI 2%, 45%), retention in HIV care (82% versus 69%, RD 13%, -6%, 32%), and viral suppression (96% versus 90%, RD 7%, -7%, 20%) compared to usual care. Adverse events did not differ by arm. These results suggest that EFB intervention should be evaluated in a fully powered randomized trial to evaluate its efficacy to improve PND and engagement in HIV care outcomes for WLHIV.

Digital Tools in the Service of Peer and Social Support for Perinatal Mental Health

PURPOSE OF REVIEW

This study is critically evaluating the current status of digital tools for perinatal mental health, specifically focusing on how these tools can enhance peer and social support.

RECENT FINDINGS

Digital tools could be used to: (1) identify individuals in need and guide them towards appropriate human-supportive care; (2) autonomously train and allocate peers to aid women experiencing perinatal mental health challenges; and (3) amplify support from their natural social network. Despite clear evidence supporting the significance of social support for perinatal mental health, there is a dearth of studies on digital tools aimed at boosting such support, leaving a gap in the evidence. Findings underscore the necessity of developing digital initiatives that explicitly aim to augment social support as an active ingredient of therapeutic change for women's perinatal mental health. To establish clear evidence of digital tools' value in providing digital peer-support, further development and research are indispensable.

Antenatal depression across trimesters as a risk for postpartum depression and estimation of the fraction of postpartum depression attributable to antenatal depression: A systematic review and meta-analysis of cohort studies

OBJECTIVE

This meta-analysis aimed at estimating the prevalence of postpartum depression (PPD) at different postpartum timepoints in women with antenatal depression (AD) in the three trimesters. We also examined the association between AD and PPD, and estimated the population attributable fraction of PPD to AD.

METHODS

This systematic review and meta-analysis identified cohort studies that determined the prevalence of PPD in women who had AD, and those that examined the association between AD and PPD from PubMed, Embase, MEDLINE, CINAHL and PsycINFO. Articles were appraised using the modified Newcastle Ottawa Scale and data were analyzed using Comprehensive Meta-Analysis.

RESULTS

Eighty-eight (88) cohort studies with a combined sample size of 1,042,448 perinatal women contributed to the meta-analysis. About 37% pregnant women who had AD, later had PPD. Those with AD had four times higher odds of developing PPD (OR: 4.58; 95% CI = 3.52-5.96). The odds of having PPD were higher when AD was observed in the first or third trimester compared to the second trimester. About 12.8% of PPD cases were attributable to AD.

CONCLUSION

The findings should inform future clinical guidelines on the screening, the frequency of screening, and follow-up care in maternal-mental health.

Preferences for enhanced treatment options to address HIV care engagement among women living with HIV and perinatal depression in Malawi

BACKGROUND

Option B + offers lifelong ART to pregnant or breastfeeding mothers, but postpartum loss to HIV care, partially driven by perinatal depression (PND), threatens the impact of this policy. This study aims to understand women's and providers' preferences for developing a feasible intervention to address PND and support engagement in HIV care among women living with PND and HIV.

METHODS

We conducted a total of 6 focus group discussions (FGDs) involving 4 clinics in Lilongwe District from December 2018 through February 2019. We conducted 2 FGDs each among 3 stakeholder groups: clinical staff, prenatal women, and postnatal women. Perinatal participants were living with HIV and screened positively for PND using the validated Edinburgh Postnatal Depression Scale (EPDS). Clinical staff were nurses who were trained antiretroviral therapy (ART) providers. Interviewers led FGDs in Chichewa using a semi-structured guide. Data were analyzed using deductive and inductive coding in NVivo 12 software.

RESULTS

Women favored ART linkage services, but providers said they already offered such services, with mixed results. Individual counselling was universally supported. A perceived benefit of group counselling was peer support, but there were concerns among women regarding confidentiality and stigma. Women liked mobile appointment reminders but identified low phone ownership as a barrier. Participants recommended home visits as an additional care engagement strategy. Women consistently discussed the need for social support from family members and friends to address PND and support engagement in HIV care.

CONCLUSION

This study highlights the importance of peer encouragement to support perinatal HIV care engagement among women with HIV and PND. The results from this study can be used to support intervention development to increase HIV care engagement and improve long-term HIV outcomes in women with PND.

Perinatal depression screening in community pharmacy: Exploring pharmacists' roles, training and resource needs using content analysis

BACKGROUND

Perinatal depression (PND) screening is often recommended in primary care settings, which includes the community pharmacy setting. However, there is limited research exploring pharmacists' perspectives on their roles in screening for perinatal mental illness.

AIM

This study aimed to explore pharmacists' views of pharmacists' roles in PND screening, as well as training and resource needs for PND screening in community pharmacy settings.

METHOD

A questionnaire including three open-ended questions focusing on pharmacists' perspectives of their role in PND screening, their training, and resource needs in this area, was disseminated to pharmacists across Australia via professional organisations and social media. Each open-ended question was separately analysed by inductive content analysis. Subcategories were deductively mapped to the Theoretical Framework of Acceptability.

RESULTS

Responses (N = 149) from the first open-ended question about pharmacists' roles in PND screening resulted in three categories (PND screening in primary care settings will support the community, community pharmacy environment, and system and policy changes) and ten subcategories. Responses to question two on training needs (n = 148) were categorised as: training content, training length, and training delivery while responses about resource needs (n = 147) fell into three categories: adapting community pharmacy operating structures, pharmacist-specific resources, and consumer-specific resources.

CONCLUSION

While some pharmacists were accepting of a role in PND screening due to pharmacists' accessibility and positive relationships with consumers, others had concerns regarding whether PND screening was within pharmacists' scope of practice. Further training and resources are needed to facilitate pharmacists' roles in PND screening, referral and care.

Developing a text message intervention for fathers with partners experiencing perinatal depression or anxiety

BACKGROUND

Support from fathers to their partners is important to reduce distress in mothers during the perinatal period when conditions such as depression and anxiety can be common. The SMS4dads digital platform delivers text messages to fathers but has not previously addressed specific messages to fathers with partners who are experiencing perinatal depression and/or anxiety (PNDA).

AIM

To develop messages, in collaboration with experienced parents and clinicians, that are suitable for fathers whose partner is experiencing PNDA.

METHODS

Messages designed to enhance the quality of partner support for mothers experiencing PNDA were drafted by the SMS4dads team based on suggestions from mothers with lived experience of PNDA. Mothers and fathers with lived experience and expert clinicians rated the messages for importance and understanding. Clinicians additionally rated clinical relevance. Open response comments from parents and clinicians were collated for each message. Re-drafted messages were screened again and checked for literacy level.

RESULTS

Forty-one draft messages received a total of 170 ratings from 24 parents and 164 ratings from 32 clinicians. Over three quarters of parents and clinicians agreed or strongly agreed that messages were understandable (parents 85.6%; clinicians 77.4%), important (parents 86.3%; clinicians 86.6%), and 85.5% of clinicians rated the messages as clinically relevant. Comments from clinicians (n = 99) and parents (n = 46) were reviewed and guided message development. Thirty re-drafted messages were screened and 16 edited based on a second round of ratings and comments from parents and clinicians.

CONCLUSION

Messages for fathers whose partners are experiencing depression and anxiety can be developed and evaluated in collaboration with lived experience of parents and clinicians.

Exploring Heterogeneity in perinatal depression: a comprehensive review

Perinatal depression (PND) is a significant contributor to maternal morbidity globally. Recognized as a major cause of poor infant development, epidemiological and interventional research on it has increased over the last decade. Recently, studies have pointed out that PND is a heterogeneous condition, with variability in its phenotypes, rather than a homogenous latent entity and a concrete diagnosis, as previously conceptualized in psychometric literature and diagnostic systems. Therefore, it is pertinent that researchers recognize this to progress in elucidating its aetiology and developing efficacious interventions.This systematic review is conducted in accordance with the Meta-analysis of observational studies in epidemiology (MOOSE). It aims to provide an updated and comprehensive account of research on heterogeneity in phenotypes of PND and its implications in research, public health, and clinical practice. It provides a synthesis and quality assessment of studies reporting heterogeneity in PND using cutting-edge statistical techniques and machine learning algorithms. After reporting the phenotypes of PND, based on heterogeneous trajectories and symptom profiles, it also elucidates the risk factors associated with severe forms of PND, followed by robust evidence for adverse child outcomes. Furthermore, recommendations are made to improve public health and clinical practice in screening, diagnosis, and treatment of PND.

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.

Effects of M-DEPTH Model of Depression Care on Maternal HIV Viral Suppression and Adherence to the PMTCT Care Continuum Among HIV-Infected Pregnant Women in Uganda: Results from a Cluster Randomized Controlled Trial at Pregnancy Completion

Perinatal depression has been shown to impede adherence to antiretroviral therapy (ART) and the prevention of mother-to-child transmission (PMTCT) care continuum; therefore, treating perinatal depression may result in increased viral suppression and PMTCT adherence. We examined the effects of the M-DEPTH (Maternal Depression Treatment in HIV) depression care model (including antidepressants and individual Problem Solving Therapy) on depression, maternal viral suppression and adherence to PMTCT care processes in an ongoing cluster-randomized controlled trial of 391 HIV-infected pregnant women (200 usual care; 191 intervention) with at least mild depressive symptoms enrolled across 8 antenatal care clinics in Uganda. At baseline, 68.3% had clinical depression and 41.7% had detectable HIV viral load. Adjusted repeated-measures multivariable regression models found that the intervention group was nearly 80% less likely to be clinically depressed [Adjusted OR (95% CI) 0.22 (0.05, 0.89)] at the 2-month post-pregnancy assessment, compared to the control group. However, the intervention and control groups did not differ meaningfully on maternal viral suppression, ART adherence, and other PMTCT care processes and outcomes. In this sample of women who were mostly virally suppressed and ART adherent at baseline, the depression care model had a strong effect on depression alleviation, but no downstream effects on viral suppression or other PMTCT care processes.Trial Registration NIH Clinical Trial Registry NCT03892915 (clinicaltrials.gov).

Perinatal Depression: A Review and an Update

Perinatal depression is a common psychiatric condition that has negative effects on pregnancy and infant outcomes. Screening for the condition is relatively easy and should be done routinely in all medical care of the pregnant and postpartum woman and her infant. The risk-benefit analysis favors the use of antidepressant medications during pregnancy and lactation compared with the risk of untreated maternal depression. Other, nonpharmacological treatments will be discussed as well as new treatments, including a new class of medications that act on the inhibitory GABAergic neurotransmitter system.

Positive affect improves a transdiagnostic model of perinatal depression symptoms

INTRODUCTION

Accurate measurement of perinatal depression is vital. We aimed to 1) test whether a factor that measured positive affect (PA) bettered a transdiagnostic model of depression symptoms and 2) replicate the model in a second sample.

METHODS

We conducted secondary analyses from two samples (n's = 657 and 142) of women in treatment at perinatal psychiatric clinics. Data were derived from items from seven commonly used measures. We compared fit indices from our original factor model-one general and six specific factors derived from the Research Domain Criteria (Loss, Potential Threat, Frustrative Nonreward, and Sleep-Wakefulness) and depression literatures (Somatic and Coping)-to our novel factor model with a PA factor. The PA factor was created by recategorizing items that measured affective states with a positive valence into a new factor. Sample 1 data were split into six perinatal periods.

RESULTS

In both samples, the addition of a PA factor improved model fit. At least partial metric invariance was found between perinatal periods, with the exception of trimester 3 - postpartum period 1.

LIMITATIONS

Our measures did not operationalize PA in the same way as in the positive valence system in RDoC and we were unable to perform longitudinal analyses on our cross-validation sample.

CONCLUSIONS

Clinicians and researchers are encouraged to consider these findings as a template for understanding symptoms of depression in perinatal patients, which can be used to guide treatment planning and the development of more effective screening, prevention, and intervention tools to prevent deleterious outcomes.

Technology-assisted cognitive-behavior therapy delivered by peers versus standard cognitive behavior therapy delivered by community health workers for perinatal depression: study protocol of a cluster randomized controlled non-inferiority trial

BACKGROUND

The lack of trained mental health professionals is a key barrier to scale-up of evidence-based psychological interventions in low and middle-income countries. We have developed an app that allows a peer with no prior experience of health-care delivery to deliver the cognitive therapy-based intervention for perinatal depression, the Thinking Healthy Programme (THP). This trial aims to assess the effectiveness and cost-effectiveness of this Technology-assisted peer-delivered THP versus standard face-to-face Thinking Healthy Programme delivered by trained health workers.

METHODS

We will employ a non-inferiority stratified cluster randomized controlled trial design comparing the two formats of intervention delivery. A total of 980 women in the second or third trimester of pregnancy with a diagnosis of Major Depressive Episode, evaluated with the Structured Clinical Interview for DSM-V Disorders (SCID), will be recruited into the trial. The unit of randomization will be 70 village clusters randomly allocated in a 1:1 ratio to the intervention and control arms. The primary outcome is defined as remission from major depressive episode at 3 months postnatal measured with the SCID. Data will also be collected on symptoms of anxiety, disability, quality of life, service use and costs, and infant-related outcomes such as exclusive breastfeeding and immunization rates. Data will be collected on the primary outcome and selected secondary outcomes (depression and anxiety scores, exclusive breastfeeding) at 6 months postnatal to evaluate if the improvements are sustained in the longer-term. We are especially interested in sustained improvement (recovery) from major depressive episode.

DISCUSSION

This trial will evaluate the effectiveness and cost-effectiveness of a technology-assisted peer-delivered cognitive behavioral therapy-based intervention in rural Pakistan. If shown to be effective, the novel delivery format could play a role in reducing the treatment gap for perinatal depression and other common mental disorders in LMIC.

TRIAL REGISTRATION

The trial was registered at Clinicaltrials.gov (NCT05353491) on 29 April 2022.

Supporting optimal dietary behaviors in women with perinatal depression: A qualitative exploration of experiences, practices, and challenges

BACKGROUND

Women with perinatal depression (PD) are at high risk for unhealthy dietary behaviors and suboptimal child feeding practices. Despite evidence supporting the importance of healthful nutrition-related behaviors during and after pregnancy, few behavioral nutrition interventions for women with PD have been developed. The objectives of this study were to identify nutrition-related challenges and needs among women with PD and to elucidate the role that feeding plays in mother-infant interaction, to inform the development of nutrition interventions.

METHODS

Using a qualitative study design, in-depth interviews were conducted with 18 mothers with a history of PD and 10 interdisciplinary healthcare providers with expertise in PD. Data were thematically analyzed using a hybrid inductive and deductive coding approach.

RESULTS

Mean age of mothers was 31 ± 6 years, 56% identified as non-Hispanic White, and 33% identified as Black/African American. Eighty percent of healthcare providers practiced for more than five years. Six themes were identified: (a) Time scarcity mindset; (b) Importance of social support; (c) Unrealistic expectations of motherhood; (d) Mom as the last priority; (e) Postpartum body changes and shape ideals; and (f) Contentment associated with infant and young child feeding.

CONCLUSION

Women with PD have several needs pertaining to their nutrition and that of their children. The findings from this study illustrate key considerations and recommendations for addressing these needs.

Predicting prenatal depression and assessing model bias using machine learning models

Perinatal depression (PND) is one of the most common medical complications during pregnancy and postpartum period, affecting 10-20% of pregnant individuals. Black and Latina women have higher rates of PND, yet they are less likely to be diagnosed and receive treatment. Machine learning (ML) models based on Electronic Medical Records (EMRs) have been effective in predicting postpartum depression in middle-class White women but have rarely included sufficient proportions of racial and ethnic minorities, which contributed to biases in ML models for minority women. Our goal is to determine whether ML models could serve to predict depression in early pregnancy in racial/ethnic minority women by leveraging EMR data. We extracted EMRs from a hospital in a large urban city that mostly served low-income Black and Hispanic women (N=5,875) in the U.S. Depressive symptom severity was assessed from a self-reported questionnaire, PHQ-9. We investigated multiple ML classifiers, used Shapley Additive Explanations (SHAP) for model interpretation, and determined model prediction bias with two metrics, Disparate Impact, and Equal Opportunity Difference. While ML model (Elastic Net) performance was low (ROCAUC=0.67), we identified well-known factors associated with PND, such as unplanned pregnancy and being single, as well as underexplored factors, such as self-report pain levels, lower levels of prenatal vitamin supplement intake, asthma, carrying a male fetus, and lower platelet levels blood. Our findings showed that despite being based on a sample mostly composed of 75% low-income minority women (54% Black and 27% Latina), the model performance was lower for these communities. In conclusion, ML models based on EMRs could moderately predict depression in early pregnancy, but their performance is biased against low-income minority women.

The association between preconception cannabis use and depression and anxiety during pregnancy

OBJECTIVE

Cannabis use among individuals of reproductive age has increased with cannabis legalization and heightened stress during the COVID-19 pandemic. Our study provides data on preconception cannabis use and cannabis use disorder (CUD) during the pandemic and models the association between preconception cannabis use and depression and anxiety during pregnancy.

METHODS

Data on substance use and depression and anxiety symptoms were collected from questionnaires and the Structured Clinical Interview for DSM-5 (SCID-5) from pregnant individuals in Oregon in 2019-2022. Linear regression was used to model the association between the frequency of preconception cannabis use and scores on the Center for Epidemiological Studies of Depression-Revised (CESD-R) and Beck Anxiety Inventory (BAI).

RESULTS

The prevalence of preconception cannabis use was 27.8% among 227 study participants. CUD was diagnosed in 19% of cannabis users, or 5.3% of the overall sample. Daily cannabis use, compared to rare/never use, was associated with increases in CESD-R (β = 6.22, p 0.029) and BAI (β = 4.71, p 0.045) scores.

CONCLUSIONS

Cannabis use and CUD are common among individuals of reproductive age. Given the association between preconception cannabis use and depression and anxiety during pregnancy, more attention is needed on screening and counseling of cannabis use among people of reproductive age.

Perinatal depression during the fourth wave of the COVID-19 outbreak in a single prenatal clinic in Southern Italy: The role of loneliness, anxiety, and maternal support

Background

The current study aimed at assessing the levels of perinatal depression (i.e., both antenatal and postnatal) during the fourth wave of the COVID-19 outbreak in a group of Italian women, as well as to evaluate the role of loneliness, anxiety, and lack of maternal support in cumulatively predicting perinatal depression.

Methods

A cross-sectional study was conducted with 200 Italian women recruited during a peak of the COVID-19 pandemic in Italy (i.e., from September to December 2021) from a single prenatal clinic in Southern Italy. A non-parametric binomial test was conducted to assess whether the perinatal depression frequencies of the current sample differed from those found in a pre-Covid reference group. Additionally, hierarchical multiple linear regression analyses assessing whether loneliness, anxiety, and maternal support affected women's perinatal depression were also conducted.

Results

The general prevalence of perinatal depression was significantly higher in participants recruited during the fourth wave of the COVID-19 pandemic compared to the pre-Covid reference group (29% vs. 9.2%). However, results showed that, contrary to postnatal depression (18.2% vs. 19.9%), only the prevalence of antenatal depression was significantly higher compared to the pre-Covid reference group (39.6% vs. 6.4%). Furthermore, loneliness and anxiety, but not maternal support, were associated with higher levels of PD.

Limitations

Limitations concerned the cross-sectional nature of the study and the relatively small sample size.

Conclusions

This study sheds light on the need to address perinatal mental health of women during major stressful events, such as the COVID-19 pandemic.

Impact of Transfer of Maternal Care for Fetal Anomalies on Maternal Depression and Anxiety Screening: A Prospective Cohort at a Tertiary Care Center

INTRODUCTION

Perinatal depression and anxiety are major causes of maternal morbidity, and are more common in high-risk pregnancies compared to low-risk pregnancies. This study used validated screening tools to assess the prevalence of depression and anxiety symptoms in pregnant patients who transferred their obstetric care to a specialized fetal center for fetal anomaly.

METHODS

This is a prospective cohort of patients with a fetal anomaly prompting transfer of obstetric care to Texas Children's Hospital Fetal Center between January 2021 and February 2022. The primary outcome was a self-assessed Edinburgh Postnatal Depression Scale score of 13 or higher, either antepartum or postpartum ("ever-positive EPDS"). Secondary outcomes included self-assessed Perinatal Anxiety Screening Scale (PASS) scores of 21 or higher ("ever-positive PASS"), obstetric outcomes, and neonatal outcomes. A frequentist analysis was performed.

RESULTS

Of 149 women who transferred to Texas Children's Hospital during the study period, 94 enrolled in this study. Twenty-six percent of women had an ever-positive EPDS; 20% of patients had an ever-positive PASS. Patients were more likely to have an ever-positive EPDS if they were single (46% compared to 20%, p = 0.025). Women who had an ever-positive EPDS were more likely to be referred to psychiatry (46% compared to 14%, p = 0.004) and psychotherapy (29% compared to 1%, p < 0.001). Surprisingly, patients were more likely to have an ever-positive PASS if they reported good social support (p = 0.03). Antepartum EPDS and PASS scores had no relationship with postpartum EPDS scores.

CONCLUSION

Women who transfer care to a tertiary setting have positive EPDS scores at double the rate of the general population, but tend to experience this either antepartum or postpartum (not both). Fetal centers should be prepared to screen for mental health symptoms before and after delivery and provide appropriate referral or treatment.

Effectiveness of digital psychological interventions in reducing perinatal depression: a systematic review of meta-analyses

Digital psychological interventions have been widely used clinically in recent years, but the methodological quality and quality of evidence of related studies are unclear, thus interfering with the translation of practice outcomes and the application of clinical decisions. We searched for meta-analyses of randomized controlled trials in the PubMed, Web of Science, Embase, Cochrane Library, JBI Database, CINAHL, and PsycINFO databases as well as some databases containing gray literature up to 27 April 2022 using a combination of keywords. After two researchers independently screened and extracted data from the literature, the methodological quality of the included literature was evaluated by the AMSTAR 2 scale, and the evidence quality of the outcome index was graded by the Grading of Recommendations, Assessment, Development, and Evaluation system. A total of 12 meta-analyses reporting the positive impact of digital psychological interventions in the prevention and/or treatment of depressive symptoms in perinatal women were included, but the methodological quality and evidence level of the included studies were low. Digital psychological interventions are effective in reducing perinatal depression, but the methodological quality and reliability of outcome indicators are mostly low. Improving study designs, using higher-quality clinical evidence, conducting systematic evaluation studies strictly following the procedures, and standardizing the reporting of study results are recommended.

Antenatal mobile-delivered mindfulness-based intervention to reduce perinatal depression risk and improve obstetric and neonatal outcomes: A randomized controlled trial

OBJECTIVES

One in five mothers will experience perinatal depression (PND) during pregnancy and within their first year following childbirth. Current evidence suggests the short-term efficacy of Mindfulness-based interventions (MBI) for perinatal women, but the extent to which this positive impact remains the early postpartum period is unclear. This study investigated the short- and maintenance efficacy of a mobile-delivered four-immeasurable MBI on PND, and obstetric and neonatal outcomes.

METHODS

Seventy-five adult pregnant women suffering from heightened distress were randomized to receive a mobile-delivered four-immeasurable MBI (n = 38) or a web-based perinatal education program (n = 37). PND was measured by Edinburgh Postnatal Depression Scale at baseline, post-intervention, 37th-week gestation, and 4-6 weeks postpartum. Outcomes also included obstetric and neonatal outcomes, trait mindfulness, self-compassion, and positive affect.

RESULTS

Participants reported an average age of 30.6 (SD = 3.1) years with a mean gestational age of 18.8 (SD = 4.6) weeks. In intention-to-treat analyses, women in the mindfulness group showed a significantly greater reduction in depression from baseline to post-intervention (adjusted mean change difference [β] = -3.9; 95%CI = [-6.05, -1.81]; d = -0.6), and the reduction sustained until 4-6 weeks postpartum (β = -6.3; 95%CI = [-8.43, -4.12]; d = -1.0), compared with control. They had a significantly reduced risk of emergent cesarean section (relative risk = 0.5) and gave birth to infants with higher Apgar scores (β = 0.6;p = .03; d = 0.7). Depression reduction before giving birth significantly mediated the intervention effect on lowering the emergency cesarean risk.

CONCLUSIONS

With a reasonably low dropout rate (13.2 %), the mobile-delivered MBI can be an acceptable and effective intervention for reducing depression throughout pregnancy and postpartum. Our study also suggests the potential benefits of early prevention for mitigating emergent cesarean section risk and enhancing neonatal health.

An economic evaluation of targeted case-finding strategies for identifying postnatal depression: A model-based analysis comparing common case-finding instruments

BACKGROUND

Half of women with postnatal depression (PND) are not identified in routine care. We aimed to estimate the cost-effectiveness of PND case-finding in women with risk factors for PND.

METHODS

A decision tree was developed to represent the one-year costs and health outcomes associated with case-finding and treatment for PND. The sensitivity and specificity of case-finding instruments, and prevalence and severity of PND, for women with ≥1 PND risk factor were estimated from a cohort of postnatal women. Risk factors were history of anxiety/depression, age < 20 years, and adverse life events. Other model parameters were derived from published literature and expert consultation. Case-finding for high-risk women only was compared with no case-finding and universal case-finding.

RESULTS

More than half of the cohort had one or more PND risk factor (57.8 %; 95 % CI 52.7 %-62.7 %). The most cost-effective case-finding strategy was the Edinburgh Postnatal Depression Scale with a cut-off of ≥10 (EPDS-10). Among high-risk women, there is a high probability that EPDS-10 case-finding for PND is cost-effective compared to no case-finding (78.5 % at a threshold of £20,000/QALY), with an ICER of £8146/QALY gained. Universal case-finding is even more cost-effective at £2945/QALY gained (versus no case-finding). There is a greater health improvement with universal rather than targeted case-finding.

LIMITATIONS

The model includes costs and health benefits for mothers in the first year postpartum, the broader (e.g. families, societal) and long-term impacts are also important.

CONCLUSIONS

Universal PND case-finding is more cost-effective than targeted case-finding which itself is more cost-effective than not case-finding.

Intrahepatic cholestasis of pregnancy worsening perinatal depressive tendency: A follow-up study from the second trimester to the sixth week postpartum

The total bile acid (TBA) is usually used to diagnose intrahepatic cholestasis of pregnancy (ICP) as a common clinical index. Recently many research reports on the microbiota-gut-brain axis (MGB axis) suggest that bile acids have an influence on human mental illnesses such as anxiety and depression, linked closely to intestinal microbial population. However, there is still a lack of clinical data to support intrinsic relationships about human cases. In this study, we conducted a follow-up study of 25 ICP and 98 healthy pregnant women to investigate the influence of ICP disease on perinatal depression. To further explore the effect of TBA concentration, we reviewed data of another 41 ICP women then added their cross-sectional data. The results showed that ICP disease increased mental scale scores but a conventional efficient treatment by using ursodeoxycholic acid (UDCA) could not decrease scores, suggesting intrahepatic cholestasis might make some key bile acids not to be processed by gut microbiota. UDCA could not replace the function of gut microbiota for easing depression and the change of bile acid composition in intestines worsened perinatal depressive tendency through the MGB axis.

Barriers and facilitators of psychological help-seeking behaviors for perinatal women with depressive symptoms: A qualitative systematic review based on the Consolidated Framework for Implementation Research

OBJECTIVE

To identify barriers and facilitators related to psychological help-seeking behaviors of perinatal depression from all related stakeholders (e.g., perinatal women, family members, mental health care providers, and policymakers).

DESIGN

A literature search of six English-language databases (PubMed, Web of Science, Embase, PsycINFO, the Cochrane Library, CINAHL) and three Chinese-language databases (China National Knowledge Infrastructure, Wan Fang, Chinese Biomedical Literature Databases). Studies published in English or Chinese using qualitative or mixed methods to explore the psychological help-seeking behaviors of women with perinatal depression were included. Data extraction was synthesized for common themes based on the Consolidated Framework for Implementation Research. The Joanna Briggs Institute Qualitative Assessment and Review Instrument was used to appraise methodologic quality.

PARTICIPANTS AND SETTINGS

Perinatal women with depression, mental health care providers (e.g., pediatricians/nurses, social workers, nurse-midwives, perinatal psychiatrists, community health workers, and administrators), partners and informal caregivers (e.g., community birth attendants, elderly mothers, and men of reproductive age) based in high, middle and low income countries.

FINDINGS

Forty-three articles were included in this review and presented according to the Consolidated Framework for Implementation Research domains (in parentheses). The most common barriers to help seeking were stigma (individual characteristics), misconceptions (individual characteristics), cultural beliefs (inner setting), and lack of social support (outer setting). The most common facilitators were providing adequate support (outer setting) and perinatal health care professional training on how to detect, manage and discuss depression; establishing supportive relationships with mental health care providers; and eroding stigma (all three implementation processes).

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

This systematic review could serve as a reference framework for health authorities to develop diverse strategies for improving the psychological help-seeking behaviors of women with perinatal depression. More high-quality studies focused on the Consolidated Framework for Implementation Research characteristics of available interventions, and implementation processes are needed in future research.

Relationship between antenatal sleep quality and depression in perinatal women: A comprehensive meta-analysis of observational studies

BACKGROUND

Perinatal depression is a global mental health problem. Studies have suggested that perinatal depression is related to poor sleep quality during pregnancy. However, evidence on the influence and mechanism of sleep quality on the risk of developing perinatal depression remains limited and inconclusive.

METHODS

A systematic review was conducted in PubMed, Web of Science, Embase, CINAHI and Cochrane Library for relevant original quantitative studies published in English. A hand search of the reference list of relevant studies was also performed. Meta-analysis was performed using RevMan software and a random-effects model. Potential heterogeneity source was explored by subgroup and sensitivity analyses, and potential publication bias was tested using funnel plots and Begg's test.

RESULTS

A total of ten studies involving 39,574 participants were included in our meta-analysis. Overall, women who experienced poor sleep quality during pregnancy were at a significantly higher risk of developing depression, with antenatal depression 3.72 times higher, postpartum depression 2.71 times higher, and perinatal depression 3.46 times higher, compared to those did not experience poor sleep quality.

LIMITATIONS

Different measuring tools and unobserved confounding factors may make some bias in our result. What's more, not all included studies were initially designed to assess the association between antenatal sleep quality and the risk of developing perinatal depression.

CONCLUSION

Our meta-analysis found that antenatal sleep quality was negatively associated with the risk for perinatal depression. Our findings highlight the importance of improving sleep quality during pregnancy for mental health among perinatal women.

Adaptation and integration of the thinking healthy programme into pregnancy schools in Istanbul, Turkey

BACKGROUND

Perinatal mental health is a major public health concern. In Turkey, public hospitals operate pregnancy schools which provides an opportunity to integrate an evidence-based Thinking Healthy Programme (THP) for perinatal depression. The aim of this study is to adapt the THP for universal use in the group setting and to understand its acceptability and feasibility for integration into the existing antenatal care programme for both face-to-face and online delivery.

METHODS

Following an expert-led adaptation process using the Bernal Framework, field testing was conducted on a group of women and facilitators followed by in-depth interviews (n:8) and group discussions (n = 13). Data were analysed using Thematic Framework Analysis.

RESULTS

Minor but significant adaptations were made to the individually delivered THP for use in the universal group pregnancy schools. Initial findings indicate that the THP-group version was acceptable to its target population and could be integrated into the antenatal care plan for delivery during face-to-face and online group classes.

CONCLUSION

THP is transferable to the Turkish cultural and healthcare context. The THP-group version has the potential to add value to Turkey's existing perinatal healthcare programme.

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.