Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: systematic review and meta-analysis of individual participant data

Toward early screening for early management of postnatal depression? Relationships between clinical signs present in the infant and underlying maternal postnatal depression

OBJECTIVE

The objective was to screen for maternal postnatal depression (MPD) by administering the Edinburgh Postnatal Depression Scale (EPDS) during the first "peak" of incidence of MPD (i. e., between the 6th and the 10th week of the infant's life) and to therefore explore the relationship between mothers' EPDS scores and early clinical signs in the infant. We wanted to evaluate the relevance of a diagnostic tool that combines the EPDS with questions focused on clinical signs displayed by the infant.

PARTICIPANTS

Seven hundred and sixty seven mothers aged 18-46 (M = 30.5, SD = 4.9) participated in the study, representing 49.2% of all women who delivered in the study area during the research inclusion period. Main outcome measures: Sociodemographic data were collected. MPD was measured by EPDS (score ≥ 12). The presence of clinical signs in the infant was investigated by closed (i.e., yes or no) questions inquiring into whether the infant has or has had difficulty sleeping, feeding difficulties, crying difficult to calm, or other difficulties.

RESULTS

The prevalence of MPD in our sample was 22.16%. The relationships between MPD and early clinical signs present in the infant, i.e., sleep difficulties, feeding problems, crying difficult to calm (p < 0.001), and other problems (p = 0.004), were very significant, as confirmed by a chi-square test of independence. In particular, sleep difficulties (OR = 2.05, CI 1.41-2.99) and feeding difficulties (OR = 1.59, CI 1.10-2.30) seemed to predict MPD.

CONCLUSIONS

Early clinical signs in the infant can alert the medical team to potential psychological suffering on the part of the mother, at which time the EPDS can be proposed. The use of this method has the potential to improve screening for, and therefore early management of, MPD.

Postpartum Depression-Identifying Risk and Access to Intervention

PURPOSE OF REVIEW

As maternal mortality climbs in the USA with mental health conditions driving these preventable deaths, the field of reproductive psychiatry must shift towards identification of women and other birthing individuals at risk and facilitating access. This review brings together recent studies regarding risk of perinatal depression and highlights important comorbidities that place individuals at higher vulnerability to poor perinatal outcomes.

RECENT FINDINGS

Recent research suggests that identifying risk for perinatal depression including historical diagnoses of depression, anxiety, trauma, and comorbid substance use and intimate partner violence may move the field to focus on preventive care in peripartum populations. Emerging data shows stark health inequities in racial and ethnic minority populations historically marginalized by the health system and in other vulnerable groups such as LGBTQ+ individuals and those with severe mental illness. Innovative models of care using systems-level approaches can provide opportunities for identification and risk analyses of vulnerable peripartum patients and facilitate access to therapeutic or preventive interventions. Utilizing intergenerational approaches and leveraging multidisciplinary teams that thoughtfully target high-risk women and other birthing individuals could promote significant changes to population-level care in maternal health.

The Value of HPA Axis Hormones as Biomarkers for Screening and Early Diagnosis of Postpartum Depression: Updated Information About Methodology

Because of the high prevalence of postpartum depression (PPD) and the suffering involved, early diagnosis is urgent; however, current screening tools and diagnosis are inadequate. In addition to conventional methods such as the Edinburgh Postnatal Depression Scale and clinical interviews, several hormones in the hypothalamic-pituitary-adrenal (HPA) axis, such as corticotrophin-releasing hormone, adrenocorticotropic hormone, and cortisol, have been considered because of their critical roles in stress regulation in the mothers. The study designs are complicated, however, and so the effectiveness of these hormones as biomarkers for PPD is still controversial. Such inconsistency may have resulted from the variation in methodology between studies. The methodology problems in the investigation of PPD and HPA axis hormones have not been reported extensively. We therefore sought to summarize the methodological problems of studies published in the past decade, including the strengths and weaknesses of the examinations and the technological difficulties involved. Our findings suggest that (a) suitable samples and appropriate detection methods would reduce heterogeneity among trials; (b) the cutoff value of the scale test should be carefully selected for determining the performance of biomarker tests; (c) evaluation methods and criteria should be chosen with consideration of the tools feasible for use in local hospitals and population; and (d) the cost of diagnosis should be reduced. We hope that these findings provide insight for future investigations of HPA axis hormones as biomarkers for screening and early diagnosis of PPD.

The factor structure of the Edinburgh Postnatal Depression Scale among perinatal high-risk and community samples in London

Timely and accurate detection of perinatal mental health problems is essential for the wellbeing of both mother and child. Growing evidence has suggested that the Edinburgh Postnatal Depression Scale (EPDS) is not a unidimensional measure of perinatal depression, but can be used to screen for anxiety disorders. We aimed to assess the factor structure of the EPDS in 3 different groups of women: n = 266 pregnant women at high-risk of depression ("Perinatal Stress Study"), n = 471 pregnant women from a community sample, and n = 637 early postnatal women from a community sample ("developing Human Connectome Project"). Exploratory factor analysis (40% of each sample) and confirmatory factor analysis (60% of each sample) were performed. The relationship between EPDS scores and history of mental health concerns was investigated. Results suggested that a 3-factor model (depression, anxiety, and anhedonia) is the most appropriate across groups. The anxiety subscale (EPDS-3A) emerged consistently and was related to maternal history of anxiety disorders in the prenatal sample (W = 6861, p < 0.001). EPDS total score was related to history of mental health problems in both the prenatal (W = 12,185, p < 0.001) and postnatal samples (W = 30,044, p < 0.001). In both high-risk and community samples in the perinatal period, the EPDS appears to consist of depression, anxiety, and anhedonia subscales. A better understanding of the multifactorial structure of the EPDS can inform diagnosis and management of women in the prenatal and postnatal period. Further research is required to validate the EPDS-3A as a screening tool for anxiety.

The quality of father-child feeding interactions mediates the effect of maternal depression on children's psychopathological symptoms

Research has shown that Postnatal maternal depression (PND) is associated with children's emotional and behavioral problems during infancy, but the possible effect of father-child relationship quality on this association is yet to be thoroughly investigated. We recruited 401 families (802 parents; 401 children) via mental health clinics in Central Italy. We divided families into two groups: Group 1 included families with mothers with PND; Group 2 included families with mothers without PND (control group). The assessment took place at T1 (18 months of age of children) and T2 (36 months of age of children): postnatal maternal depression was measured through the Edinburgh Postnatal Depression Scale (EPDS); parent-child relationship quality was assessed through the Scale for the Assessment of Feeding Interactions (SVIA); and the child emotional-behavioral functioning was evaluated with the Child-Behavior-Checklist (CBCL). Compared to the control group, the children of the groups where mothers had PND, showed overall higher scores (i.e., more maladaptive) on the CBCL. A direct effect of postnatal maternal depression on children's emotional-behavioral functioning was found, both at T1 and at T2. A mediation effect of father-child relationship quality between postnatal maternal depression and child outcomes was also found. These results could inform prevention and intervention programs in families with mothers with PND.

Alcohol consumption habits and associations with anxiety or depressive symptoms postpartum in women with high socioeconomic status in Sweden

Postpar tum depression and anxiety are common among new mothers. It is well-established that in the general population alcohol use is associated with depression and anxiety. Linking alcohol consumption to symptoms of postpartum depression (PPDS) or postpartum anxiety (PPAS) is presently less established. This study aims to determine if alcohol consumption pre-pregnancy, 6 weeks postpartum, 6 months postpartum, or changes in alcohol consumption are associated with PPDS or PPAS. Longitudinal data on 3849 women from a Swedish perinatal cohort were analyzed using logistic regression analyses for associations between alcohol consumption and symptoms of anxiety or depression, as assessed with the Edinburgh Postnatal Depression Scale. There was no association between pre-pregnancy drinking habits and PPDS (p = 0.588, n = 2479) or PPAS (p = 0.942; n = 2449) at 6 weeks postpartum. Similarly, no associations were observed between concurrent drinking habits at 6 weeks postpartum and PPAS (p = 0.070, n = 3626), 6 months postpartum and PPDS (0.647, n = 3461) or PPAS (p = 0.700, n = 3431). However, there was an association between drinking habits at 6 weeks postpartum and concurrent PPDS (p = 0.047, n = 3659). In conclusion, robust associations were not found between postpartum alcohol consumption and mood symptoms. This lack of association between poor mental health and risk behaviors in new mothers could be interpreted as a result of long-term policy work and high participation in Swedish maternity care. Future studies need to address these research questions in more diverse socio-cultural contexts.

Evaluating adherence to American College of Obstetricians and Gynecologists guidelines at the first obstetric visit

Objective:

This is a prospective observational cohort study with the objective of assessing adherence to the American College of Obstetricians and Gynecologists guidelines regarding the first prenatal visit and determining what patient and provider factors are associated with high adherence in a faculty obstetric clinic at an academic medical center.

Methods:

The American College of Obstetricians and Gynecologists guidelines recommend addressing 72 topics early in prenatal care. A research assistant observed the first prenatal encounter and noted which topics were discussed during the visit. Patient and clinic characteristics were also collected. The primary outcome was the percentage of topics covered at each visit. After analyzing all encounters, patient encounters that scored above the median score were compared with encounters scoring below the median using bivariate comparisons with respect to patient and clinic characteristics. A multivariable Poisson regression model with robust error variance was performed on characteristics with a p value of ⩽0.2.

Results:

Fifty-one patient encounters met inclusion criteria and the median score for topics covered was 74%. Patients with chronic disease were more likely to have a higher percentage of topics covered (odds ratio 1.67, 95% confidence interval: 0.91–3.09). Patients who completed a prenatal questionnaire were also more likely to have a higher percentage (odds ratio 2.28, 95% confidence interval: 1.00–5.15) as well as patients who had nurse-led education integrated into their visit during (odds ratio 1.82, 95% confidence interval: 1.19–2.78). Patient satisfaction had no correlation with the number of topics covered.

Conclusion:

The number of topics to cover at the first prenatal visit has expanded creating challenges for patients and providers. Integration of prenatal questionnaires and nurse-led education has the potential to address gaps in antenatal care.

Children born to women in opioid maintenance treatment: A longitudinal study of child behavioral problems and parenting stress

In the wake of the "opioid epidemic", there is considerable concern regarding potential harmful long-term effects of prenatal opioid exposure. Opioid misuse and addiction confer increased exposure to lifestyle stressors and health burdens. Accordingly, it is challenging to disentangle effects of prenatal opioid exposure per se from factors related to maternal stress. In this study, we followed 36 women enrolled in comprehensive opioid maintenance treatment (OMT) program and their children alongside 36 age-matched mother-child dyads from a community sample (COMP) from pregnancy until child-age 8 years. Across five sessions, we used a battery of well-established questionnaires to investigate trajectories of parenting stress and mental health symptoms as well as child behavior problems. The 8-year retention was relatively high (OMT: 72%, COMP: 67%), and the OMT sample remarkably stable and well-functioning, with minimal concomitant illicit drug use. Mixed effects regressions showed significantly different trajectories of child behavior problems (F = 3.8, p = 0.024) and parenting stress (F = 3.1, p = 0.016) in the two groups. Differences in experienced stress were largely explained by more distress specifically related to the parenting role in the OMT group (F = 9.7, p = 0.003). The OMT sample also reported higher psychological distress (F = 15.6, p < 0.001) than the comparison group, but notably few participants presented with problems that warranted clinical intervention. The results underscore the benefits of tailored follow-up of children prenatally exposed to opioids and their families beyond infancy and toddlerhood. Long-term direct effects of prenatal opioid exposure on behavior problems are likely modest, given an otherwise stable caregiving environment conducive to healthy development.

The association of unplanned pregnancy with perinatal depression: a longitudinal cohort study

Perinatal depression is common, affecting approximately 7-13% of women. Studies have shown an association between unplanned pregnancy and perinatal depressive symptoms, but many used a cross-sectional design and limited postnatal follow-up. The current study investigated the association of unplanned pregnancy with perinatal depressive symptoms using a longitudinal cohort study that followed women from the first trimester until 12 months postpartum. Pregnant women (N = 1928) provided demographic and clinical data and information about pregnancy intention at the first trimester. Depressive symptoms were assessed during each trimester of pregnancy and five times postpartum using the Edinburgh Postnatal Depression Scale (EPDS) until 12 months postpartum. Mixed model analyses were used to investigate the association between an unplanned pregnancy and the level of depressive symptoms. Women with an unplanned pregnancy (N = 111, 5.8%) reported persistently higher levels of depressive symptoms during the entire perinatal period compared to women with a planned pregnancy, after adjustment for confounders (p < 0.001). However, the course of depressive symptom scores over time in women with an unplanned pregnancy was similar to that of women with a planned pregnancy. Lower age (p = 0.006), unemployment (p = 0.004), and history of depression (p < 0.001) were significantly associated with higher levels of perinatal depressive symptoms. An unplanned pregnancy may have a long-lasting negative impact on a woman's perinatal mental health. Therefore, women with an unplanned pregnancy may benefit from systematic follow-up during the perinatal period with contingent mental health support.

Birth Experience, Postpartum PTSD and Depression before and during the Pandemic of COVID-19 in Russia

The aim of the study is to investigate the changes in the maternal healthcare system during the pandemic and their associations with maternal mental health in Russia. A sample of Russian women who gave birth during the first year of the COVID-19 pandemic (n = 1645) and matched controls, i.e., women who gave birth before the COVID-19 pandemic (n = 611), completed an anonymous Internet survey about recent childbirth. They were assessed for childbirth-related posttraumatic stress disorder (PTSD) and postpartum depression (PPD). Clinically relevant symptoms of PPD and PTSD were high before the pandemic and showed no significant change during the pandemic (p = 0.48 and p = 0.64, respectively). We found a notable increase in the frequency of obstetric violence (p = 0.015) during the pandemic, which, in turn, has a strong correlation with birth-related PTSD and PPD. The problem of ethical communication with patients among maternal healthcare professionals is acute in Russia, and it has been exacerbated by the pandemic. Family and doula support during labor can be a potential protective factor against obstetric violence.

Validation of the intolerance of uncertainty scale as a screening tool for perinatal anxiety

Background

To date, there is a significant lack of research validating clinical tools for early and accurate detection of anxiety disorders in perinatal populations. Intolerance of uncertainty was recently identified as a significant risk factor for postpartum anxiety symptoms and is a key trait of non-perinatal anxiety disorders. The present study aimed to validate the Intolerance of Uncertainty Scale (IUS) in a perinatal population and evaluate its use as a screening tool for anxiety disorders.

Methods

Psychiatric diagnoses were assessed in a sample of perinatal women (n = 198), in addition to completing a self-report battery of questionnaires. Psychometric properties including internal consistency and convergent and discriminant validity were assessed. Determination of an optimal clinical cut-off score was measured through a ROC analysis in which the area under the curve, sensitivity, specificity, as well as positive and negative predictive values were calculated.

Results

The IUS demonstrated excellent internal consistency (α = 0.95) and an optimal clinical cut-off score of 64 or greater was established, yielding a sensitivity of 89%. The IUS also demonstrated very good positive (79%) and negative (80%) predictive values.

Conclusions

These findings suggest that the IUS represents a clinically useful screening tool to be used as an aid for the early and accurate detection of perinatal anxiety.

Physiological responses to cuddling babies with hypoxic-ischaemic encephalopathy during therapeutic hypothermia: an observational study

OBJECTIVES

To determine whether parents cuddling infants during therapeutic hypothermia (TH) would affect cooling therapy, cardiorespiratory or neurophysiological measures. The secondary aim was to explore parent-infant bonding, maternal postnatal depression and breastfeeding.

DESIGN

Prospective observational study.

SETTING

Two tertiary neonatal intensive care units (NICU).

PARTICIPANTS

Parents and their term-born infants (n=27) receiving TH and intensive care for neonatal hypoxic-ischaemic encephalopathy.

INTERVENTIONS

Cuddling up to 2 hours during TH using a standard operating procedure developed in the study (CoolCuddle).

MAIN OUTCOME MEASURES

Mean difference in temperature, cardiorespiratory and neurophysiological variables before, during and after the cuddle. Secondary outcomes were parental bonding, maternal postnatal depression and breastfeeding.

RESULTS

During 70 CoolCuddles (115 cumulative hours), there were measurable increases in rectal temperature (0.07°C (0.03 to 0.10)) and upper margin of amplitude-integrated electroencephalogram (1.80 µV (0.83 to 2.72)) and decreases in oxygen saturations (-0.57% (-1.08 to -0.05)) compared with the precuddle period. After the cuddle, there was an increase in end-tidal CO₂ (0.25 kPa (95% CI 0.14 to 0.35)) and mean blood pressure (4.09 mm Hg (95% CI 0.96 to 7.21)) compared with the precuddle period. From discharge to 8 weeks postpartum, maternal postnatal depression declined (13 (56.5%) vs 5 (23.8%), p=0.007); breastfeeding rate differed (71% vs 50%, p=0.043), but was higher than national average at discharge (70% vs 54.6%) and mother-infant bonding (median (IQR): 3 (0-6) vs 3 (1-4)) remained stable.

CONCLUSION

In this small study, CoolCuddle was associated with clinically non-significant, but measurable, changes in temperature, cardiorespiration and neurophysiology. No infant met the criteria to stop the cuddles or had any predefined adverse events. CoolCuddle may improve breastfeeding and requires investigation in different NICU settings.

A systematic review and meta-analysis of diagnostic test accuracy studies of self-report screening instruments for common mental disorders in Arabic-speaking adults

BACKGROUND

Self-report screening instruments are frequently used as scalable methods to detect common mental disorders (CMDs), but their validity across cultural and linguistic groups is unclear. We summarized the diagnostic accuracy of brief questionnaires on symptoms of depression, anxiety and posttraumatic stress disorder (PTSD) among Arabic-speaking adults.

METHODS

Five databases were searched from inception to 22 January 2021 (PROSPERO: CRD42018070645). Studies were included when diagnostic accuracy of brief (maximally 25 items) psychological questionnaires was assessed in Arabic-speaking populations and the reference standard was a clinical interview. Data on sensitivity/specificity, area under the curve, and data to generate 2 × 2 tables at various thresholds were extracted. Meta-analysis was performed using the diagmeta package in R. Quality of studies was assessed with QUADAS-2.

RESULTS

Thirty-two studies (N participants = 4042) reporting on 17 questionnaires with 5-25 items targeting depression/anxiety (n = 14), general distress (n = 2), and PTSD (n = 1) were included. Seventeen studies (53%) scored high risk on at least two QUADAS-2 domains. The meta-analysis identified an optimal threshold of 11 (sensitivity 76.9%, specificity 85.1%) for the Edinburgh Postnatal Depression Scale (EPDS) (n studies = 7, n participants = 711), 7 (sensitivity 81.9%, specificity 87.6%) for the Hospital Anxiety and Depression Scale (HADS) anxiety subscale and 6 (sensitivity 73.0%, specificity 88.6%) for the depression subscale (n studies = 4, n participants = 492), and 8 (sensitivity 86.0%, specificity 83.9%) for the Self-Reporting Questionnaire (SRQ-20) (n studies = 4, n participants = 459).

CONCLUSION

We present optimal thresholds to screen for perinatal depression with the EPDS, anxiety/depression with the HADS, and CMDs with the SRQ-20. More research on Arabic-language questionnaires, especially those targeting PTSD, is needed.

Postnatal depression: identification of risk factors in the short-stay maternity program in Belgium. A cross-sectional study

Background

Postnatal depression (PND) is one of the most frequent complications in women of childbearing age in the developed world. The onset of PND is influenced by several risk factors. In an attempt to avoid unnecessary long maternity stays, the Short Stay Maternity programme was launched, shifting care from the hospital environment to the outpatient setting.

Aim

In order to develop an efficient programme to trace vulnerable women after childbirth and to provide support within primary care, the aim was to create an inventory of the risk factors for PND within the population of women participating in the short-stay programme.

Design & setting

This study is a cross-sectional study without follow-up. Women in Belgium were invited by email to participate in the Short Stay Maternity programme within 3 months of delivery.

Method

The questionnaire addressed background features and feelings during the maternity period, supplemented with the validated Dutch version of the Edinburgh Postnatal Depression Scale (EPDS). The primary outcome measure of the questionnaire was the score on the EPDS.

Results

A total of 131 (27.46%) of the invited women participated. Sixteen participants (12.21%) presented with a positive score on the EPDS. The odds ratio (OR) for a positive score on the EPDS when experiencing negative feelings was 13.5 (95% confidence interval [CI] = 4.14 to 44.01). If only material support was provided, the OR for a positive EPDS score was OR 11.2 (95% CI = 2.72 to 55.5).

Conclusion

In this study, two risk factors were identified for PND: negative feelings during pregnancy and the provision of only material support by the partner.

Effect of Online 1-Day Cognitive Behavioral Therapy-Based Workshops Plus Usual Care vs Usual Care Alone for Postpartum Depression: A Randomized Clinical Trial

IMPORTANCE

Postpartum depression (PPD) affects as many as 20% of mothers, yet just 1 in 10 of these women receives evidence-based treatment. The COVID-19 pandemic has increased PPD risk, reduced treatment access, and shifted preferences toward virtual care.

OBJECTIVE

To determine whether an online 1-day cognitive behavioral therapy (CBT)-based workshop added to treatment as usual improves PPD, anxiety, social support, mother-infant relationship quality, and infant temperament more than treatment as usual alone.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial included 403 women with PPD who were recruited across Ontario, Canada, during the COVID-19 pandemic (April 20 to October 4, 2020). Women with Edinburgh Postnatal Depression Scale (EPDS) scores of at least 10 who were 18 years or older and had an infant younger than 12 months were eligible.

INTERVENTIONS

Women were randomly assigned to receive a live, interactive online 1-day CBT-based workshop delivered by a registered psychotherapist, psychiatrist, or clinical psychology graduate student in addition to treatment as usual (n = 202) or to receive treatment as usual and wait-listed to receive the workshop 12 weeks later (n = 201).

MAIN OUTCOMES AND MEASURES

The primary outcome was change in PPD (EPDS scores) in experimental and wait list control groups 12 weeks after baseline. Secondary outcomes included maternal anxiety (7-item Generalized Anxiety Disorder Questionnaire [GAD-7]), social support (Social Provisions Scale), quality of the mother-infant relationship (Postpartum Bonding Questionnaire), and infant temperament (Infant Behavior Questionnaire-Revised Very Short Form).

RESULTS

Participants all identified as women with a mean (SD) age of 31.8 (4.4) years. The workshop led to significant mean (SD) reductions in EPDS scores (from 16.47 [4.41] to 11.65 [4.83]; B = -4.82; P < .001) and was associated with a higher odds of exhibiting a clinically significant decrease in EPDS scores (odds ratio, 4.15; 95% CI, 2.66-6.46). The mean (SD) GAD-7 scores decreased from 12.41 (5.12) to 7.97 (5.54) after the workshop (B = -4.44; 95% CI, -5.47 to -3.38; P < .001) and participants were more likely to experience a clinically significant change (odds ratio, 3.09; 95% CI, 1.99-4.81). Mothers also reported improvements in bonding (B = -3.22; 95% CI, -4.72 to -1.71; P < .001), infant-focused anxiety (B = -1.64; 95% CI, -2.25 to 1.00; P < .001), social support (B = 3.31; 95% CI, 1.04 to 5.57; P < .001), and positive affectivity/surgency in infants (B = 0.31; 95% CI, 0.05 to 0.56; P < .001).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, an online 1-day CBT-based workshop for PPD provides an effective, brief option for mothers, reducing PPD and anxiety as well as improving social support, the mother-infant relationship, and positive affectivity/surgency in offspring.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04485000.

Edinburgh Postnatal Depression Scale used in South Korea

Background: The Edinburgh Postnatal Depression Scale (EPDS), a validated screening tool for prenatal and postnatal depression, was included as a reimbursable item by the National Health Insurance Service of Korea in 2020. However, multiple Korean versions of the EPDS are used for public health programs and research. This study aimed to summarize the use of this scale in Korea and evaluate the distribution of validities, depression scores, and prevalence of depression according to Korean versions of the EPDS.Methods: Korean versions of the EPDS most frequently used in public health policies and programs were summarized through internet searches using snowball strategy. A systematic literature review was conducted to evaluate the prenatal and postnatal depression scores and prevalence of depression measured using different Korean versions of the scale.Results: We identified four Korean versions of the EPDS that are commonly used in public health programs and research. Among them, published evidence regarding validity and reliability was available for two versions. A review of 19 papers that assessed prenatal and postnatal depression using these versions showed large heterogeneity in scores and the prevalence of depression.Conclusion: When measuring prenatal and postnatal depression using the EPDS, characteristics of the scale must be considered when interpreting results. A standardized Korean version of the EPDS needs to be developed by comparing the validity and reliability of different Korean versions. A field manual for screening should also be developed and distributed.

The Methylation of Clock Genes in Perinatal Depression: Which Role for Oxytocin?

Background: Perinatal Depression (PD) is a widespread disabling condition that is hypothesized to be associated with abnormalities in circadian rhythms and neuropeptide release including oxytocin (OXT). Methods: Fourty-four pregnant women (28 with PD, and 16 controls) were evaluated through the Edinburgh Postnatal Depression Scale (EPDS), the State/Trait Anxiety Inventory Form Y (STAI-Y), and the Prenatal Attachment Inventory (PAI). A blood sample was collected from all participants, and OXT plasma levels, DNA methylation of clock genes, as well as of FOXp3 and HERV-W were measured. Linear regression analyses were performed to assess the effect of oxytocin on the methylation of selected genes. Continuous ordinal regression models was further applied to see if the score of rating scales was associated to gene methylation, adjusting for oxytocin-methylation interaction. Results: OXT plasma levels were positively associated with CRY1 methylation. Women with higher OXT plasma levels showed an association between higher degree of CRY2 methylation (thus, reduced expression) and lower EPDS (OR = 0.21; P = 0.043) and STAI-S scores (OR = 6.96; P = 0.019). Finally, with high OXT levels, hypermethylation of CRY1 was associated to higher scores on the PAI (OR = 2.74; P = 0.029) while higher methylation of HERV-W related to lower PAI scores (OR = 0.273; P = 0.019). Conclusion: Our results suggest a possible protective role played by oxytocin in the development of PD by promoting a favorable methylation profile characterized by reduced expression of CRY1 and CRY2. Moreover, oxytocin strengthens the association between maternal prenatal attachment with a favorable pattern of methylation of clock genes and HERV-W, which is essential for pregnancy outcomes.

Association of Maternal Depressive Symptoms During the Perinatal Period With Oppositional Defiant Disorder in Children and Adolescents

IMPORTANCE

An association between perinatal maternal depression and risk of oppositional defiant disorder (ODD) in offspring has not been established. Identifying early determinants of ODD can help inform preventative intervention efforts.

OBJECTIVE

To investigate the association between maternal perinatal depressive symptoms and the risk of ODD in offspring aged 7 to 15 years.

DESIGN, SETTING, AND PARTICIPANTS

This population-based longitudinal birth cohort study used data from the Avon Longitudinal Study of Parents and Children (ALSPAC), in Bristol, UK. All pregnant women residents in Avon, UK, with expected delivery dates from April 1, 1991, to December 31, 1992, were invited to participate in the study. The study cohort ranged from approximately 8000 (at 7 years of age) to 4000 (at 15 years of age) mother-offspring pairs. Data were analyzed from November 2020 to July 2021.

MAIN OUTCOMES AND MEASURES

Maternal depressive symptoms were measured using the Edinburgh Postnatal Depression Scale (EPDS) antenatally at 18 and 32 weeks of gestation and postnatally at 8 weeks and 8 months. This study primarily used a cutoff score of 12 or more on the EPDS to identify mothers with symptoms of depression, and the continuous EPDS scores were used to confirm the results of the main analyses. Offspring ODD at 7, 10, 13, and 15 years of age were diagnosed using the parent-reported Development and Well-Being Assessment.

RESULTS

Of 7994 mother-offspring pairs for whom data were available on offspring ODD at 7 years, 4102 offspring (51.3%) were boys. The mean (SD) age of mothers was 28.6 (4.6) years. Maternal antenatal depressive symptoms (measured at 32 weeks of gestation) were associated with offspring ODD (adjusted odds ratio [AOR], 1.75; 95% CI, 1.33-2.31). Offspring of mothers with postpartum depressive symptoms at 8 weeks and 8 months were more than 2 times more likely to have a diagnosis of ODD over time (AOR at 8 weeks, 2.24 [95% CI, 1.74-2.90]; AOR at 8 months, 2.04 [95% CI, 1.55-2.68]), and maternal persistent depressive symptoms were associated with a 4-fold increased risk of offspring ODD (AOR, 3.59; 95% CI, 1.98-6.52).

CONCLUSIONS AND RELEVANCE

These findings suggest that perinatal depressive symptoms are associated with ODD in offspring and further support the need for early identification and management of prenatal and postnatal depression in women of childbearing age.

Selective cutoff reporting in studies of the accuracy of the Patient Health Questionnaire-9 and Edinburgh Postnatal Depression Scale: Comparison of results based on published cutoffs versus all cutoffs using individual participant data meta-analysis

OBJECTIVES

Selectively reported results from only well-performing cutoffs in diagnostic accuracy studies may bias estimates in meta-analyses. We investigated cutoff reporting patterns for the Patient Health Questionnaire-9 (PHQ-9; standard cutoff 10) and Edinburgh Postnatal Depression Scale (EPDS; no standard cutoff, commonly used 10-13) and compared accuracy estimates based on published cutoffs versus all cutoffs.

METHODS

We conducted bivariate random effects meta-analyses using individual participant data to compare accuracy from published versus all cutoffs.

RESULTS

For the PHQ-9 (30 studies, N = 11,773), published results underestimated sensitivity for cutoffs below 10 (median difference: -0.06) and overestimated for cutoffs above 10 (median difference: 0.07). EPDS (19 studies, N = 3637) sensitivity estimates from published results were similar for cutoffs below 10 (median difference: 0.00) but higher for cutoffs above 13 (median difference: 0.14). Specificity estimates from published and all cutoffs were similar for both tools. The mean cutoff of all reported cutoffs in PHQ-9 studies with optimal cutoff below 10 was 8.8 compared to 11.8 for those with optimal cutoffs above 10. Mean for EPDS studies with optimal cutoffs below 10 was 9.9 compared to 11.8 for those with optimal cutoffs greater than 10.

CONCLUSION

Selective cutoff reporting was more pronounced for the PHQ-9 than EPDS.

Mood instability, depression, and anxiety in pregnancy and adverse neonatal outcomes

Background

Antenatal women experience an increased level of mood and anxiety symptoms, which have negative effects on mothers’ mental and physical health as well as the health of their newborns. The relation of maternal depression and anxiety in pregnancy with neonate outcomes is well-studied with inconsistent findings. However, the association between antenatal mood instability (MI) and neonatal outcomes has not been investigated even though antenatal women experience an elevated level of MI. We sought to address this gap and to contribute to the literature about pregnancy neonate outcomes by examining the relationship among antenatal MI, depression, and anxiety and neonatal outcomes.

Methods

A prospective cohort of women (n = 555) participated in this study at early pregnancy (T1, 17.4 ± 4.9 weeks) and late pregnancy (T2, 30.6 ± 2.7 weeks). The Edinburgh Postnatal Depression Scale (EPDS) was used to assess antenatal depressive symptoms, anxiety was measured by the EPDS anxiety subscale, and mood instability was measured by a visual analogue scale with five questions. These mood states together with stress, social support, as well as lifestyle were also examined in relation to neonatal outcomes using chi-square tests and logistic regression models.

Results

Mood instability, depression, and anxiety were unrelated to adverse neonatal outcomes. Only primiparous status was associated with small for gestational age after Bonferroni correction.

Conclusions

We report no associations between antenatal mood symptoms including MI, depression, and anxiety and neonatal outcomes. More studies are required to further explore the relationship between antenatal mood instability, depression, and anxiety and neonatal outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04021-y.

Can the Edinburgh Postnatal Depression Scale-3A be used to screen for anxiety?

Background

Anxiety in the ante- and postnatal period is prevalent, often co-occurs with depression, and can have adverse consequences for the infant. Therefore, perinatal mental health screening programs should not only focus on depression but also on detecting anxiety. However, in many already implemented perinatal screening programs, adding extra screening instruments is not feasible. We examine the utility of a subscale of the Edinburgh Postnatal Depression Scale (EPDS) consisting of items 3, 4, and 5 (EPDS-3A) for detecting anxiety in new mothers.

Methods

We used confirmatory factor analysis (CFA) to confirm the presence of the EPDS-3A found in a previous study (n = 320) where exploratory factor analysis (EFA) was used. For the CFA we used a sample of new mothers (n = 442) with children aged 2–11 months recruited from the same population from which mothers for the previous study was recruited. Three models were tested and compared. Receiver operating characteristics of the EPDS-3A were investigated in relation to anxiety caseness status on the combined sample (N = 762). Sample weighing was used to match the dataset to the target population. Cross tabulation was used to investigate the proportion of anxiety cases identified by the EPDS-3A above those identified with the total EPDS.

Results

The presence of the EPDS-3A was confirmed. An EFA-driven, two-dimensional 7-item model showed the best data fit with one factor representing the anxiety subscale consisting of items 3, 4, and 5. An EPDS-3A score of ≥ 5 was the most optimal for identifying cases of anxiety (sensitivity: 70.9; specificity: 92.2; AUC: 0.926). Further, we found that the EPDS-3A identifies an additional 2.5% of anxiety cases that would not have been identified with the total EPDS.

Conclusions

The EPDS-3A can be used as a time-efficient screening for possible anxiety in ante- and postnatal mothers. However, adding the EPDS-3A to routine screening with the total EPDS does not lead to a substantial increase in the number of women identified. In line with previous studies, this study confirms that the EPDS identifies anxiety in addition to depression. Therefore, assessment and treatment adjusted to the specific emotional difficulties is imperative.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-021-00623-5.

Impact of COVID-19 pandemic on postpartum depression among mothers of extreme and early preterm infants

Objective

To examine the impact of the coronavirus disease 2019 (COVID‐19) pandemic and the resulting isolation measures on the risk of postpartum depression (PPD) after preterm birth.

Methods

This is a cross‐sectional study of mothers of extreme and early preterm infants who completed the Edinburgh Postnatal Depression Scale (EPDS) at the standardized 3–6 months follow‐up consultation for preterm infants. Mothers assessed during the COVID‐19 pandemic (n = 34; from April 1, 2020 to March 31, 2021) were compared with an antecedent control group (n = 108; from January 1, 2017 to December 31, 2019). A multivariable logistic regression model was used to examine the relationship between the pandemic and the risk of PPD (EPDS score ≥13).

Results

The prevalence of depressive symptoms was significantly higher in the COVID‐19 study group (26% versus 12%, P = 0.043). The multivariable logistic regression model showed a significant association between the COVID‐19 pandemic and the risk of PPD (adjusted odds ratio 3.60, 95% confidence interval 1.06–12.59, P = 0.040).

Conclusion

Among mothers of extreme and early preterm infants, the COVID‐19 pandemic was independently associated with a higher risk of PPD. This confirms the need for a close and long‐term follow up of maternal psychological health after preterm birth.

The COVID‐19 pandemic was independently associated with a higher risk of postpartum depression among mothers of extreme and early preterm infants.

Parental Stress and Mental Health Symptoms in the NICU: Recognition and Interventions

Parental experiences in the NICU are often characterized by psychological stress and anxiety following the birth of a critically ill or premature infant. Such stress can have a negative impact on parents and their vulnerable infants during NICU hospitalization as well as after discharge. These infants are also at increased risk for adverse developmental, cognitive, academic, and mental health outcomes. Identifying parents at risk for psychological distress is important and feasible with the use of well-validated screening instruments. Screening for psychological distress is essential for identifying families in need of referral for psychological support and resources. Numerous interventions have been implemented in the NICU to support parents. These include staff-based support such as wellness rounds and education in developmental care as well as parental-based support that includes cognitive behavioral therapy and home visitation programs. Comprehensive interventions should use a multidisciplinary approach that involves not only NICU staff but also key stakeholders such as social workers, spiritual/religious representatives, specialists in developmental care, and psychiatrists/psychologists to help support families and facilitate the transition to the home. Future efforts should include raising awareness of the psychological stresses of NICU parents and encouraging the development of programs to provide parents with psychological support.

Prenatal and Postnatal Anxiety and Depression in Mothers during the COVID-19 Pandemic

The aim of this study was to assess the changes in the occurrence of prenatal and postnatal anxiety and depression symptoms, and to assess what factors significantly affect the appearance of symptoms of depression and anxiety in young mothers. The study group consisted of 130 women after childbirth. Due to the ongoing restrictions caused by the COVID-19 pandemic, the survey was prepared online. The questionnaire was fully anonymous, and it contained the authors' own questions and two standardized questionnaires: the Edinburgh Postnatal Depression Scale (EPDS) and Generalized Anxiety Disorders GAD-7. The conducted analysis clearly indicated that the level of postpartum depression, in as many as 52 of the mothers, had increased significantly compared to the time before delivery, when symptoms of depression were shown by 22 women (p = 0.009). However, there was no statistically significant change between prenatal and postnatal anxiety. There are many factors associated with postnatal depression. The strongest predictors turned out to be average socioeconomic status, history of anxiety disorders, past neurosis or depression, lack of or inadequate level of assistance from healthcare professionals, as well as lactation problems and postpartum pain.

States Transitions Inference of Postpartum Depression Based on Multi-State Markov Model

Background: Postpartum depression (PPD) has been recognized as a severe public health problem worldwide due to its high incidence and the detrimental consequences not only for the mother but for the infant and the family. However, the pattern of natural transition trajectories of PPD has rarely been explored. Methods: In this research, a quantitative longitudinal study was conducted to explore the PPD progression process, providing information on the transition probability, hazard ratio, and the mean sojourn time in the three postnatal mental states, namely normal state, mild PPD, and severe PPD. The multi-state Markov model was built based on 912 depression status assessments in 304 Chinese primiparous women over multiple time points of six weeks postpartum, three months postpartum, and six months postpartum. Results: Among the 608 PPD status transitions from one visit to the next visit, 6.2% (38/608) showed deterioration of mental status from the level at the previous visit; while 40.0% (243/608) showed improvement at the next visit. A subject in normal state who does transition then has a probability of 49.8% of worsening to mild PPD, and 50.2% to severe PPD. A subject with mild PPD who does transition has a 20.0% chance of worsening to severe PPD. A subject with severe PPD is more likely to improve to mild PPD than developing to the normal state. On average, the sojourn time in the normal state, mild PPD, and severe PPD was 64.12, 6.29, and 9.37 weeks, respectively. Women in normal state had 6.0%, 8.5%, 8.7%, and 8.8% chances of progress to severe PPD within three months, nine months, one year, and three years, respectively. Increased all kinds of supports were associated with decreased risk of deterioration from normal state to severe PPD (hazard ratio, HR: 0.42-0.65); and increased informational supports, evaluation of support, and maternal age were associated with alleviation from severe PPD to normal state (HR: 1.46-2.27). Conclusions: The PPD state transition probabilities caused more attention and awareness about the regular PPD screening for postnatal women and the timely intervention for women with mild or severe PPD. The preventive actions on PPD should be conducted at the early stages, and three yearly; at least one yearly screening is strongly recommended. Emotional support, material support, informational support, and evaluation of support had significant positive associations with the prevention of PPD progression transitions. The derived transition probabilities and sojourn time can serve as an importance reference for health professionals to make proactive plans and target interventions for PPD.

Triggering of postpartum depression and insomnia with cognitive impairment in Argentinian women during the pandemic COVID-19 social isolation in relation to reproductive and health factors

Objective

The 2019 coronavirus disease pandemic (COVID-19) required strict confinement measures that differentially impacted the individual's daily life. Thus, this work aimed to study postpartum women's mental health in Argentina during mandatory social isolation.

Design

A cross-sectional survey was conducted from May to July 2020, which included five validated questionnaires to assess postpartum depression (Postpartum Depression Screening Scale‐Short Form), insomnia (Insomnia Severity Index), memory complaints (Memory Complaint Scale), metacognition (Brief Metamemory and Metaconcentration Scale), and breastfeeding self-efficacy (Breastfeeding Self-Efficacy Scale-Short Form). Sociodemographic variables, social isolation characteristics, and breastfeeding practices were also collected. This study was conducted in accordance with the Declaration of Helsinki. Statistical analysis included zero-order correlations, multiple logistic regressions, and a set of structural equation models (SEM) to test direct and indirect effects. Goodness-of-fit indices were calculated for SEM.

Setting

Postpartum women were recruited from public hospitals, private health clinics, and online community recruitment in the Cordoba province (Argentina).

Participants

305 postpartum women from Argentina.

Measurements and findings

37% of women reported postpartum depression, 46% insomnia, 42% memory impairment, 60% low metaconcentration, 50% low metamemory, and 23% low breastfeeding efficacy. Also, significant associations were found demonstrating that social isolation promoted postpartum depression and insomnia were reciprocally related, which compromised female cognition and efficacy. This situation was aggravated in women during late postpartum, with previous children, and by low social support (e.g., family, health professionals), with non-exclusive breastfeeding being increased.

Key conclusions

This is the first study addressing postpartum women's mental status during social isolation in Argentina, which was a promoting factor for postpartum depression and insomnia that were reciprocally related. This situation was also aggravated by reproductive factors, such as late postpartum, multiparity, breastfeeding frequency, and non-exclusive breastfeeding. Additionally, breastfeeding self-efficacy depended on mental health status, and euthymia therefore favoured the practice of exclusive breastfeeding.

Prenatal Exposure to Bisphenols and Phthalates and Postpartum Depression: The Role of Neurosteroid Hormone Disruption

CONTEXT

Postpartum depression (PPD) is a serious psychiatric disorder. While causes remain poorly understood, perinatal sex hormone fluctuations are an important factor, and allopregnanolone in particular has emerged as a key determinant. Although synthetic environmental chemicals such as bisphenols and phthalates are known to affect sex hormones, no studies have measured allopregnanolone and the consequences of these hormonal changes on PPD have not been interrogated.

OBJECTIVE

To investigate associations of repeated measures of urinary bisphenols and phthalates in early and midpregnancy with serum pregnenolone, progesterone, allopregnanolone, and pregnanolone concentrations in midpregnancy and PPD symptoms at 4 months postpartum.

METHODS

Prospective cohort study of 139 pregnant women recruited between 2016 and 2018. Bisphenols and phthalates were measured in early and midpregnancy urine samples. Serum sex steroid hormone concentrations were measured in midpregnancy. PPD was assessed at 4 months postpartum using the Edinburgh Postnatal Depression Scale (EPDS). Multiple informant models were fit using generalized estimating equations. Serum levels of allopregnanolone, progesterone, pregnanolone, and pregnenolone were examined as log-transformed continuous variables. PPD symptoms were examined as continuous EPDS scores and dichotomously with scores ≥10 defined as PPD.

RESULTS

Di-n-octyl phthalate (DnOP) and diisononyl phthalate (DiNP) metabolites were associated with reduced progesterone concentrations. Log-unit increases in ∑DnOP and ∑DiNP predicted 8.1% (95% CI -15.2%, -0.4%) and 7.7% (95% CI -13.3%, -1.7%) lower progesterone, respectively. ∑DnOP was associated with increased odds of PPD (odds ratio 1.48; 95% CI 1.04, 2.11).

CONCLUSION

Endocrine disrupting chemicals may influence hormonal shifts during pregnancy as well as contribute to PPD.

Cord blood DNA methylation modifications in infants are associated with white matter microstructure in the context of prenatal maternal depression and anxiety

Maternal and environmental factors influence brain networks and architecture via both physiological pathways and epigenetic modifications. In particular, prenatal maternal depression and anxiety symptoms appear to impact infant white matter (WM) microstructure, leading us to investigate whether epigenetic modifications (i.e., DNA methylation) contribute to these WM differences. To determine if infants of women with depression and anxiety symptoms exhibit epigenetic modifications linked to neurodevelopmental changes, 52 umbilical cord bloods (CBs) were profiled. We observed 219 differentially methylated genomic positions (DMPs; FDR p < 0.05) in CB that were associated with magnetic resonance imaging measures of WM microstructure at 1 month of age and in regions previously described to be related to maternal depression and anxiety symptoms. Genomic characterization of these associated DMPs revealed 143 unique genes with significant relationships to processes involved in neurodevelopment, GTPase activity, or the canonical Wnt signaling pathway. Separate regression models for female (n = 24) and male (n = 28) infants found 142 associated DMPs in females and 116 associated DMPs in males (nominal p value < 0.001, R > 0.5), which were annotated to 98 and 81 genes, respectively. Together, these findings suggest that umbilical CB DNA methylation levels at birth are associated with 1-month WM microstructure.

The clinical performance and cost-effectiveness of two psychosocial assessment models in maternity care: The Perinatal Integrated Psychosocial Assessment study

PROBLEM

Although perinatal universal depression and psychosocial assessment is recommended in Australia, its clinical performance and cost-effectiveness remain uncertain.

AIM

To compare the performance and cost-effectiveness of two models of psychosocial assessment: Usual-Care and Perinatal Integrated Psychosocial Assessment (PIPA).

METHODS

Women attending their first antenatal visit were prospectively recruited to this cohort study. Endorsement of significant depressive symptoms or psychosocial risk generated an 'at-risk' flag identifying those needing referral to the Triage Committee. Based on its detailed algorithm, a higher threshold of risk was required to trigger the 'at-risk' flag for PIPA than for Usual-Care. Each model's performance was evaluated using the midwife's agreement with the 'at-risk' flag as the reference standard. Cost-effectiveness was limited to the identification of True Positive and False Positive cases. Staffing costs associated with administering each screening model were quantified using a bottom-up time-in-motion approach.

FINDINGS

Both models performed well at identifying 'at-risk' women (sensitivity: Usual-Care 0.82 versus PIPA 0.78). However, the PIPA model was more effective at eliminating False Positives and correctly identifying 'at-risk' women (Positive Predictive Value: PIPA 0.69 versus Usual Care 0.41). PIPA was associated with small incremental savings for both True Positives detected and False Positives averted.

DISCUSSION

Overall PIPA performed better than Usual-Care as a psychosocial screening model and was a cost-saving and relatively effective approach for detecting True Positives and averting False Positives. These initial findings warrant evaluation of longer-term costs and outcomes of women identified by the models as 'at-risk' and 'not at-risk' of perinatal psychosocial morbidity.

Effect of a Brief Supportive and Educational Intervention on the Psychological Well-Being of Mothers with Babies in Neonatal Wards of a Tertiary Hospital in Ibadan, Nigeria

OBJECTIVE

To assess the effect of a supportive educational intervention on the psychological wellbeing of mothers whose babies were admitted to Neonatal Care Unit (NCU) in Nigeria.

METHODS

Controlled trial involving 41 mothers whose babies were consecutively admitted into two NCUs (21 in the intervention group and 19 controls). The intervention group received two group-based sessions which included psychological coping strategies, and familiarity with NCU environment, equipment, personnel and procedures. The control group received usual care. Outcome measures were depressive symptoms (Edinburg Postnatal Depression Scale-EPDS), stress-related to NCU (Parental Stressor Scale: Neonatal Intensive Care Unit-PSS: NICU) and post-traumatic symptoms (Impact Event Scale-Revised-IES-R).

RESULTS

Difference-in-Differences (DiD) analysis showed a difference of -4.70 in PSS: NICU score in favour of the intervention group which was statistically significant [F(3, 75) = 9.47, p < 0.0001, R2 = 0.28]. The differences in EPDS (0.91) and IES-R (2.55) were not statistically significant [F(3, 75) = 10.10, p = 0.74] and [F(3, 75) = 10.13, p = 0.73], respectively. All the mothers in the treatment group expressed satisfaction with the intervention.

CONCLUSION

This brief group-based supportive educational intervention for mothers with babies in NCU was feasible, acceptable and helpful in reducing stress related to NCU. Larger controlled trials are recommended to establish the generalizability of these findings in this region.

LAY SUMMARY

Babies born too early and or with complications require admission to special hospital called Neonatal Care Unit (NCU) to help them to survive. However, parents whose babies are admitted to NCU can find the experience frightening. We examined how to reduce the fear and stress mothers in Nigeria experience when their babies are admitted to NCU.We had two groups of mothers. The first group made up of 21 mothers was taught how to cope with the stress of having a baby in NCU. They were also shown how the various equipment in the NCU work, what the staff in NCU do and what types of things need to be done to help their babies. The second group of 19 mothers received usual care but did not have the extra teaching the first group received. After 2 weeks, we checked the level of depression and stress the mothers in both groups had compared with the level before the first group received the extra teaching.We found that mothers in the first group who received the extra teaching were less stressed about having their babies in the NCU compared with the mothers that did not receive the teaching.

Communication Across Maternal Social Networks During England's First National Lockdown and Its Association With Postnatal Depressive Symptoms

Postnatal/postpartum depression (PND/PPD) had a pre-COVID-19 estimated prevalence ranging up to 23% in Europe, 33% in Australia, and 64% in America, and is detrimental to both mothers and their infants. Low social support is a key risk factor for developing PND. From an evolutionary perspective this is perhaps unsurprising, as humans evolved as cooperative childrearers, inherently reliant on social support to raise children. The coronavirus pandemic has created a situation in which support from social networks beyond the nuclear family is likely to be even more important to new mothers, as it poses risks and stresses for mothers to contend with; whilst at the same time, social distancing measures designed to limit transmission create unprecedented alterations to their access to such support. Using data from 162 mothers living in London with infants aged ≤6 months, we explore how communication with members of a mother's social network related to her experience of postnatal depressive symptoms during the first "lockdown" in England. Levels of depressive symptoms, as assessed via the Edinburgh Postnatal Depression Scale, were high, with 47.5% of the participants meeting a ≥11 cut-off for PND. Quasi-Poisson regression modelling found that the number of network members seen in-person, and remote communication with a higher proportion of those not seen, was negatively associated with depressive symptoms; however, contact with a higher proportion of relatives was positively associated with symptoms, suggesting kin risked seeing mothers in need. Thematic qualitative analysis of open text responses found that mothers experienced a burden of constant mothering, inadequacy of virtual contact, and sadness and worries about lost social opportunities, while support from partners facilitated family bonding. While Western childrearing norms focus on intensive parenting, and fathers are key caregivers, our results highlight that it still "takes a village" to raise children in high-income populations and mothers are struggling in its absence.

Accuracy of the Hospital Anxiety and Depression Scale Depression subscale (HADS-D) to screen for major depression: systematic review and individual participant data meta-analysis

OBJECTIVE

To evaluate the accuracy of the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) to screen for major depression among people with physical health problems.

DESIGN

Systematic review and individual participant data meta-analysis.

DATA SOURCES

Medline, Medline In-Process and Other Non-Indexed Citations, PsycInfo, and Web of Science (from inception to 25 October 2018).

REVIEW METHODS

Eligible datasets included HADS-D scores and major depression status based on a validated diagnostic interview. Primary study data and study level data extracted from primary reports were combined. For HADS-D cut-off thresholds of 5-15, a bivariate random effects meta-analysis was used to estimate pooled sensitivity and specificity, separately, in studies that used semi-structured diagnostic interviews (eg, Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders), fully structured interviews (eg, Composite International Diagnostic Interview), and the Mini International Neuropsychiatric Interview. One stage meta-regression was used to examine whether accuracy was associated with reference standard categories and the characteristics of participants. Sensitivity analyses were done to assess whether including published results from studies that did not provide raw data influenced the results.

RESULTS

Individual participant data were obtained from 101 of 168 eligible studies (60%; 25 574 participants (72% of eligible participants), 2549 with major depression). Combined sensitivity and specificity was maximised at a cut-off value of seven or higher for semi-structured interviews, fully structured interviews, and the Mini International Neuropsychiatric Interview. Among studies with a semi-structured interview (57 studies, 10 664 participants, 1048 with major depression), sensitivity and specificity were 0.82 (95% confidence interval 0.76 to 0.87) and 0.78 (0.74 to 0.81) for a cut-off value of seven or higher, 0.74 (0.68 to 0.79) and 0.84 (0.81 to 0.87) for a cut-off value of eight or higher, and 0.44 (0.38 to 0.51) and 0.95 (0.93 to 0.96) for a cut-off value of 11 or higher. Accuracy was similar across reference standards and subgroups and when published results from studies that did not contribute data were included.

CONCLUSIONS

When screening for major depression, a HADS-D cut-off value of seven or higher maximised combined sensitivity and specificity. A cut-off value of eight or higher generated similar combined sensitivity and specificity but was less sensitive and more specific. To identify medically ill patients with depression with the HADS-D, lower cut-off values could be used to avoid false negatives and higher cut-off values to reduce false positives and identify people with higher symptom levels.

TRIAL REGISTRATION

PROSPERO CRD42015016761.

Prenatal antidepressant exposure and sex differences in neonatal corpus callosum microstructure

Prenatal exposure to selective serotonin reuptake inhibitor (SSRI) antidepressants may influence white matter (WM) development, as previous studies report widespread microstructural alterations and reduced interhemispheric connectivity in SSRI-exposed infants. In rodents, perinatal SSRIs had sex-specific disruptions in corpus callosum (CC) axon architecture and connectivity; yet it is unknown whether SSRI-related brain outcomes in humans are sex specific. In this study, the neonate CC was selected as a region-of-interest to investigate whether prenatal SSRI exposure has sex-specific effects on early WM microstructure. On postnatal day 7, diffusion tensor imaging was used to assess WM microstructure in SSRI-exposed (n = 24; 12 male) and nonexposed (n = 48; 28 male) term-born neonates. Fractional anisotropy was extracted from CC voxels and a multivariate discriminant analysis was used to identify latent patterns differing between neonates grouped by SSRI-exposure and sex. Analysis revealed localized variations in CC fractional anisotropy that significantly discriminated neonate groups and correctly predicted group membership with an 82% accuracy. Such effects were identified across three dimensions, representing sex differences in SSRI-exposed neonates (genu, splenium), SSRI-related effects independent of sex (genu-to-rostral body), and sex differences in nonexposed neonates (isthmus-splenium, posterior midbody). Our findings suggest that CC microstructure may have a sex-specific, localized, developmental sensitivity to prenatal SSRI exposure.

Language Proficiency and Migrant-Native Disparities in Postpartum Depressive Symptoms

Migrant women have a higher risk of developing postpartum depressive symptoms (PPDS) than do native women. This study aimed to investigate the role of host-country language proficiency in this disparity. We analysed the data of 1475 migrant and 1415 native women who gave birth at a Portuguese public hospital between 2017 and 2019 and were participants in the baMBINO cohort study. Migrants’ language proficiency was self-rated and comprised understanding, speaking, reading, and writing skills. PPDS were assessed using the Edinburgh Postnatal Depression Scale with a cut-off score of ≥10. Multivariable logistic regression models were fitted to estimate the association between language proficiency and PPDS. PPDS were experienced by 7.2% of native women and 12.4% among migrants (p < 0.001). Increasing proportions of PPDS were observed among decreasing Portuguese proficiency levels; 11% among full, 13% among intermediate, and 18% among limited proficiency women (ptrend < 0.001). Full (aOR 1.63 (95% CI 1.21–2.19)), intermediate (aOR 1.68 (95% CI 1.16–2.42)), and limited (aOR 2.55 (95% CI 1.64–3.99)) language proficiencies were associated with increasingly higher odds of PPDS among migrant women, compared to native proficiency. Prevention measures should target migrant women at high risk of PPDS, namely those with limited language skills, and promote awareness, early detection, and help-seeking, in addition to facilitating communication in their perinatal healthcare encounters.

Predicting women with depressive symptoms postpartum with machine learning methods

Postpartum depression (PPD) is a detrimental health condition that affects 12% of new mothers. Despite negative effects on mothers’ and children’s health, many women do not receive adequate care. Preventive interventions are cost-efficient among high-risk women, but our ability to identify these is poor. We leveraged the power of clinical, demographic, and psychometric data to assess if machine learning methods can make accurate predictions of postpartum depression. Data were obtained from a population-based prospective cohort study in Uppsala, Sweden, collected between 2009 and 2018 (BASIC study, n = 4313). Sub-analyses among women without previous depression were performed. The extremely randomized trees method provided robust performance with highest accuracy and well-balanced sensitivity and specificity (accuracy 73%, sensitivity 72%, specificity 75%, positive predictive value 33%, negative predictive value 94%, area under the curve 81%). Among women without earlier mental health issues, the accuracy was 64%. The variables setting women at most risk for PPD were depression and anxiety during pregnancy, as well as variables related to resilience and personality. Future clinical models that could be implemented directly after delivery might consider including these variables in order to identify women at high risk for postpartum depression to facilitate individualized follow-up and cost-effectiveness.

Data-driven methods distort optimal cutoffs and accuracy estimates of depression screening tools: a simulation study using individual participant data

OBJECTIVE

To evaluate, across multiple sample sizes, the degree that data-driven methods result in (1) optimal cutoffs different from population optimal cutoff and (2) bias in accuracy estimates.

STUDY DESIGN AND SETTING

A total of 1,000 samples of sample size 100, 200, 500 and 1,000 each were randomly drawn to simulate studies of different sample sizes from a database (n = 13,255) synthesized to assess Edinburgh Postnatal Depression Scale (EPDS) screening accuracy. Optimal cutoffs were selected by maximizing Youden's J (sensitivity+specificity-1). Optimal cutoffs and accuracy estimates in simulated samples were compared to population values.

RESULTS

Optimal cutoffs in simulated samples ranged from ≥ 5 to ≥ 17 for n = 100, ≥ 6 to ≥ 16 for n = 200, ≥ 6 to ≥ 14 for n = 500, and ≥ 8 to ≥ 13 for n = 1,000. Percentage of simulated samples identifying the population optimal cutoff (≥ 11) was 30% for n = 100, 35% for n = 200, 53% for n = 500, and 71% for n = 1,000. Mean overestimation of sensitivity and underestimation of specificity were 6.5 percentage point (pp) and -1.3 pp for n = 100, 4.2 pp and -1.1 pp for n = 200, 1.8 pp and -1.0 pp for n = 500, and 1.4 pp and -1.0 pp for n = 1,000.

CONCLUSIONS

Small accuracy studies may identify inaccurate optimal cutoff and overstate accuracy estimates with data-driven methods.

Impact of the Covid-19 pandemic on perinatal mental health (Riseup-PPD-COVID-19): protocol for an international prospective cohort study

BACKGROUND

Corona Virus Disease 19 (COVID-19) is a new pandemic, declared a public health emergency by the World Health Organization, which could have negative consequences for pregnant and postpartum women. The scarce evidence published to date suggests that perinatal mental health has deteriorated since the COVID-19 outbreak. However, the few studies published so far have some limitations, such as a cross-sectional design and the omission of important factors for the understanding of perinatal mental health, including governmental restriction measures and healthcare practices implemented at the maternity hospitals. Within the Riseup-PPD COST Action, a study is underway to assess the impact of COVID-19 in perinatal mental health. The primary objectives are to (1) evaluate changes in perinatal mental health outcomes; and (2) determine the risk and protective factors for perinatal mental health during the COVID-19 pandemic. Additionally, we will compare the results between the countries participating in the study.

METHODS

This is an international prospective cohort study, with a baseline and three follow-up assessments over a six-month period. It is being carried out in 11 European countries (Albania, Bulgaria, Cyprus, France, Greece, Israel, Malta, Portugal, Spain, Turkey, and the United Kingdom), Argentina, Brazil and Chile. The sample consists of adult pregnant and postpartum women (with infants up to 6 months of age). The assessment includes measures on COVID-19 epidemiology and public health measures (Oxford COVID-19 Government Response Tracker dataset), Coronavirus Perinatal Experiences (COPE questionnaires), psychological distress (BSI-18), depression (EPDS), anxiety (GAD-7) and post-traumatic stress symptoms (PTSD checklist for DSM-V).

DISCUSSION

This study will provide important information for understanding the impact of the COVID-19 pandemic on perinatal mental health and well-being, including the identification of potential risk and protective factors by implementing predictive models using machine learning techniques. The findings will help policymakers develop suitable guidelines and prevention strategies for perinatal mental health and contribute to designing tailored mental health interventions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04595123 .

Mental health status of pregnant and breastfeeding women during the COVID-19 pandemic-A multinational cross-sectional study

Introduction

Evidence on perinatal mental health during the coronavirus disease 2019 (COVID‐19) pandemic and its potential determinants is limited. Therefore, this multinational study aimed to assess the mental health status of pregnant and breastfeeding women during the pandemic, and to explore potential associations between depressive symptoms, anxiety, and stress and women's sociodemographic, health, and reproductive characteristics.

Material and methods

A cross‐sectional, web‐based study was performed in Ireland, Norway, Switzerland, the Netherlands, and the UK between 16 June and 14 July 2020. Pregnant and breastfeeding women up to 3 months postpartum who were older than 18 years of age were eligible. The online, anonymous survey was promoted through social media and hospital websites. The Edinburgh Depression Scale (EDS), the Generalized Anxiety Disorder seven‐item scale (GAD‐7), and the Perceived Stress Scale (PSS) were used to assess mental health status. Regression model analysis was used to identify factors associated with poor mental health status.

Results

In total, 9041 women participated (including 3907 pregnant and 5134 breastfeeding women). The prevalence of major depressive symptoms (EDS ≥ 13) was 15% in the pregnancy cohort and and 13% the breastfeeding cohort. Moderate to severe generalized anxiety symptoms (GAD ≥ 10) were found among 11% and 10% of the pregnant and breastfeeding women. The mean (±SD) PSS scores for pregnant and breastfeeding women were 14.1 ± 6.6 and 13.7 ± 6.6, respectively. Risk factors associated with poor mental health included having a chronic mental illness, a chronic somatic illness in the postpartum period, smoking, having an unplanned pregnancy, professional status, and living in the UK or Ireland.

Conclusions

This multinational study found high levels of depressive symptoms and generalized anxiety among pregnant and breastfeeding women during the COVID‐19 outbreak. The study findings underline the importance of monitoring perinatal mental health during pandemics and other societal crises to safeguard maternal and infant mental health.

Parental Sensitivity and Responsiveness as Mediators Between Postpartum Mental Health and Bonding in Mothers and Fathers

Background: There is a lack of studies that examine the complex relationship between parental mental health, parental sensitivity and responsiveness, and parent-infant bonding. This study aimed to test whether parental sensitivity and responsiveness were mediators between postpartum mental health (depression, anxiety, and stress) and parent-infant bonding in mothers and fathers. Method: Mothers (n = 427) and fathers (n = 170) of infants aged up to 1-year-old participated in an online study. The parents completed questionnaires on depression (Edinburgh Postnatal Depression Scale, EPDS), anxiety and stress (Depression, Anxiety, and Stress Scale, DASS-21). Parent-infant bonding was measured by Postpartum Bonding Questionnaire (PBQ) that has three components: Impaired bonding (PBQ1), Anxiety about care and parental distress (PBQ2), and Lack of enjoyment and affection with infant (PB3Q). Parental sensitivity was measured as the number of correct recognitions of infant facial expressions (City Infant Faces Database, CIFD). Responsiveness was measured as a self-report with two subscales of responsiveness and non-responsiveness (Maternal Infant Responsiveness Instrument, MIRI). Results: The path analysis showed that the model had a good fit to the data. Parental sex was a significant moderator, indicating different paths in mothers and fathers. In mothers, responsiveness and non-responsiveness were significant mediators between depression symptoms and three dimensions of bonding. In fathers, only non-responsiveness was a significant mediator between anxiety and PBQ3. Although recognizing infant facial expressions directly affected PBQ3 in mothers (but not in fathers), it was not a significant mediator between mental health and bonding. Conclusion: Higher levels of parental mental health problems (depression and anxiety) were associated with lower levels of parental responsiveness, which is, in turn, related to poor parent-infant bonding. Prevention and intervention programs should be offered for both mothers and fathers, focusing on postpartum mental health promotion and enhancing responsiveness in infant care.

Sensitivity and reliability of screening measures for paternal postpartum depression: an integrative review

The American Academy of Pediatrics (AAP) recommends screening mothers for Postpartum Depression (PPD) during the postpartum period. Research shows depression in parents is associated with impaired growth and development in their children. The National Perinatal Association (NPA) encourages screening fathers for depression at least twice during the first postpartum year, however a preferred screening tool has yet to be determined. To promote optimal outcomes for children, providers must assess the mental health of all new parents, regardless of gender. Therefore, the purpose of this integrative review is to examine previous scientific evidence regarding the sensitivity of screening measures for postpartum depression in fathers. Future research should be directed towards describing the psychometric properties of a tool to assess postpartum mood disorders in American fathers while analyzing appropriate screening intervals during the postpartum period.

Screening for perinatal depression with the Patient Health Questionnaire depression scale (PHQ-9): A systematic review and meta-analysis

OBJECTIVES

Perinatal depression (PND) is a prevalent and disabling problem both during pregnancy and the postpartum period. The legacy screening measure has been the Edinburgh Postnatal Depression Scale (EPDS). This systematic review examines the validity of the PHQ-9 as a screener for PND.

METHODS

The following databases were searched from January 2001 (when the PHQ-9 was first published) through June 2020: MEDLINE, Embase, and PsychInfo. Studies that compared the PHQ-9 to a criterion standard psychiatric interview were used to determine the operating characteristics of sensitivity, specificity and area under the curve (AUC). Studies comparing the PHQ-9 to the EPDS and other depression scales evaluated convergent validity.

RESULTS

A total of 35 articles were eligible for criterion (n = 10) or convergent (n = 25) validity. Meta-analysis of the 7 criterion validity studies using the standard PHQ-9 cut point ≥10 showed a pooled sensitivity, specificity and AUC of 0.84, 0.81 and 0.89, respectively. Operating characteristics of the PHQ-9 and EPDS were nearly identical in head-to-head comparison studies. The median correlation between the PHQ-9 and EPDS was 0.59, and categorical agreement was moderate.

CONCLUSIONS

The PHQ-9 appears to be a viable option for perinatal depression screening with operating characteristics similar to the legacy EPDS.