Predicting postnatal depression among pregnant women

How mothers feel: Validation of a measure of maternal mood

RATIONALE

Low mood may affect developing relationships with a new baby, partner and family. Early identification of mood disturbance is crucial to improve outcomes for women perinatally. Instruments such as the Edinburgh Postnatal Depression Scale (EPDS) are used routinely, with evidence that some women do not feel comfortable with how they are asked about their mental health.

OBJECTIVE

To develop a mood checklist as a user-friendly, effective measure of well-being in post-partum women, for use by health professionals.

METHODS

Cognitive interviews with women who had recently given birth assessed response format and face validity of a prototype measure. A cross-sectional survey followed. A random split-half instrument development protocol was used. Exploratory factor analysis determined factor structure with the first sample,. The second sample confirmed factor structure and evaluationof key psychometric variables and known-groups discriminant validity (KGDV), requiring a supplementary between-subjects design with stratification based on case negative/case positive classification using EPDSscreening cut-off criteria.

RESULTS

Cognitive interview data confirmed the face validity of the measure. Exploratory factor analysis indicated an 18 item two-factor model with two (negatively) correlated factors. Factor 1 loaded with items reflecting positive mood and factor 2 negative items. Confirmatory factor analysis showed a good fit to the two-factor model across the full spectrum of fit indices. Statistically significant differences between groups were observed in relation to as EPDS caseness classification. Cronbach alpha coefficients for the positive and negative subscales revealed acceptable internal consistency of 0.79 and 0.72, respectively.

CONCLUSION

The outcome checklist may be appropriate for use in clinical practice. It demonstrated effective psychometric properties and clear cross-validation with existing commonly used measures.

A systematic review, evidence synthesis and meta-analysis of quantitative and qualitative studies evaluating the clinical effectiveness, the cost-effectiveness, safety and acceptability of interventions to prevent postnatal depression

BACKGROUND

Postnatal depression (PND) is a major depressive disorder in the year following childbirth, which impacts on women, their infants and their families. A range of interventions has been developed to prevent PND.

OBJECTIVES

To (1) evaluate the clinical effectiveness, cost-effectiveness, acceptability and safety of antenatal and postnatal interventions for pregnant and postnatal women to prevent PND; (2) apply rigorous methods of systematic reviewing of quantitative and qualitative studies, evidence synthesis and decision-analytic modelling to evaluate the preventive impact on women, their infants and their families; and (3) estimate cost-effectiveness.

DATA SOURCES

We searched MEDLINE, EMBASE, Science Citation Index and other databases (from inception to July 2013) in December 2012, and we were updated by electronic alerts until July 2013.

REVIEW METHODS

Two reviewers independently screened titles and abstracts with consensus agreement. We undertook quality assessment. All universal, selective and indicated preventive interventions for pregnant women and women in the first 6 postnatal weeks were included. All outcomes were included, focusing on the Edinburgh Postnatal Depression Scale (EPDS), diagnostic instruments and infant outcomes. The quantitative evidence was synthesised using network meta-analyses (NMAs). A mathematical model was constructed to explore the cost-effectiveness of interventions contained within the NMA for EPDS values.

RESULTS

From 3072 records identified, 122 papers (86 trials) were included in the quantitative review. From 2152 records, 56 papers (44 studies) were included in the qualitative review. The results were inconclusive. The most beneficial interventions appeared to be midwifery redesigned postnatal care [as shown by the mean 12-month EPDS score difference of -1.43 (95% credible interval -4.00 to 1.36)], person-centred approach (PCA)-based and cognitive-behavioural therapy (CBT)-based intervention (universal), interpersonal psychotherapy (IPT)-based intervention and education on preparing for parenting (selective), promoting parent-infant interaction, peer support, IPT-based intervention and PCA-based and CBT-based intervention (indicated). Women valued seeing the same health worker, the involvement of partners and access to several visits from a midwife or health visitor trained in person-centred or cognitive-behavioural approaches. The most cost-effective interventions were estimated to be midwifery redesigned postnatal care (universal), PCA-based intervention (indicated) and IPT-based intervention in the sensitivity analysis (indicated), although there was considerable uncertainty. Expected value of partial perfect information (EVPPI) for efficacy data was in excess of £150M for each population. Given the EVPPI values, future trials assessing the relative efficacies of promising interventions appears to represent value for money.

LIMITATIONS

In the NMAs, some trials were omitted because they could not be connected to the main network of evidence or did not provide EPDS scores. This may have introduced reporting or selection bias. No adjustment was made for the lack of quality of some trials. Although we appraised a very large number of studies, much of the evidence was inconclusive.

CONCLUSIONS

Interventions warrant replication within randomised controlled trials (RCTs). Several interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty.

FUTURE WORK RECOMMENDATIONS

Several interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty. Future research conducting RCTs to establish which interventions are most clinically effective and cost-effective should be considered.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012003273.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Economic and Health Predictors of National Postpartum Depression Prevalence: A Systematic Review, Meta-analysis, and Meta-Regression of 291 Studies from 56 Countries

BACKGROUND

Postpartum depression (PPD) poses a major global public health challenge. PPD is the most common complication associated with childbirth and exerts harmful effects on children. Although hundreds of PPD studies have been published, we lack accurate global or national PPD prevalence estimates and have no clear account of why PPD appears to vary so dramatically between nations. Accordingly, we conducted a meta-analysis to estimate the global and national prevalence of PPD and a meta-regression to identify economic, health, social, or policy factors associated with national PPD prevalence.

METHODS

We conducted a systematic review of all papers reporting PPD prevalence using the Edinburgh Postnatal Depression Scale. PPD prevalence and methods were extracted from each study. Random effects meta-analysis was used to estimate global and national PPD prevalence. To test for country level predictors, we drew on data from UNICEF, WHO, and the World Bank. Random effects meta-regression was used to test national predictors of PPD prevalence.

FINDINGS

291 studies of 296284 women from 56 countries were identified. The global pooled prevalence of PPD was 17.7% (95% confidence interval: 16.6-18.8%), with significant heterogeneity across nations (Q = 16,823, p = 0.000, I2 = 98%), ranging from 3% (2-5%) in Singapore to 38% (35-41%) in Chile. Nations with significantly higher rates of income inequality (R2 = 41%), maternal mortality (R2 = 19%), infant mortality (R2 = 16%), or women of childbearing age working ≥40 h a week (R2 = 31%) have higher rates of PPD. Together, these factors explain 73% of the national variation in PPD prevalence.

INTERPRETATION

The global prevalence of PPD is greater than previously thought and varies dramatically by nation. Disparities in wealth inequality and maternal-child-health factors explain much of the national variation in PPD prevalence.

Mechanisms of Resilience in Children of Mothers Who Self-Report with Depressive Symptoms in the First Postnatal Year

Background

Symptoms of maternal postnatal depression are associated with an increased risk of adverse effects on child development. However, some children exposed to postnatal depression have outcomes similar to unexposed children, and can be referred to as resilient. This study aimed to determine the mechanisms of resilience in children exposed to depressive symptoms postnatally.

Method

Data are from a prospective cohort study, the Avon Longitudinal Study of Parents and Children. Self-report questionnaire data were collected during pregnancy and the child’s first 2 years regarding maternal views of parenting and her perception of the child. The Edinburgh Postnatal Depression Scale (EPDS) was completed postnatally at 8 months and the Strengths and Difficulties Questionnaire (SDQ) at age 11 years. Exposed children who scored above the median score of non-exposed children were defined as resilient. Structural equation modeling was used to investigate the development of resilience.

Results

From the core ALSPAC cohort, 1,009 children (6.9%) were exposed to maternal depression at 8 months postnatally. The SDQ total difficulties scores at 11 years of age indicated that 325 (32.2%) were resilient, 684 were non-resilient. Maternal positive feelings about parenting and child non-verbal communication at 15 months increased the likelihood of later resilience.

Conclusions

In this study, resilience was associated with two factors: the child’s nonverbal communication at 15 months and by maternal positive feelings about parenting. Early intervention to support mother-child interaction and foster child development in women identified with postnatal depressive symptoms may benefit later child resilience.

Postpartum psychiatric disorders: Early diagnosis and management

Postpartum period is demanding period characterized by overwhelming biological, physical, social, and emotional changes. It requires significant personal and interpersonal adaptation, especially in case of primigravida. Pregnant women and their families have lots of aspirations from the postpartum period, which is colored by the joyful arrival of a new baby. Unfortunately, women in the postpartum period can be vulnerable to a range of psychiatric disorders like postpartum blues, depression, and psychosis. Perinatal mental illness is largely under-diagnosed and can have far reaching ramifications for both the mother and the infant. Early screening, diagnosis, and management are very important and must be considered as mandatory part of postpartum care.

Psychiatric symptoms and disorders associated with reproductive cyclicity in women: advances in screening tools

Female-specific psychiatric illness including premenstrual dysphoria, perinatal depression, and psychopathology related to the perimenopausal period are often underdiagnosed and treated. These conditions can negatively affect the quality of life for women and their families. The development of screening tools has helped guide our understanding of these conditions. There is a wide disparity in the methods, definitions, and tools used in studies relevant to female-specific psychiatric illness. As a result, there is no consensus on one tool that is most appropriate for use in a research or clinical setting. In reviewing this topic, we hope to highlight the evolution of various tools as they have built on preexisting instruments and to identify the psychometric properties and clinical applicability of available tools. It would be valuable for researchers to reach a consensus on a core set of screening instruments specific to female psychopathology to gain consistency within and between clinical settings.

Measuring the risk factors for postpartum depression: development of the Japanese version of the Postpartum Depression Predictors Inventory-Revised (PDPI-R-J)

Background

Postpartum depression (PPD) is a global phenomenon. Depression in the first month following delivery is experienced by 20% of mothers in Japan. Therefore, a screening instrument that identifies the risk for depression during pregnancy and in the early postpartum period is required for primary prevention. The aims of this study were to develop the Japanese version of the Postpartum Depression Predictors Inventory-Revised (PDPI-R-J) and determine its predictive validity during pregnancy and one month after delivery.

Methods

In order to develop the inventory, two bilingual translators translated the PDPI-R into Japanese. Then, back translation was done and a thorough discussion with the original developer was conducted in order to establish semantic equivalence. After the PDPI-R-J was developed, the study used a prospective cohort design. A total of 84 women in their eighth month of pregnancy participated in the study. Seventy-six mothers completed the PDPI-R-J at the first month after childbirth. Women were diagnosed using Mini-International Neuropsychiatric Interview (M.I.N.I.) to determine the presence of minor or major depression at the first month after childbirth and the receiver operating characteristic curve was plotted to evaluate the predictive capacity of PDPI-R-J.

Results

Of the 76 mothers who completed the PDPI-R-J during the first-month assessment, 16 mothers (21%) met the PPD criteria. The prenatal version of the PDPI-R-J administered during pregnancy accurately predicted 62.8% of PPD (95% CI 0.48–0.77) and the postpartum version administered at the first month after delivery predicted 82.0% of PPD (95% CI 0.71–0.93). The cutoffs identified were 5.5 for the prenatal version and 7.5 for the postpartum version. The PDPI-R-J postpartum version, which includes items relating to the infant, increased the predictive validity of PPD (0.67 to 0.82). Comments from the participants included that the use of the PDPI-R-J enhanced the chance to openly communicate about their history and risks for depression with the researchers, if any existed.

Conclusions

The PDPI-R-J was found to be a useful and valid screening tool for predicting PPD. Both the prenatal and postpartum versions should be continuously administered to mothers because delivery and infant-related factors affect the potential for PPD.

Psychosocial and psychological interventions for preventing postpartum depression

BACKGROUND

Epidemiological studies and meta-analyses of predictive studies have consistently demonstrated the importance of psychosocial and psychological variables as postpartum depression risk factors. While interventions based on these variables may be effective treatment strategies, theoretically they may also be used in pregnancy and the early postpartum period to prevent postpartum depression.

OBJECTIVES

Primary: to assess the effect of diverse psychosocial and psychological interventions compared with usual antepartum, intrapartum, or postpartum care to reduce the risk of developing postpartum depression. Secondary: to examine (1) the effectiveness of specific types of psychosocial and psychological interventions, (2) the effectiveness of professionally-based versus lay-based interventions, (3) the effectiveness of individually-based versus group-based interventions, (4) the effects of intervention onset and duration, and (5) whether interventions are more effective in women selected with specific risk factors.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2011), scanned secondary references and contacted experts in the field. We updated the search on 31 December 2012 and added the results to the awaiting classification section of the review for assessment at the next update.

SELECTION CRITERIA

All published and unpublished randomised controlled trials of acceptable quality comparing a psychosocial or psychological intervention with usual antenatal, intrapartum, or postpartum care.

DATA COLLECTION AND ANALYSIS

Review authors and a research co-ordinator with Cochrane review experience participated in the evaluation of methodological quality and data extraction. Additional information was sought from several trial researchers. Results are presented using risk ratio (RR) for categorical data and mean difference (MD) for continuous data.

MAIN RESULTS

Twenty-eight trials, involving almost 17,000 women, contributed data to the review. Overall, women who received a psychosocial or psychological intervention were significantly less likely to develop postpartum depression compared with those receiving standard care (average RR 0.78, 95% confidence interval (CI) 0.66 to 0.93; 20 trials, 14,727 women). Several promising interventions include: (1) the provision of intensive, individualised postpartum home visits provided by public health nurses or midwives (RR 0.56, 95% CI 0.43 to 0.73; two trials, 1262 women); (2) lay (peer)-based telephone support (RR 0.54, 95% CI 0.38 to 0.77; one trial, 612 women); and (3) interpersonal psychotherapy (standardised mean difference -0.27, 95% CI -0.52 to -0.01; five trials, 366 women). Professional- and lay-based interventions were both effective in reducing the risk to develop depressive symptomatology. Individually-based interventions reduced depressive symptomatology at final assessment (RR 0.75, 95% CI 0.61 to 0.92; 14 trials, 12,914 women) as did multiple-contact interventions (RR 0.78, 95% CI 0.66 to 0.93; 16 trials, 11,850 women). Interventions that were initiated in the postpartum period also significantly reduced the risk to develop depressive symptomatology (RR 0.73, 95% CI 0.59 to 0.90; 12 trials, 12,786 women). Identifying mothers 'at-risk' assisted the prevention of postpartum depression (RR 0.66, 95% CI 0.50 to 0.88; eight trials, 1853 women).

AUTHORS' CONCLUSIONS

Overall, psychosocial and psychological interventions significantly reduce the number of women who develop postpartum depression. Promising interventions include the provision of intensive, professionally-based postpartum home visits, telephone-based peer support, and interpersonal psychotherapy.

Risk and protective factors associated with postnatal depression in Mexican adolescents

We explored factors associated with postnatal depression and further evaluated whether any of these risk and protective factors are specific for adolescent mothers. Data concerning depression levels, family and individual factors were collected in a cross-sectional study which surveyed 298 women in Monterrey, N.L., Mexico. Mean maternal age was 24.64 years, and 27.18% of the mothers were between 14 and 19 years old. Prevalence of postnatal depression was higher in adolescents (16.05%) than in adult mothers (14.29%) but, on average, this difference was not significant. The association between individual factors and postnatal depression for both adult and adolescent mothers was explored. Our results revealed that social support is significantly associated with less possibility of postnatal depression in both groups, and that this effect is stronger for adolescents (OR=0.81) than for adults (OR=0.92). For the sample as a whole postnatal depression was associated with lower levels of education, reported fear during labor and living with partner. We also found that having a girl greatly increased the possibility of postnatal depression. We conclude that social support is a protective factor associated with postnatal depression, especially for adolescents.

Risk factors for postpartum depression: the role of the Postpartum Depression Predictors Inventory-Revised (PDPI-R). Results from the Perinatal Depression-Research & Screening Unit (PNDReScU) study

The aims of this study were to identify the frequency of the risk factors for postpartum depression (PPD) listed in the Postpartum Depression Predictors Inventory-Revised (PDPI-R) during pregnancy and 1 month after delivery and to determine the predictive validity of the PDPI-R. The study used a prospective cohort design. Women completed the PDPI-R at the 3rd and the 8th months of pregnancy and at the 1st month after childbirth. Women were prospectively followed across three different time points during the postpartum using Structured Clinical Interview for DSM-IV Disorders to determine the presence of major or minor depression. The prenatal version of the PDPI-R administered at two different time points during pregnancy predicted accurately 72.6% and 78.2% of PPD and the full version administered at the 1st month after delivery predicted 83.4% of PPD. The cutoffs identified were 3.5 for the prenatal version and 5.5 for the full version. The PDPI-R is a useful and a valid screening tool for PPD.

Antenatal psychosocial assessment: how accurate are we in determining 'low-risk' status? A pilot study

Routine Comprehensive Psychosocial Assessment was implemented antenatally at a public hospital in Sydney in 2000. The assessment, completed on all women, classifies them as (1) currently, or at high-risk of becoming, distressed, or, (2) not currently, or at low risk of becoming, distressed during the perinatal period. This pilot study followed up a sample of women (N = 50) from the latter group at 6 weeks postpartum to explore the accuracy of 'low risk' identification. All but one woman reported that they continued to do well during their pregnancy. By 6 weeks postpartum only one woman scored high on the validated depression measure though data from a semi-structured interview indicated that a further four women experienced sub-clinical difficulty in the early weeks postpartum. The antenatal classification of women as 'low risk' using this assessment method appears to be substantially accurate, though this finding needs to be replicated in a larger study.

Exploring the Postpartum Adjustment Questionnaire as a predictor of postpartum depression

OBJECTIVE

To evaluate the usefulness of the Postpartum Adjustment Questionnaire in predicting symptoms of postpartum depression as measured by scores from the Postpartum Depression Screening Scale.

DESIGN

Prospective descriptive.

SETTING

Mid-sized urban regional medical center.

PARTICIPANTS

A convenience sample of 200 English-speaking postpartum women.

MAIN OUTCOME MEASURES

Postpartum Depression Screening Scale scores and demographic data obtained at 6 weeks postpartum were compared with Postpartum Adjustment Questionnaire scores obtained before women were discharged from the hospital following delivery.

RESULTS

Using the total Postpartum Adjustment Questionnaire score, a cut point of 4 or higher was found to have the best positive predictive power in predicting postpartum depression symptoms. However, similar results were seen when 1 question from the Postpartum Adjustment Questionnaire was used rather than the entire survey. Overall, the Postpartum Adjustment Questionnaire had a moderate correlation (.28) with Postpartum Depression Screening Scale scores.

CONCLUSION

The Postpartum Adjustment Questionnaire may be a valid predictor of postpartum depression, although it will identify only about 40% of women who develop this condition. Using a single question to identify women at risk for postpartum depression offers a cost-effective alternative to the complete questionnaire. Further studies with larger, multiethnic samples are needed before conclusions can be drawn and definitive recommendations for practice made.

Antenatal psychosocial assessment for reducing perinatal mental health morbidity

BACKGROUND

Mental health conditions arising in the perinatal period, including depression, have the potential to impact negatively on not only the woman but also her partner, infant, and family. The capacity for routine, universal antenatal psychosocial assessment, and thus the potential for reduction of morbidity, is very significant.

OBJECTIVES

To evaluate the impact of antenatal psychosocial assessment on perinatal mental health morbidity.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, the Cochrane Depression, Anxiety and Neurosis Group's Trials Register (CCDAN TR-Studies), HSRProj in the National Library of Medicine (USA), and the Current Controlled Trials website: http://www.controlled trials.com/ and the UK National Research Register (last searched March 2008).

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trials for eligibility; they also extracted data from included trials and assessed the trials for potential bias.

MAIN RESULTS

Two trials met criteria for an RCT of antenatal psychosocial assessment. One trial examined the impact of an antenatal tool (ALPHA) on clinician awareness of psychosocial risk, and the capacity of the antenatal ALPHA to predict women with elevated postnatal Edinburgh Depression Scale (EDS) scores, finding a trend towards increased clinician awareness of 'high level' psychosocial risk where the ALPHA intervention had been used (relative risk (RR) 4.61 95% confidence interval (CI) 0.99 to 21.39). No differences between groups were seen for numbers of women with antenatal EDS scores, a score of greater than 9 being identified by ALPHA as of concern for depression (RR 0.69 95% CI 0.35 to 1.38); 139 providers. The other trial reported no differences in EPS scores greater than 12 at 16 weeks postpartum between the intervention (communication about the EDS scores with the woman and her healthcare providers plus a patient information booklet) and the standard care groups (RR 0.86 95% CI 0.61 to 1.21; 371 women).

AUTHORS' CONCLUSIONS

While the use of an antenatal psychosocial assessment may increase the clinician's awareness of psychosocial risk, neither of these small studies provides sufficient evidence that routine antenatal psychosocial assessment by itself leads to improved perinatal mental health outcomes. Further studies with better sample size and statistical power are required to further explore this important public health issue. It will also be important to examine outcomes up to one year postpartum not only for mother, but also infant and family.

Effects of music therapy on psychological health of women during pregnancy

AIMS AND OBJECTIVES

The purpose of this study was to examine the effects of music therapy on stress, anxiety and depression in Taiwanese pregnant women.

BACKGROUND

The value of music therapy is slowly being realized by nurses in various clinical areas, including obstetrics. Previous studies have demonstrated a high prevalence of psychological stress during pregnancy. Few studies have examined the effects of music therapy on reducing psychological stress during pregnancy.

DESIGN

A randomized experimental study design was developed and implemented.

METHODS

Two hundred and thirty-six pregnant women were randomly assigned to music therapy (n = 116) and control (n = 120) groups. The music therapy group received two weeks of music intervention. The control group received only general prenatal care. Psychological health was assessed using three self-report measures: Perceived Stress Scale (PSS), State Scale of the State-Trait Anxiety Inventory (S-STAI) and Edinburgh Postnatal Depression Scale (EPDS).

RESULTS

In a paired t-test, the music therapy group showed significant decrease in PSS, S-STAI and EPDS after two weeks. The control group only showed a significant decrease in PSS after two weeks. This decrease was not as substantial as in the experimental group. An ancova test with the pretest scores as the control revealed that the changes in PSS, S-STAI and EPDS after two weeks were significantly decreased in the experimental group compared with the control group.

CONCLUSIONS

This controlled trial provides preliminary evidence that two-week music therapy during pregnancy provides quantifiable psychological benefits.

RELEVANCE TO CLINICAL PRACTICE

The findings can be used to encourage pregnant women to use this cost-effective method of music in their daily life to reduce their stress, anxiety and depression. Further research is needed to test the long-term benefits.

Does antenatal screening for psychosocial risk factors predict postnatal depression? A follow-up study of 154 women in Adelaide, South Australia

OBJECTIVE

This study investigated the effectiveness of antenatal screening for psychosocial risk factors in predicting postnatal depression, in women living in a socioeconomically deprived area.

METHOD

154 women completed the Antenatal Psychosocial Questionnaire (APQ) and the Edinburgh Postnatal Depression Scale (EPDS). Logistic regression analysis was used to identify antenatal psychosocial risk factors predictive of EPDS caseness, with an EPDS score of 10 or more being taken to indicate depression.

RESULTS

Antenatal depression was more common than postnatal depression. 44 women (30%) met criteria for antenatal depression and 33 women (22.6%) met criteria for postnatal depression. 21 women (14.4%) were depressed both before and after delivery of their baby, and women who had antenatal depression were significantly more likely to be depressed postnatally. Whilst there were high rates of endorsement of antenatal psychosocial risk factors, the only item from the APQ that predicted postnatal depression was emotional abuse as a child.

CONCLUSION

Antenatal screening for psychosocial risk factors was useful in identifying problems during the antenatal period, but was not useful as a predictor of postnatal depression.

Further Development of the Postpartum Depression Predictors Inventory‐Revised

OBJECTIVES

To describe the newly developed item coding and computation of the total score for the Postpartum Depression Predictors Inventory-Revised along with recommended cutoff points.

DESIGN

Methodologic research.

SETTING

Obstetrician and gynecologist offices in the Pacific Northwest.

PARTICIPANTS

This longitudinal study included 139 women; the study began in the participant's third trimester of pregnancy and ended at 8 months after childbirth.

METHODS

The participants completed the Postpartum Depression Predictors Inventory-Revised in their third trimester of pregnancy and again at 2 and 6 months after childbirth. Postpartum depression symptoms were measured by the Edinburgh Postnatal Depression Scale and psychiatric nurse practitioner interview at 2 and 6 months after childbirth.

MAIN OUTCOME MEASURES

Sensitivity and specificity of the Postpartum Depression Predictors Inventory-Revised at three points: prenatal and 2 and 6 months after childbirth.

RESULTS

The receiver operating characteristic curve analysis indicated that the Prenatal Postpartum Depression Predictors Inventory-Revised performed well and explained 67% of the variance of postpartum depressive symptomatology as measured by Edinburgh Postnatal Depression Scale scores. The Prenatal Postpartum Depression Predictors Inventory-Revised yielded a sensitivity of .76 and a specificity of .54 at a cutoff score of 10.5.

CONCLUSIONS

A cutoff score of 10.5 is recommended when using the Postpartum Depression Predictors Inventory-Revised during pregnancy. Further research needs to be conducted on recommended cutoff scores for use of the Postpartum Depression Predictors Inventory-Revised during the postpartum period.

Prevalence and psychosocial correlates of depressed mood during pregnancy and after childbirth in a Moroccan sample

The objective of the current study was to determine the prevalence of depression among 100 women followed from the first trimester of pregnancy to 9 months after delivery. Mini International Neuropsychiatric Interview, Edinburgh Postnatal Depression Scale and Paykel Life Events Inventory were used. Seventeen per cent of the subjects experienced depression during postpartum, 19.2% started their episode during pregnancy. Psychosocial variables were positively correlated to depression during pregnancy.

Are Slovenian midwives and nurses ready to take on a greater role in caring for women with postnatal depression?

OBJECTIVE

to answer the question of whether Slovenian midwives and nurses feel prepared to take over the responsibility for the care of women with postnatal depression.

DESIGN

questionnaire survey using a tool designed with data from previously conducted focus groups and a literature review.

SETTING

the central maternity hospital and six community centres in the Slovenian capital city of Ljubljana.

PARTICIPANTS

134 participants completed the questionnaire, out of 175 distributed. The sample consisted of 86 participants from the maternity hospital, who were almost evenly divided into midwives and nurses, and 48 participants from the community services, where nurses prevailed over midwives.

FINDINGS

participants lacked knowledge of postnatal mental health, and 99% of them expressed the need for more information. They considered the woman's partner to be the most appropriate person to detect postnatal depression, and doctors to be the key people involved in the treatment. In order to take over the role of prevention, detection and management of postnatal depression, midwives and nurses felt that they would need more knowledge and more continuous contact with women.

KEY CONCLUSIONS

most participants did not know the main characteristics of postnatal depression, and were not confident in their knowledge. They felt that they lacked continuity in the care they could provide, and this affected their ability to establish a trusting relationship with women.

IMPLICATIONS FOR PRACTICE

information on postnatal mental health should be provided during undergraduate study of midwifery and nursing, and with continuous education through seminars and workshops in Slovenia. In order to enable continuity of carer, the role of the midwife should be expanded in pregnancy, and more visits in the puerperium should be planned.

Prospective testing of the Brisbane Postnatal Depression Index

BACKGROUND

Over 50 percent of women have one or more risk factors for postnatal depression during pregnancy or in the perinatal period, but only 10 to 15 percent become clinically depressed. The objective of this study was to prospectively test the Brisbane Postnatal Depression Index (referred to here as Index), to validate a theoretical index that was developed earlier, and to establish whether the index could be introduced as a clinically useful method to detect women who may be at risk for developing postnatal depression.

METHODS

Antenatally, women were asked about social support and about personal and family history of mental illness, including postnatal depression. Responses were scored according to predefined ratings on the Index. In the postnatal wards, 353 women were recruited and their scores for "blues," social support, feelings about the baby, and satisfaction with the birth process were added. Sixteen weeks after hospital discharge, women were asked to complete the Edinburgh Postnatal Depression Scale. The Brisbane Index was validated by the number of women scoring more than 12 on the Edinburgh Postnatal Depression Scale at 16 weeks postpartum who were correctly predicted by a score of more than 6 on the Index. Sensitivity, specificity, positive predictive value, and negative predictive value for the Index, using >6 as a cutoff point, were calculated. "Ease of use" was assessed informally with participants and staff responsible for administration and scoring the instrument.

RESULTS

Compared with results from the derivation study, prospective testing of the index showed an improvement in sensitivity from 36.3 to 47.5 percent and a small decrease in specificity, but no improvement on the positive predictive value from 39.8 to 39.6 percent.

CONCLUSION

The Brisbane Postnatal Depression Index was validated in a prospective sample, but its sensitivity and specificity require improvement before introduction as a measure of prediction.

Psychosocial and psychological interventions for preventing postpartum depression

BACKGROUND

The cause of postpartum depression remains unclear, with extensive research suggesting a multi-factorial aetiology. However, epidemiological studies and meta-analyses of predictive studies have consistently demonstrated the importance of psychosocial and psychological variables. While interventions based on these variables may be effective treatment strategies, theoretically they may also be used in pregnancy and the early postpartum period to prevent postpartum depression.

OBJECTIVES

Primary: to assess the effect of diverse psychosocial and psychological interventions compared with usual antepartum, intrapartum, or postpartum care to reduce the risk of developing postpartum depression. Secondary: to examine (1) the effectiveness of specific types of psychosocial and psychological interventions, (2) the effectiveness of individual versus group-based interventions, (3) the effects of intervention onset and duration, and (4) whether interventions are more effective in women selected with specific risk factors.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (January 27 2004), the Cochrane Depression, Anxiety and Neurosis Group trials register (October 2003), the Cochrane Central Register of Controlled Trials (October 2003), MEDLINE (1966 to 2004), EMBASE (1980 to 2004) and CINAHL (1982 to 2004). We scanned secondary references and contacted experts in the field.

SELECTION CRITERIA

All published and unpublished randomised controlled trials of acceptable quality comparing a psychosocial or psychological intervention with usual antenatal, intrapartum, or postpartum care.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

Fifteen trials, involving over 7600 women, were included. Overall, women who received a psychosocial intervention were equally likely to develop postpartum depression as those receiving standard care (relative risk (RR) 0.81, 95% confidence interval (CI) 0.65 to 1.02). One promising intervention appears to be the provision of intensive postpartum support provided by public health nurses or midwives (RR 0.68, 95% CI 0.55 to 0.84). Identifying mothers 'at-risk' assisted the prevention of postpartum depression (RR 0.67, 95% CI 0.51 to 0.89). Interventions with only a postnatal component appeared to be more beneficial (RR 0.76, 95% CI 0.58 to 0.98) than interventions that also incorporated an antenatal component. While individually-based interventions may be more effective (RR 0.76, 95% CI 0.59 to 1.00) than those that are group-based, women who received multiple-contact intervention were just as likely to experience postpartum depression as those who received a single-contact intervention.

REVIEWERS' CONCLUSIONS

Overall psychosocial interventions do not reduce the numbers of women who develop postpartum depression. However, a promising intervention is the provision of intensive, professionally-based postpartum support.

Considering a simple strategy for detection of women at risk of psychological distress after childbirth

BACKGROUND

Postpartum depression is a common, severe, yet often undetected condition. Between 10 and 15 percent of new mothers suffer from depressive disorders in the first year after childbirth. The objective of this study was to investigate whether asking women questions about their daily life constituted a useful strategy to detect women at risk of developing psychological distress after childbirth.

METHODS

A prospective study of 330 first- and second-time mothers was conducted. Structured interviews with women were performed at the maternity unit 1 to 2 days after childbirth, and postal questionnaires were sent to participants 5 months later. An interviewer wrote down her perception of the mood of participants, in the form of three short statements, immediately after the interview. This perception was compared with the score of the woman on the General Health Questionnaire scale, which was included in the 5 months' questionnaire.

RESULTS

The interviewer's perception of women's mood was significantly associated with the score on the General Health Questionnaire scale 5 months later. Multivariate analysis showed that the interviewer's perception of anxiety was a better predictor of postpartum psychological distress at 5 months than women's answers to questions about their mood before pregnancy and 1 to 2 days after delivery.

CONCLUSIONS

Asking the new mother questions about her private and occupational life can be considered as one of many possible ways to improve the identification of women at risk of developing postpartum depression.

A simplified predictive index for the detection of women at risk for postnatal depression

BACKGROUND

Many women who suffer from postnatal depression are never diagnosed or treated. The objective of this study was to develop an index for use in maternity settings that identifies women who may be at risk for postnatal depression.

METHODS

Women (n = 1762) attending the "booking-in" clinic were screened for antenatal risk factors for postnatal depression. On the third postnatal day eligible women were screened for postnatal risk factors. The Edinburgh Postnatal Depression Scale was mailed to participants 16 weeks after the birth. A predictive index was developed, based on the mean Edinburgh Postnatal Depression Scale scores for each risk factor. The sensitivity, specificity, positive predictive value, and negative predictive value were used to assess the diagnostic value of the index.

RESULTS

Seven hundred and twenty-three (50.1%) of the eligible women completed all phases of the study. Of this group, 93 (12.2%) women scored higher than 12 on the Edinburgh Postnatal Depression Scale. At a cutoff of 6, the index had positive predictive value of 39.8 percent for postnatal depression, a threefold improvement over the base rate.

CONCLUSION

The Brisbane Postnatal Depression Index provides a clinically useful method for identifying women at risk for developing postnatal depression. It has applications for early intervention or to identify high-risk groups for research purposes.

Antenatal screening for postnatal depression: a systematic review

OBJECTIVE

To describe the screening properties of the antenatal tools which have been developed to predict depression after birth and to summarize the implications of the findings for antenatal screening.

METHOD

Systematic review and secondary analysis of published papers.

RESULTS

Sixteen studies including sufficient data for the calculation of screening properties were identified. The majority developed a study-specific screening instrument. Outcome assessments used the Edinburgh Postnatal Depression Scale or standardized diagnostic psychiatric interviews, or both. In the two largest population-based studies, the proportion of women screening as positive ('at risk' of postnatal depression) was 16 and 52%, respectively, and of these only 35 and 8% actually developed depression after birth.

CONCLUSION

No screening instrument(s) met the criteria for routine application in the antenatal period. Factors that may have affected poor sensitivity and positive predictive values include the exclusion of key domains in predicting risk, particularly personality, a past history of abuse and postnatal events, the contribution of which may be being under-estimated in studies evaluating antenatal risk prediction tools.

The role of alternative medicine in treating postnatal depression

Postnatal depression is a serious and debilitating condition. Due to the perceived stigma of mental illness, the incidence of it is underreported and many mothers refuse psychiatric help either assuming postnatal depression to be normal or because of the potential consequences of having a psychiatric history. Community practitioners who are in contact with new mothers may welcome additional interventions which can enhance the supportive care they give to these women. This article discusses the evidence for a number of these interventions which mothers may find more acceptable than orthodox treatment. The aim of this article is to highlight the possible role of a number of complementary and alternative medicines as adjuncts or alternative treatments for postnatal depression. The interventions discussed in this article include Ayurvedic medicine, herbalism, homeopathy, aromatherapy, massage, hypnosis and traditional Chinese medicine (TCM). With the exception of TCM and Ayurvedic medicine, these interventions have been supported by the House of Lord's Select Committee on Science and Technology (2000) as having an evidence base. Ayurvedic medicine and TCM have been included in this article however, because a number of clients may be using them as their main system of health care--thereby validating the need for information regarding their efficacy. This article is not exhaustive, nor a licence to practice, but is intended as a resource for practitioners with a sound understanding of postnatal depression and conventional treatments whose clients may reject these approaches and be looking for alternative interventions. The final choice of treatment should be the result of discussion between the health visitor and the client and will depend on considerations such as availability, cost and acceptability of the intervention--this article does not, therefore, suggest a 'best option' approach. In addition, it does not address the professional and legal responsibilities of practitioners since these have been well reviewed by Darley (1995), Mantle (1997), Knape (1998) and Rankin-Box (2001).

Revision of the postpartum depression predictors inventory

Postpartum depression has been described as a thief that steals motherhood. Early recognition is one of the major challenges with this devastating mood disorder. This article describes a revised version of the Postpartum Depression Predictors Inventory (PDPI) based on the results of an updated meta-analysis. This revised inventory consists of 13 risk factors related to postpartum depression. Guide questions for each of the 13 predictors that clinicians can use during an interview process also are included. Included among these 13 predictors in the PDPI-Revised are four new risk factors: self-esteem, marital status, socioeconomic status, and unplanned/unwanted pregnancy. Ideally, this checklist should be completed each trimester to update a pregnant woman's risk status. After a woman gives birth, the PDPI-Revised should be used to continue to monitor her risk status because she can develop postpartum depression at any time during the 1st year after childbirth.

What interventions may reduce postpartum depression

Postnatal depression is a major public health problem affecting about one in seven women after childbirth. Depression is also common during pregnancy and throughout the perinatal period it is associated with symptoms of anxiety. Apart from the adverse consequences for women themselves becoming depressed when they are going through demanding physical and social changes, there are additional concerns. There is the possible negative impact of maternal depression on the relationship between mother and child and on the child's emotional, behavioural and cognitive development. Primary prevention and early intervention/secondary prevention strategies are potentially important in view of the frequent contact pregnant women, new mothers and infants have with health services, but the effectiveness of these strategies needs to be tested. In the past year there have been five new studies of antenatal screening for postnatal depression. These studies are consistent with nine earlier studies in showing that there is no evidence to support routine antenatal screening for postnatal depression. Seven new primary prevention/early intervention trials add evidence on a wide range of interventions ranging from practical support to individual interpersonal therapy, but without identifying significant differences in depression as an outcome. Two new trials of secondary prevention, one involving interpersonal therapy and the other including partners in a series of psychoeducational visits, show promise but neither is large enough to form a basis for practice change. Novel interventions, or promising findings, with a strong basis in theory need to be tested in trials which are appropriately sized and which comply with internationally accepted design and reporting guidelines.

Operative intervention in delivery is associated with compromised early mother-infant interaction

OBJECTIVE

To investigate the effects of mode and place of delivery on first mother-infant contact and maternal emotional wellbeing.

DESIGN

A prospective, longitudinal study.

PARTICIPANTS

A sociodemographically representative sample of 203 consecutive primiparous women was recruited, of whom 81% (n = 164) were followed up.

SETTING

Four metropolitan hospitals, including one accredited baby friendly hospital, in Melbourne, Australia, 1997.

METHODS

During the postnatal hospital stay women were interviewed and medical records were inspected.

PARTICIPANTS

completed two self-report psychometric measures: the Edinburgh Postnatal Depression Scale (EPDS) and the Profile of Moods States (POMS). Follow up at eight months postpartum comprised completion of a postal questionnaire and repeat administration of the standardised self-report psychometric mood questionnaires.

RESULTS

The First Contact Index provides a measure of the first contact between a mother and her baby after the birth. Two-way analysis of variance revealed significant differences in First Contact Index between three modes of delivery groups: spontaneous, instrumentally-assisted, and caesarean section (P < 0.001) and four hospital of delivery groups (P < 0.001), but there was no significant interaction effect (P = 0.55). Significant negative correlations existed between the First Contact Index and both the POMS and EPDS scores at two days postpartum (POMS, r = -0.339, 95% Cl -0.46 to -0.22; EPDS, r = -0.279, 95% CI -0.41 to -0.16), even within delivery groups, and these were still present at eight months postpartum (POMS, r = -0.298, 95% CI -0.44 to -0.14, EPDS, r = -0.206, 95% CI -0.36 to -0.03).

CONCLUSION

Instrumental and surgical delivery exert a negative impact on first postnatal contact between a mother and her baby which has persistent adverse maternal emotional correlates. Hospital practices associated with obstetric intervention in delivery also varied and are amenable to change, enabling optimal first mother-baby interaction regardless of mode of delivery.

The role of alternative medicine in treating postnatal depression

Postnatal depression is a serious and debilitating condition. Due to the perceived stigma of mental illness, the incidence of it is under-reported and many mothers refuse psychiatric help, either assuming postnatal depression to be normal or because of the potential consequences of having a psychiatric history. Community practitioners who are in contact enhance the supportive care they give to these women. This article discusses the evidence for a number of these interventions which mothers may find more acceptable than orthodox treatment.

Perinatal depression: a randomized controlled trial of an antenatal education intervention for primiparas

BACKGROUND

Depression can be an unexpected and distressing companion for a woman during the major life transition of becoming a mother for the first time. Researchers now demonstrate that approximately 50 percent of women will experience perinatal distress. Therefore, the etiology and management of perinatal depression is essential for a quality care of childbearing women. The objectives of this study were to develop an education intervention tailored to the information needs of primiparous women about perinatal depression, to deliver this intervention antenatally, and to conduct a randomized controlled trial to determine the effect of the antenatal education intervention in the reduction of postnatal depression.

METHOD

A prospective, randomized controlled trial of the education intervention (n = 206) was conducted at three sites in Australia. The outcome of changes in mood state was measured by the Profile of Mood States questionnaire once antenatally (12-28 wk), and twice postnatally (8-12 and 16-24 wk); social support and demographic data were also collected. The education package was administered to the intervention group at the antenatal assessment of mood.

RESULTS

A significant and steady reduction in scores (overall and on the subscales) was observed over time for both groups that showed significant improvement in symptoms of depression. No difference was detected when comparing the intervention group with the control group. Additional multivariate regression analyses revealed no relevant influence of social support or demographic variables.

CONCLUSIONS

Women in both the study and control groups were more depressed antenatally than postnatally. The finding that the education intervention made no difference challenges the two strongly held tenets of health education in childbearing women-that depression can be reduced through education and that antenatal education interventions can endure into the postnatal period.

An international study exploring levels of postpartum depressive symptomatology

OBJECTIVE

Differences in postpartum depressive symptomatology (PPDS) among an international sample of 892 women from nine countries representing five continents were explored.

METHOD

Edinburgh Postnatal Depression Scale (EPDS) and Beck Depression Inventory (BDI) were used to assess PPDS among a convenience sample that completed the two questionnaires twice, yielding a total of four sets of scores per subject. Women sampled were primiparae with no obstetrical complications, and had a healthy baby. Depression history and therapy were ruled out as exclusion criteria.

RESULTS

Mean scores for EPDS and BDI varied across sites at both time points (P value<.001). European and Australian women had the lowest levels of PPDS, USA women fell at the midpoint, and women from Asia and South America had the highest depressive symptom scores. The moderate concordance between the EPDS and BDI suggested that the measures have complementary uses for screening and assessment.

CONCLUSION

Utility of EPDS and BDI for yielding profiles of postpartum women's depressive symptomatology was demonstrated. Further research to validate depressive symptom measures with diverse international populations is indicated.

A checklist to identify women at risk for developing postpartum depression

This article describes the Postpartum Depression Predictors Inventory, a checklist to identify women at risk for developing this devastating illness. Postpartum depression wreaks havoc not only on mothers, but also on their entire families. Researchers have reported that postpartum depression has a moderate to large adverse effect on mother-infant interaction. Children older than 1 year whose mothers had postpartum depression have been reported to display more behavioral problems and cognitive deficits than children of mothers who were not depressed. It is crucial to identify and treat women with postpartum depression as early as possible. This problem often continues due to lack of identification. Identifying women at risk and providing early treatment interventions are the first steps in dealing with this problem.