Counselling in a general practice setting: controlled study of health visitor intervention in treatment of postnatal depression

Effectiveness of interpersonal psychotherapy in comparison to other psychological and pharmacological interventions for reducing depressive symptoms in women diagnosed with postpartum depression in low- and middle-income countries: A systematic review

Background

Postpartum depression (PPD) is a condition that can affect any woman regardless of ethnicity, age, party, marital status, income, and type of delivery. This condition is highly prevalent worldwide. PPD, if not treated timely, can affect the maternal-child bond and can have a detrimental impact on the future cognitive, emotional, and behavioral development of the child. Interpersonal psychotherapy (IPT) has been reported as an effective treatment of PPD in previous studies as this focuses on relationship and social support issues. Previous reviews conducted in developed nations have reported the superior efficacy of IPT in comparison to other treatment options. There is no systematic review conducted in low to middle-income countries on the efficacy of IPT on PPD. Therefore it was necessary to undertake a systematic review to assess the effectiveness of IPT in reducing the depression among postpartum women in low and middle-income countries (LMICs).

Objectives

The main aim of this systematic review was to assess the effectiveness of IPT alone or in conjunction with pharmacological therapy and/or other psychological and psychosocial interventions, in reducing depressive symptoms among women diagnosed with PPD residing in LMICs.

Search Methods

The systematic search encompassed several prominent databases and grey literature. Furthermore, experts specializing in the field of IPT were consulted to identify any relevant studies conducted in LMICs that fulfilled the predetermined eligibility criteria. The most recent search update was performed in July 2022.

Selection Criteria

The PICOS criteria were meticulously defined for this review as described. Participants: Postpartum women diagnosed with PPD in LMICs were included. Intervention: IPT either as a standalone treatment or in conjunction with pharmacological therapy was included. Comparison: any form of psychological therapy or pharmacological therapy, whether administered individually or in combination, was considered for comparison. Study designs: experimental and quasi-experimental, factorial designs, and quantitative components (experimental, quasi-experimental, factorial designs) of mixed methods designs were eligible to be included. Studies with single-group study designs and qualitative studies were excluded from the review.

Data Collection and Analysis

Two reviewers from our team conducted a rigorous screening process to determine the eligibility of articles for inclusion. This involved an initial evaluation of titles and abstracts, followed by a comprehensive assessment of the full text of selected articles. In instances where discrepancies arose between the two reviewers, resolution was achieved through discussion or consultation with a third author to establish a consensus. Following the screening process, two team members independently extracted pertinent information and data from the studies that met the inclusion criteria. The treatment effect of the intervention, in comparison to the control group, was subsequently analyzed utilizing the fixed effects model taking into account the small number of studies.

Main Results

A total of 17,588 studies were identified from various databases, and 6493 duplicate studies were removed. Subsequently, 9380 studies underwent independent title and abstract screening resulting in the exclusion of 9040 studies. 345 full texts were thoroughly assessed leading to the exclusion of 341 studies, finally including 4 studies for review. The four included trials were randomized trials and comprised a total sample size of 188 women diagnosed with PPD residing in LMICs. Among these studies, three compared IPT with usual treatment, while one study compared IPT with antidepressant medications (ADMs). In terms of the providers of IPT, in one study, IPT was administered by nurses, while psychologists delivered IPT in another study. In one study, community health workers were responsible for providing IPT. However, in one study, information regarding the specific providers of IPT was not available or reported. The primary outcome measure reported in all four studies was depression, assessed using the Edinburgh Postnatal Depression Scale (EPDS). The geographical distribution of the studies included; one conducted in Zambia, one in Kenya, one in Pakistan, and one in Iran. Out of the four studies, three were included in the meta-analysis, as missing data from one study could not be obtained. Based on the overall treatment effect, it was found that depression scores decreased significantly more in the IPT group compared to other interventions (usual treatment or ADMs) (standardized mean difference [SMD] -0.62, 95% confidence interval [CI] (-1.01, -0.23), Z = 3.13 (p = 0.002), χ 2 = 49.49; df = 2; p < 0.00001; I 2 = 96%; 3 studies, n = 136). Out of the three studies, two studies compared the effectiveness of IPT in reducing depression scores specifically when compared to the usual treatment, and in both studies, depression scores were reduced significantly in the IPT group as compared to the usual treatment group. Only one study directly compared the effectiveness of IPT with ADM, reporting that IPT was more effective than ADM in reducing depression scores among postpartum women. Regarding adverse outcomes, only one study reported suicidal ideation with one participant in the IPT group and two in the ADM group (RR 0.50, 95% CI (0.05, 5.30), p = 0.56, n = 78). The same study reported seven participants in the ADM group had adverse drug reactions as compared to none in the IPT group (RR 15.0, 95% CI (0.89, 254), p = 0.06, n = 78).

Authors' Conclusions

Our comprehensive search yielded a limited number of four studies conducted in such settings. Despite the scarcity of available evidence, the findings collectively suggest that IPT is indeed an effective treatment for reducing PPD when compared to usual treatment and pharmacological therapy. However given the low certainty of evidence, there is a need for further research in the form of well-designed randomized controlled trials with larger sample sizes and a reduced risk of bias. Such studies would greatly contribute to enhancing the strength and reliability of the evidence base regarding the effectiveness of IPT in the context of PPD in LMICs. The knowledge generated from future research endeavors would be highly valuable in guiding the development of more affordable and cost-effective treatment approaches for PPD in resource-limited settings.

The efficacy of individual humanistic-experiential therapies for the treatment of depression: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating the efficacy of individual humanistic-experiential therapies (HEPs) for depression.

METHOD

Database searches (Scopus, Medline, and PsycINFO) identified RCTs comparing any HEP intervention with a treatment-as-usual (TAU) control or active alternative intervention for the treatment of depression. Included studies were assessed using the Risk of Bias 2 tool and narratively synthesized. Post-treatment and follow-up effect sizes were aggregated using random-effects meta-analysis and moderators of treatment effect were explored (PROSPERO: CRD42021240485).

RESULTS

Seventeen RCTs, synthesized across four meta-analyzes, indicated HEP depression outcomes were significantly better than TAU controls at post-treatment (g = 0.41, 95% CI [0.18, 0.65], n = 735), but not significantly different at follow-up (g = 0.14, 95% CI [-0.30, 0.58], n = 631). HEP depression outcomes were comparable to active treatments at post-treatment (g = -0.09, 95% CI [-0.26, 0.08], n = 2131), but significantly favored non-HEP alternative interventions at follow-up (g = -0.21, 95% CI [-0.35, -0.07], n = 1196).

CONCLUSION

Relative to usual care, HEPs are effective in the short-term and comparable to non-HEP alternative interventions at post-treatment, but not at follow-up. However, imprecision, inconsistency, and risk of bias concerns were identified as limitations of the evidence included. Future large-scale trials of HEPs with equipoise between comparator conditions are required.

A Randomized Controlled Trial of Listening Visits for Mothers of Hospitalized Newborns

BACKGROUND

Emotional distress is frequently experienced by mothers whose newborns are hospitalized in a neonatal intensive care unit (NICU). Among these women, there is a critical need for emotional support conveniently delivered at the newborn's point of care by a trusted and medically knowledgeable professional: a NICU nurse. One promising way to enhance in situ delivery of emotional care is to have a NICU nurse provide Listening Visits (LVs), a brief support intervention developed expressly for delivery by nurses to depressed postpartum women.

OBJECTIVES

This trial assessed the feasibility of having NICU nurses deliver LVs to emotionally distressed mothers of hospitalized newborns and compared depression outcomes in a small sample of participants randomized to LVs or usual care (UC).

METHODS

In this pilot randomized controlled trial, emotionally distressed mothers of hospitalized newborns were randomized to receive up to six LVs from a NICU nurse or UC from a NICU social worker. To assess change in depression symptoms, women were invited to complete the Inventory of Depression and Anxiety Symptoms-General Depression Scale at enrollment and 4 and 8 weeks post-enrollment.

RESULTS

Depression symptoms declined over time for both groups, with no difference between the two groups. A post hoc analysis of reliable change found higher rates of improvement at the 4-week assessment among recipients of LVs than UC.

DISCUSSION

NICU nurses successfully implemented LVs during this trial. Depression symptom scores did not significantly differ in the two groups posttreatment or at follow-up. Nevertheless, post hoc analyses indicated comparatively higher rates of clinical improvement immediately after LVs, suggesting the intervention can reduce maternal depression early on when women are most distressed.

Psychological treatment of perinatal depression: a meta-analysis

BACKGROUND

Depression during pregnancy and after the birth of a child is highly prevalent and an important public health problem. Psychological interventions are the first-line treatment and, although a considerable number of randomized trials have been conducted, no recent comprehensive meta-analysis has evaluated treatment effects.

METHODS

We used an existing database of randomized controlled trials of psychotherapies for adult depression and included studies aimed at perinatal depression. Random effects models were used in all analyses. We examined the effects of the interventions in the short and long term, and also examined secondary outcomes.

RESULTS

Forty-three studies with 49 comparisons and 6270 participants between an intervention and control group were included. The overall effect size was g = 0.67 [95% confidence interval (CI) 0.45~0.89; numbers needed-to-be-treated = 4.39] with high heterogeneity (I2 = 80%; 95% CI 75~85). This effect size remained largely unchanged and significant in a series of sensitivity analyses, although some publication bias was found. The effects remained significant at 6-12 months follow-up. Significant effects were also found for social support, anxiety, functional limitations, parental stress and marital stress, although the number of studies for each outcome was low. All results should be considered with caution because of the high levels of heterogeneity in most analyses.

CONCLUSIONS

Psychological interventions are probably effective in the treatment of perinatal depression, with effects that last at least up to 6-12 months and probably also have effects on social support, anxiety, functional impairment, parental stress, and marital stress.

Perinatal mental health counselling programme: A scoping review

OBJECTIVE

To map the evidence on a Perinatal Mental Health Counselling Programme, identifying its characteristics, participants, and outcomes.

METHODS

This review followed the guidelines of the Joanna Briggs Institute and PRISMA-ScR. Published and unpublished studies, from 2011 to 2021, written in English, Portuguese or Spanish were included.

RESULTS

Despite the high number of articles identified, only nine articles were included in the final analysis, mainly from Iran, Italy and one Portuguese study. All articles referred to community health care centres and hospitals. The sessions varied between 6 and 16 and lasted 30-90 min. The method used was either individual and/or group, with weekly or monthly sessions or whenever deemed necessary throughout the evaluation. Different techniques were found, but emotional management, problem-solving, relaxation and mindfulness techniques were highlighted. Participants are pregnant women, partners, or family members. All articles suggest a decrease in the levels of stress, anxiety, and depression after the counselling intervention.

CONCLUSION

Perinatal counselling programme have varied characteristics and mental health nurses are potential facilitators.

Telehealth Listening Visits for emotionally distressed mothers of hospitalized newborns: Proof-of-concept

Problem

Newborn admission to the neonatal intensive care unit (NICU) is stressful. Yet in clinical practice, at best, NICU mothers are screened for depression and if indicated, referred to a mental-health specialist. At worst, no action is taken. Listening Visits, an empirically supported nurse-delivered intervention addressing emotional distress, can be conveniently provided by a NICU nurse. Prompted by the need to minimize face-to-face contacts during the pandemic, the primary purpose of this small pilot trial was to assess the feasibility of having nurses provide Listening Visits to NICU mothers over Zoom. Secondarily, we assessed pre-to post-Listening Visits depression symptom scores as a preliminary evaluation of the effectiveness of this type of support.

Materials and methods

Nine NICU mothers with mildly to moderately severe depression symptoms received up to six Listening Visits sessions from a NICU nurse via Zoom. Participants completed the Inventory Depression and Anxiety Symptoms-General Depression scale (IDAS-GD) at study entry and 4- and 8-weeks post enrollment. They completed the Client Satisfaction Questionnaire (CSQ) at the 8-week assessment.

Results

Using an intent-to-treat approach, the effect of time from the mixed model analysis of IDAS-GD was statistically significant (F(2,26) = 10.50, p < 0.001), indicating improvement in IDAS-GD scores from baseline to follow-up. The average CSQ score was high (M = 29.0, SD = 3.3), with 75% of participants rating the quality of help they received as "excellent".

Discussion

In this pilot trial, we learned it is feasible to provide Listening Visits over Zoom, that this mode of delivery is associated with a significant decrease in depression symptom scores, and that women value this approach.

Clinical trial registration

[https://clinicaltrials.gov/], identifier [#201805961].

Evaluation of psychological training for nurses and midwives to optimise care for women with perinatal depression: a systematic review and meta-analysis

Objective Perinatal depression is linked to poor maternal health and infant development outcomes. The World Health Organization recommends expanding the mental health education and training of primary care providers to improve the quality of perinatal depression care. The present study evaluated the effect of various psychological training methods on nurses' and midwives' competence in administering care to and alleviating symptoms in patients with perinatal depression. Methods A comprehensive search of the PubMed, MEDLINE, Cochrane Library, EMBASE, Web of Science, and CINAHL databases was performed. The data were independently extracted by two reviewers, and the critical appraisal tools of the Joanna Briggs Institute were used for quality assessment. Random-effects meta-analysis was conducted using Review Manager 5.4 software. Findings A total of 13 articles including 246 nurses and midwives and 4,381 perinatal women were reviewed. Care administered through both face-to-face (relative risk [RR] 0.70, 95% confidence interval [CI] 0.61-0.74) and digital training (RR 0.44, 95% CI 0.26-0.74) significantly mitigated symptoms of perinatal depression. Significant benefits were observed after 3- to 5-day and 8-day training, for which the RR were 0.75 (95% CI 0.59-0.97) and 0.72 (95% CI 0.66-0.85), respectively. Studies with high intervention fidelity more effectively reduced the risk of depressive symptoms in perinatal women than those with low intervention fidelity. Key conclusions and implications for practice Compared with face-to-face, digital training methods were more effective in reducing the risk of depressive symptoms. High intervention fidelity and 3- to 5-day and 8-day training resulted in better outcomes. The present findings can serve as a reference for the design of psychological training programs for nurses and midwives to equip them with effective strategies for administering care to patients with perinatal depression.

Listening Visits for maternal depression: a meta-analysis

Listening Visits are a non-directive counseling intervention delivered by nurses to depressed postpartum women. In 2007, Listening Visits were listed as a recommended treatment in British national guidelines. They were removed from the guideline update, due to the small effect size drawn from a meta-analysis of five clinical trials with depressed and non-depressed postpartum women. The purpose of this meta-analysis is to provide an estimate of the true population effect of Listening Visits as a treatment for maternal depression compared to control conditions. A meta-analytic review was conducted of studies published before October 2020. Inclusion criteria required that the study was a pragmatic or randomized trial of Listening Visits delivered by non-mental health specialists to mothers with elevated symptoms of maternal depression. Post-treatment depression rates for the treatment and control groups were extracted from eligible studies. Six studies met eligibility criteria which included 703 participants. Analyses of observed effect sizes corrected for study artifacts revealed an estimate of 0.66 (95% CI: 0.32, 0.99) with high heterogeneity (Q = 17.95, p = 0.003, I² = 72.14). After removing outliers and addressing heterogeneity across observed effect sizes, the meta-analytic estimate across four methodologically similar studies and 651 participants was 0.43 (95% CI: 0.24, 0.62). The moderate effect size for Listening Visits, considered together with the advantages afforded by how, where, and who provides this treatment, supports Listening Visits as a first-line intervention in a stepped care approach for mothers with mild to moderately severe depression symptoms.

Implementation and Effectiveness of Nonspecialist-Delivered Interventions for Perinatal Mental Health in High-Income Countries: A Systematic Review and Meta-analysis

IMPORTANCE

Task sharing-or training of nonspecialist providers with no formal training in counseling-is an effective strategy to improve access to evidence-based counseling interventions and has the potential to address the burden of perinatal depression and anxiety.

OBJECTIVES

To identify the relevant implementation processes (who, what, where, and how) and to assess the effectiveness of counseling interventions delivered by nonspecialist providers for perinatal depression and anxiety in high-income countries.

DATA SOURCES

CINAHL, Ovid MEDLINE, Ovid MEDLINE In-Process, PsycINFO, Web of Science, Cochrane Central Register of Controlled Trials, and Embase through December 31, 2019. Relevant systematic reviews were also considered.

STUDY SELECTION

Randomized clinical trials of counseling interventions that assessed depression or anxiety after intervention, delivered by a nonspecialist provider for adults, and that targeted perinatal populations in a high-income country were included. Self-help interventions that did not include a provider component were excluded.

DATA EXTRACTION AND SYNTHESIS

Four researchers independently reviewed abstracts and full-text articles, and 2 independently rated the quality of included studies. Random-effects meta-analysis was used to estimate the benefits of the interventions. The Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline was followed.

MAIN OUTCOMES AND MEASURES

For implementation processes, the frequencies represented by a total or percentage were estimated, where the denominator is the total number of eligible trials, unless otherwise indicated. For effectiveness, primary and secondary outcome data of depression, anxiety, or both symptoms were used, with separate analyses for prevention and treatment, stratified by depression or anxiety. Subgroup analyses compared outcome types (anxiety vs depression) and study objectives (treatment vs prevention).

RESULTS

In total, 46 trials (18 321 participants) were included in the systematic review; 44 trials (18 101 participants) were included in the meta-analysis. Interventions were implemented across 11 countries, with the majority in Australia, UK, and US. Two-thirds (65%) of counseling interventions were provided by nurses and midwives, lasted a mean of 11.2 weeks (95% CI, 6.4-16.0 weeks), and most were delivered face to face (31 [67.4%]). Only 2 interventions were delivered online. A dearth of information related to important implementation processes, such as supervision, fidelity, and participant sociodemographic characteristics, was observed in many articles. Compared with controls, counseling interventions were associated with lower depressive symptoms (standardized mean difference [SMD], 0.24 [95% CI, 0.14-0.34]; 43 trials; I2 = 81%) and anxiety scores (SMD, 0.30 [95% CI, 0.11-0.50]; 11 trials; I2 = 80%). Treatment interventions were reported to be effective for both depressive symptoms (SMD, 0.38 [95% CI, 0.17-0.59]; 15 trials; I2 = 69%) and anxiety symptoms (SMD, 0.34 [95% CI, 0.09-0.58]; 6 trials; I2 = 71%). However, heterogeneity was high among the trials included in this analysis.

CONCLUSIONS AND RELEVANCE

This study found evidence in high-income countries indicating that nonspecialist providers may be effective in delivering counseling interventions. Additional studies are needed to assess digital interventions and ensure the reporting of implementation processes to inform the optimal delivery and scale-up of these services.

Experiences with the routine use of the Edinburgh Postnatal Depression Scale from health visitors' and midwives' perspectives - An exploratory qualitative study

BACKGROUND

The Edinburgh Postnatal Depression Scale has been practiced as a routine screening for postnatal depression at a municipal health care centre for more than ten years.

OBJECTIVES

The aim of this study was to examine how health visitors and midwives perceive and practice this routine screening.

STUDY DESIGN

We chose an exploratory qualitative approach, with analysis of data from focus group interviews.

METHODS

Ten health visitors and two midwives participated in two focus group interviews by sharing their thoughts and reflections. The analysis was performed in collaboration with all authors according to thematic network analysis.

FINDINGS

The Edinburgh Postnatal Depression Scale is well accepted as a screening tool. In addition to giving health visitors and midwives information about mothers who need special attention concerning mental health challenges, the Edinburgh Postnatal Depression Scale is a tool for talking about problems related to early motherhood. A trusting relationship is a prerequisite for these conversations. The health visitors seldom use the word 'depression' in contact with the individual mother. They sometimes lose opportunities to identify mothers in need of help because of a tight time schedule and social and cultural factors. Collaboration on a daily basis with colleagues and family therapists, and monthly guidance from mental health professionals are necessary to secure professional quality and confidence.

CONCLUSION

The Edinburgh Postnatal Depression Scale is a useful screening tool, but there are social and cultural challenges, and the available time during screening consultations is often too short. Collaboration with and guidance from other professionals are necessary.

Effectiveness of nurses and midwives-led psychological interventions on reducing depression symptoms in the perinatal period: A systematic review and meta-analysis

Aim

To evaluate the effectiveness of nurses and midwives‐led psychological interventions on the perinatal depressive symptoms.

Design

A systematic review and meta‐analysis based on the PRISMA guidelines.

Methods

Six databases were searched, including PubMed, MEDLINE, Cochrane Library, EMBASE, Web of Science and CINAHL. The search date range was before 30 September 2019. We used the Cochrane risk of bias tool to evaluate the quality of the included studies and Review Manager software 5.3 to conduct a meta‐analysis. The data were pooled using a random‐effect model.

Results

Studies (N = 827) were retrieved with 12 studies included. Psychological interventions provided by nurses and midwives have a significant effect on reducing perinatal depressive symptoms (RR: 0.72, 95% CI [0.64–0.82]). Among the approaches of psychological intervention, supportive counselling was the most effective (RR: 0.58, 95% CI [0.42–0.80]). The best intensity of intervention was six to eight sessions (RR: 0.66, 95% CI [0.55–0.79]).

Postpartum Depression: Identification and Treatment in the Clinic Setting

Perinatal care, including the management of mental health issues, often falls under the auspices of primary care providers. Postpartum depression (PPD) is a common problem that affects up to 15% of women. Most women at risk can be identified before delivery based on psychiatric history, symptoms during pregnancy, and recent psychosocial stressors. Fortunately, there have been a variety of treatment studies using antidepressants, nonpharmacologic interactions, and most recently, allopregnanolone (Brexanolone) infusion that have shown benefits. The most commonly used screening scale, Edinburgh Postnatal Depression Scale, a 10-item self-rated scale, has been translated into a variety of languages.

Maternal depression and breastfeeding in home visitation

BACKGROUND

Home visitation is a popular mechanism for supporting parents and their young children. Breastfeeding is often promoted by home visitors due to its health benefits. However, maternal depression may interfere with breastfeeding. Thus, home visitors may be attempting to encourage health-promoting behaviors like breastfeeding, but maternal depression may interfere with engagement in those behaviors.

METHOD

The data for this study were provided by the Des Moines Healthy Start and the Empowerment Family Support Project (DMHSP). We analyzed the relation between depression and breastfeeding for 364 women.

RESULTS

First, rates of elevated depression scores in this sample of women (8.7%-21.4% of women) were lower than rates of elevated depression scores reported in other studies of women enrolled in home visitation (30%-50% of women). Second, rates of breastfeeding at 3 months postpartum in this sample (56% of women) were higher than rates of breastfeeding reported in the general population (51% of women). Third, Non-Hispanic White women were significantly less likely to breastfeed compared to other racial groups. Fourth, average Edinburgh Postnatal Depression Scale (EPDS) scores during the first 3 months postpartum, but not during pregnancy, were predictive of likelihood to breastfeed at 3 months postpartum, even after accounting for demographic characteristics.

CONCLUSION

Addressing maternal depression during the early postpartum period may increase the likelihood of engaging in breastfeeding.

Using the TIDieR checklist to describe health visitor support for mothers with mental health problems: Analysis of a cross-sectional survey

At least half of the 20% of mothers who experience mental health problems (MHPs) during pregnancy or after birth are not receiving the help they need that will lead to recovery. In order to identify where improvements need to be made, it is necessary to describe exactly what is being done and the barriers and facilitators that compromise or enhance optimal care. The majority of mothers experience mild to moderate anxiety or depression. The expectation is that primary care professionals, such as health visitors (HVs), can provide the support they need that will lead to recovery. The aim of this study was to explore the views of HVs regarding the content and purpose of an intervention to support mothers with MHPs, described as 'listening visits' (LVs). A link to an online survey was offered to the members and champions of the Institute of Health Visiting (n = 9,474) March-May 2016. The survey was completed by 1,599 (17%) of the target population, of whom 85% were offering LVs. The Template for Intervention Description and Replication (TIDieR) checklist was used to provide a framework to describe commonalities and variations in practice. There appeared to be a shared understanding of the rationale for LVs but a lack of agreement about what the intervention should be called, the techniques that should be used and the duration, frequency and expected outcomes of the intervention. Contextual factors such as staff shortages; conflicting priorities; the needs and circumstances of mothers; the capability and motivation of HVs; inadequate training and supervision; and the absence of clear guidance contributed to variations in perceptions and practice. There are many ways in which the HV contribution to the assessment and management of mothers with MHPs could be improved. The intervention delivered by HVs needs to be more clearly articulated. The contextual factors influencing competent and consistent practice also need to be addressed.

Cost-effectiveness of PoNDER health visitor training for mothers at lower risk of depression: findings on prevention of postnatal depression from a cluster-randomised controlled trial

BACKGROUND

There is evidence for the cost-effectiveness of health visitor (HV) training to assess postnatal depression (PND) and deliver psychological approaches to women at risk of depression. Whether this approach is cost-effective for lower-risk women is unknown. There is a need to know the cost of HV-delivered universal provision, and how much it might cost to improve health-related quality of life for postnatal women. A sub-study of a cluster-randomised controlled trial in the former Trent region (England) previously investigated the effectiveness of PoNDER HV training in mothers at lower risk of PND. We conducted a parallel cost-effectiveness analysis at 6-months postnatal for all mothers with lower-risk status attributed to an Edinburgh Postnatal Depression Scale (EPDS) score &lt;12 at 6-weeks postnatal.

METHODS

Intervention HVs were trained in assessment and cognitive behavioural or person-centred psychological support techniques to prevent depression. Outcomes examined: quality-adjusted life-year (QALY) gains over the period between 6 weeks and 6 months derived from SF-6D (from SF-36); risk-of-depression at 6 months (dichotomising 6-month EPDS scores into lower risk (&lt;12) and at-risk (⩾12).

RESULTS

In lower-risk women, 1474 intervention (63 clusters) and 767 control participants (37 clusters) had valid 6-week and 6-month EPDS scores. Costs and outcomes data were available for 1459 participants. 6-month adjusted costs were £82 lower in intervention than control groups, with 0.002 additional QALY gained. The probability of cost-effectiveness at £20 000 was very high (99%).

CONCLUSIONS

PoNDER HV training was highly cost-effective in preventing symptoms of PND in a population of lower-risk women and cost-reducing over 6 months.

Qualitative evaluation of mental health training of auxiliary nurse midwives in rural Nepal

BACKGROUND AND OBJECTIVES

Mental illness is increasingly recognized as a global health problem. However, in many countries, including Nepal, it is difficult to talk about mental health problems due to the stigma associated with it. Hence a training programme was developed to train auxiliary nurse midwives, who otherwise are not trained in mental health as part of their pre-registration training in rural Nepal, on issues related to maternal mental health. After the training programme a selection of auxiliary nurse midwives were interviewed to establish their views on the training, its usefulness and ways to improve it.

METHODS

This qualitative study reports on the analysis of interviews conducted with auxiliary nurse midwives who participated in the training programme. The interviews addressed issues associated with the training programme as well as perceptions around mental health in rural Nepal. Transcripts were thematically analysed.

RESULTS

Three themes emerged from analysis: (1) issues related to training; (2) societal attitudes; and (3) support for women. The 'training' theme describes the benefits and limitations of training sessions. 'Societal attitudes' describes society's attitude towards mental health which is largely negative. 'Support' describes the positive behaviour and attitude towards pregnant women and new mothers.

CONCLUSION

The study supports the need for continued training for auxiliary nurse midwives who are based in the community. This gives them the opportunity to reach the whole community group and potentially have influence over reduction of stigma; offer support and diagnosis of mental ill-health. There is still stigma around giving birth to a female child which can lead to mental health problems. It is imperative to increase awareness and educate the general public regarding mental health illnesses especially involving family members of those who are affected.

Moving beyond depression screening: integrating perinatal depression treatment into OB/GYN practices

In 2015, the American College of Obstetricians and Gynecologists issued a recommendation to screen women for depression and anxiety symptoms at least once during the perinatal period. Nevertheless, many identified women will not receive care from a behavioral health specialist. Listening Visits (LV), developed for delivery by nurses and validated in the United Kingdom, have recently been evaluated in a US-based randomized controlled trial (RCT) which recruited research participants from three home-visiting programs and an urban OB/GYN practice. RCT results indicated clinically and significant improvement in depression symptoms. To bridge the gap between evidence and practice, and based on experiences garnered at the OB/GYN site during the RCT, this development paper proposes a strategy for implementing depression screening and LV into routine clinical care in this practice setting.

Child and adolescent mental health problems in primary care

Epidemiological research has revealed that psychiatric disorders in children and adolescents are common, persistent and handicapping. Only 1 in 10 of those with a disorder is seen in specialist mental health services. However, the majority of children and adolescents see their general practitioner (GP) every year. Although the majority present with physical complaints, there are indications that rates of psychiatric disorder in those attending are increased and that psychiatric disorder is associated with increased consulting. These findings raise questions about the role of primary care in the promotion and management of mental health in young people.

Risk and childbirth in psychiatry

The relationship between childbirth and serious mental illness has been known since the time of Ancient Greece. It was first described in the psychiatric literature by Esquirol and later by his pupil Marcé in 1857. A substantial number of women become mentally ill, often for the first time, following childbirth. There are few events associated with such a measurable and predictable risk to mental health as childbirth, with its nine months warning. Despite this, there is little awareness amongst general psychiatrists of the predictable and manageable risk that faces many of their female patients should they become pregnant, nor of the risks that mentally ill mothers may pose for their children.

Adaptation of the Structured Clinical Interview for DSM-IV Disorders for assessing depression in women during pregnancy and post-partum across countries and cultures

Background

To date, no study has used standardised diagnostic assessment procedures to determine whether rates of perinatal depression vary across cultures.

Aims

To adapt the Structured Clinical Interview for DSM–IV Disorders (SCID) for assessing depression and other non-psychotic psychiatric illness perinatally and to pilot the instrument in different centres and cultures.

Method

Assessments using the adapted SCID and the Edinburgh Postnatal Depression Scale were conducted during the third trimester of pregnancy and at 6 months postpartum with 296 women from ten sites in eight countries. Point prevalence rates during pregnancy and the postnatal period and adjusted 6-month period prevalence rates were computed for caseness, depression and major depression.

Results

The third trimester and 6-month point prevalence rates for perinatal depression were 6.9% and 8.0%, respectively. Postnatal 6-month period prevalence rates for perinatal depression ranged from 2.1% to 31.6% across centres and there were significant differences in these rates between centres.

Conclusions

Study findings suggest that the SCID was successfully adapted for this context. Further research on determinants of differences inprevalence of depression across cultures isneeded.

Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression

Background

Psychological interventions for postnatal depression can be beneficial in the short term but their longer-term impact is unknown.

Aims

To evaluate the long-term effect on maternal mood of three psychological treatments in relation to routine primary care.

Method

Women with post-partum depression (n=193) were assigned randomly to one of four conditions: routine primary care, non-directive counselling, cognitive–behavioural therapy or psychodynamic therapy. They were assessed immediately after the treatment phase (at 4.5 months) and at 9, 18 and 60 months post-partum.

Results

Compared with the control, all three treatments had a significant impact at 4.5 months on maternal mood (Edinburgh Postnatal Depression Scale, EPDS). Only psychodynamic therapy produced a rate of reduction in depression (Structured Clinical Interview for DSM–III–R) significantly superior to that of the control. The benefit of treatment was no longer apparent by 9 months post-partum. Treatment did not reduce subsequent episodes of post-partum depression.

Conclusions

Psychological intervention for post-partum depression improves maternal mood (EPDS) in the short term. However, this benefit is not superior to spontaneous remission in the long term.

Knowledge of the Edinburgh Postnatal Depression Scale among psychiatrists and general practitioners

The aim was to examine the impression that both general practitioners and psychiatrists have a low level of awareness and knowledge of the Edinburgh Postnatal Depression Scale (EPDS), have little experience in its use, and would not feel confident in giving advice on issues arising from its use by health visitors.

Prevention of depression: psychological and social measures

The role of pharmacotherapy in the management of depressive disorders is well-established and frequently reviewed. This paper focuses on the prospects for reducing the incidence, prevalence and morbidity of depression through psychosocial interventions. A central requirement in prevention is a knowledge of the epidemiology of the disorder being investigated. This data can be used to identify high-risk groups. By comparing the number of known cases with population levels of morbidity, it allows comment on help-seeking behaviour and accessibility of services. Also, differences in incidence and prevalence rates give some indication of the chronicity of the disorder.

Prevalence of postpartum depression and interventions utilized for its management

INTRODUCTION

Postpartum depression is a mood disorder that affects approximately 10-15% of adult mothers yearly. This study sought to determine the prevalence of postpartum depression and interventions utilized for its management in a Health facility in Ghana.

METHODS

A descriptive cross-sectional study design using a quantitative approach was used for the study. The study population included mothers and healthcare workers. Simple random sampling technique was used to select 257 mothers, while a convenience sampling technique was used to select 56 health workers for the study. A Patient Health Questionnaire was used to screen for depression and a structured questionnaire comprising closed-ended questions was used to collect primary data on the interventions for the management of postpartum depression. Data were analyzed using statistical software SPSS version 16.0.

RESULTS

Postpartum depression was prevalent among 7% of all mothers selected. The severity ranged from minimal depression to severe depression. Psychosocial support proved to be the most effective intervention (p = 0.001) that has been used by the healthcare workers to reduce depressive symptoms.

CONCLUSION

Postpartum depression is prevalent among mothers although at a lower rate and psychosocial support has been the most effective intervention in its management. Postpartum depression may affect socialization behaviors in children and the mother, and it may lead to thoughts of failure leading to deeper depression. Frequent screening exercises for postpartum depression should be organized by authorities of the hospitals in conjunction with the Ministry of Health.

Principles of Supportive Psychotherapy for Perinatal Distress

Although interpersonal psychotherapy and cognitive behavioral therapy have demonstrated efficacy in the treatment of perinatal distress, supportive psychotherapy has not been as widely studied by researchers. However, the principles of supportive psychotherapy are essential in the treatment of perinatal distress. The purpose of this article is to show that supportive psychotherapy is a plausible intervention that nurses and other maternity care providers can use with women who experience anxiety and depression in the perinatal period.

Improved Perinatal Depression Screening, Treatment, and Outcomes With a Universal Obstetric Program

OBJECTIVE

To evaluate whether universal prenatal and early postnatal screening for depression leads to increased detection, subsequent intervention, and improved depressive symptom outcomes.

METHODS

We conducted a population-based retrospective cohort study of 97,678 pregnant Kaiser Permanente Northern California members during three phases of the Universal Perinatal Depression Screening Program (preimplementation, rollout, fully implemented) from 2007 through 2014. Depression screening scores (Patient Health Questionnaire-9), depression diagnoses, individual counseling visits, demographic characteristics, and medication dispensings were extracted from electronic health records and pharmacy databases. The percentage of women screened, new depression diagnoses, and women receiving treatment were compared among the three phases (tests of trend). Changes in depressive symptom scores up to 6 months postpartum were assessed (rollout and fully implemented phases).

RESULTS

A significant increase emerged in the percentage of women screened over the three phases ranging from less than 1% (n=122) (preimplementation) to 98% (n=41,124) (fully implemented) (P<.001). Identification of a new depression diagnosis increased from 8.2% (n=1,341) (preimplementation) to 11.5% (n=4,943) (fully implemented) (P<.001). Although the observed percentage of women receiving treatment decreased (60.9% [preimplementation] to 47.1% [fully implemented]), significant increases in the expected percentage of women receiving treatment emerged (42.6% [preimplementation] to 47.1% [fully implemented]; P<.05). Similar trends were noted for women with Patient Health Questionnaire-9 scores of 15 or greater (greater severity), highlighting an increase in expected percentage of women receiving treatment (5.9% [preimplementation] to 81.9% [fully implemented]; P<.05). In the fully implemented phase, improvements in depressive symptoms up to 6 months postpartum were noted.

CONCLUSION

These data provide evidence of benefit for universal perinatal depression screening programs regarding depression identification and treatment receipt and suggest improvement in symptom outcomes for women in screening programs, especially among integrated health care systems.

A Nurse-Based Model of Psychosocial Support for Emotionally Distressed Mothers of Infants in the NICU

Mothers whose infants are hospitalized in the NICU are frequently emotionally distressed, particularly early in the hospitalization. The Family-Centered Developmental Care philosophy, widely adopted by NICUs, calls for an expanded focus on the well-being of the entire family. In this article, we describe an innovative, nurse-delivered program for emotionally distressed mothers of infants in the NICU that includes screening and an empirically supported counseling approach: Listening Visits.

Depression Treatment by Non-Mental-Health Providers: Incremental Evidence for the Effectiveness of Listening Visits

Maternal depression is a prevalent public health problem, particularly for low-income mothers of young children. Intervention development efforts, which often focus on surmounting instrumental barriers to care, have not successfully engaged and retained women in treatment. Task-sharing approaches like Listening Visits (LV) could overcome key instrumental and psychological barriers by leveraging the access of trusted, community caregivers to deliver treatment. A recent randomized controlled trial (RCT) demonstrated the efficacy of LV delivered by non-mental-health providers as compared to usual care. The present report presents results from a follow-up phase of that RCT during which participants who had completed LV were followed for an additional 8 weeks and completed measures of depression and quality of life. In addition, participants who were initially randomized to the wait-list control group received LV and were assessed. Treatment gains previously observed in participants completing LV were enhanced during the 8-week follow-up period. Participants receiving LV during the follow-up period experienced significant improvement in depressive symptoms. Results demonstrate the sustainability of LV delivered by non-mental-health providers, and provide preliminary evidence for the replicability of this approach in a sample of predominately low-income pregnant women and mothers of young children.

Depression treatment delivered at the point-of-care: a qualitative assessment of the views of low-income US mothers

BACKGROUND/OBJECTIVE

Within the first months of childbirth, clinically significant depressive symptoms are experienced by 19% of mothers in the US, and are even more prevalent among low-income and ethnic-minority women. Paradoxically, low-income and ethnic-minority mothers are faced with unique barriers that make them less likely to receive professional mental health care. To find ways to remove these barriers, a recent US trial extended use of a United Kingdom intervention, Listening Visits (LV), an evidence-based treatment delivered by home visitors/office nursing staff.

METHODS

A qualitative content analysis was conducted with participants' (N=19 in an open trial and N=49 in a randomized controlled trial) responses to a post-treatment semi-structured interview assessing their views of LV. The percentage of participants endorsing each thematic code is presented.

RESULTS

When the provider first introduced the LV intervention, 77.9% of women retrospectively reported having positive views of trying this new approach. Recipients most frequently mentioned as helpful two aspects of LV: empathic listening/support and the collaborative style of the LV provider. Half of the women (50%) did not suggest changes to how LV were delivered. Among those who suggested changes, the most frequent (42.6%) suggestion was to increase the number/duration of sessions.

CONCLUSION

Listening Visits is an acceptable depression treatment approach, as perceived by low-income, ethnic-minority mothers, which health and social service providers who serve this population can use.

Prevention of postnatal depression

Postnatal depression is the most frequent psychiatric disorder seen after childbirth, with a prevalence rate of 10% to 15%. The women at risk need to be identified by a valid and reliable method, either using a screening instrument or an interview schedule.

The preventive strategies need to have enough power to detect a clinically worthwhile effect to be considered useful in clinical practice. Many of the risk factors for developing postnatal depression are present during the pregnancy and immediate post-partum period. The risk factors for postnatal depression include depression or anxiety during pregnancy, experiencing stressful life events during pregnancy or the early puerperium, maternity blues, low levels of social support, past history of depression and poor marital adjustment. The antenatal and postnatal period provides an ideal opportunity to screen women for these risk factors. The women identified to be at risk can be identified, and preventive interventions can be implemented.

Routine clinical practice can be improved to identify some of the women at risk by better communication between health professionals. There are no antenatal screening tools that have been shown to be of benefit in predicting postnatal depression. Edinburgh Postnatal Depression Scale is widely used in the postnatal period to screen for depression. The psychosocial interventions to prevent postnatal depression have not been shown to be beneficial and there is a dearth of psychopharmacological trials to make firm conclusions about their efficacy in preventing postnatal depression. Individualised psychosocial interventions aimed at the at-risk populations and initiated in the postnatal period appear to have some benefit in preventing postnatal depression. The focus of this article will be the risk factors associated with postnatal depression, screening methods and tools to identify those at risk of developing the disorder and the psychosocial, psychological and psychopharmacological interventions to prevent postnatal depression.

Training practice nurses to assess and manage anxiety disorders: A pilot study

There is a shortage of health staff available in primary care who can assess and manage anxiety disorders using effective evidence-based psychological methods. Previous training packages have largely failed to evaluate skill acquisition. We devised a brief training package for practice nurses to learn how to treat anxiety disorders. Fourteen practice nurses acted as their own controls in a before and one month after training design to determine retention of assessment and management skills. Both were rated 'blind' in videotaped role-played interviews with an actor. With training, there were significant improvements in specific history-taking, explaining anxiety disorders, all aspects of anxiety management (breathing exercise, distraction, exposure), follow-up of patients and overall performance. Overall, 11 practice nurses (79%) were judged to be clinically effective after training compared to none before. After training, all nurses reported that they had used the training package in clinical practice. The findings are discussed in the light of the published literature, and possible future directions for research are suggested.

Depression Management by NICU Nurses

The purpose of this article was to evaluate attitudes of mothers of newborns hospitalized on the neonatal intensive care unit (NICU) toward nurse-delivered depression screening and counseling. NICU mothers ( N = 200) completed questionnaires assessing their views toward being screened for depression by nurses, treatment provider preference, and interest in learning about Listening Visits (LV), a nurse-delivered intervention. The views of 23 LV recipients were also assessed. Most mothers were receptive to depression screening by nurses, two thirds would see a nurse for counseling, and half were interested in learning more about LV. Among LV recipients, half readily embraced the idea and the remaining recipients were skeptical but opted to try. After receiving LV, recipients unanimously rated LV and the skill of the LV provider highly. Screening and counseling by NICU nurses could increase detection of depression and treatment use among at-risk women. Assessing nurses’ perspectives about implementing this model of care is an important future research direction.

Management of bipolar disorders in women by nonpharmacological methods

Several reasons justify the need for nonpharmacological interventions for bipolar disorder (BD) in women. This review focuses on psychosocial therapies for BDs in women. The research evidence for a wide range of psychosocial interventions for the management of BDs in women has been presented. All the interventions have some common components like targeting disease management, information regarding illness, and coping skills. There also are distinctive features like cognitive restructuring and self-rated mood charts in cognitive behavior therapy, regulation of sleep/wake cycles and daily routines in interpersonal sleep regulation therapy, and communication skill training in family treatments. Many psychosocial interventions hold promise as adjunctive therapies for bipolar patients. In India, there is a considerable dearth of literature in this area due lack of skilled staff for psychosocial interventions. Future trials need to: Clarify which populations are most likely to benefit from which strategies; identify putative mechanisms of action; systematically evaluate costs, benefits, and generalizability of effects, and record adverse effects.

Mental health interventions and future major depression among primary care patients with subthreshold depression

BACKGROUND

Subthreshold depression is prevalent in primary care and is associated with poorer quality of life, higher health care use and increased risk of major depressive disorder (MDD). Currently, it is unclear how subthreshold depression should be managed in primary care and no studies have investigated the relationship between current models of care and the development of MDD. This study aimed to describe usual care over a six month follow-up for primary care patients with subthreshold depression and to investigate the relationship between usual care and the development of MDD.

METHODS

Data were derived from 250 participants with subthreshold depression from the diamond study, a longitudinal cohort study of primary care patients. Participants completed questionnaires at three and six months on their health care use, the interventions they received and their depression status. Interventions were categorised according to the NICE guidelines for the management of depression in adults. Generalised estimating equation (GEE) models and logistic regression were used to estimate the association between receiving an intervention and MDD over six months.

RESULTS

Four fifths (80.8%) of participants received a mental health intervention. Therapeutic listening, reassurance, pharmacotherapy and advice to exercise were most common. Subsequent MDD was predicted by history of depression, baseline depressive symptom severity and receiving a mental health intervention.

LIMITATIONS

Usual care was assessed via patient self-report.

CONCLUSIONS

Primary care physicians deliver mental health interventions to most subthreshold patients. However, it appears that current interventions are not averting MDD. Further research to identify effective interventions which are feasible in primary care is needed.

Implementation of an innovative nurse-delivered depression intervention for mothers of NICU infants

Depression affects approximately 19% of all postpartum women, and mounting evidence indicates increased risk for mothers of preterm infants, with prevalence estimates ranging from 28% to 67%. The current approach to management of maternal symptoms related to postpartum depression in the neonatal intensive care unit (NICU) ranges from no intervention to depression screening and referral. For depressed mothers of NICU infants, obtaining treatment is especially difficult and usually becomes a secondary priority; thus, we looked to a nurse-delivered counseling model. Listening visits (LV) are an empirically supported nurse-delivered intervention that focuses on relationship building and exploration of a mother's problems through active reflective listening and collaborative problem solving. An LV open trial in the NICU has been conducted to evaluate the effectiveness of this intervention for mothers of hospitalized infants. Results indicate that LV are associated with a reduction in both maternal depressive and anxiety symptoms. This case study following the description of the intervention demonstrates how the authors used the experiences from the NICU open trial to expand the application of LV to this new setting.

Depression treatment for impoverished mothers by point-of-care providers: A randomized controlled trial

OBJECTIVE

Depression in low-income, ethnic-minority women of childbearing age is prevalent and compromises infant and child development. Yet numerous barriers prevent treatment delivery. Listening Visits (LV), an empirically supported intervention developed for delivery by British home-visiting nurses, could address this unmet mental health need. This randomized controlled trial (RCT) evaluated the effectiveness of LV delivered at a woman's usual point-of-care, including home visits or an ob-gyn office.

METHOD

Listening Visits were delivered to depressed pregnant women or mothers of young children by their point-of-care provider (e.g., home visitor or physician's assistant), all of whom had low levels of prior counseling experience. Three quarters of the study's participants were low-income. Of those who reported ethnicity, all identified themselves as minorities. Participants from 4 study sites (N = 66) were randomized in a 2:1 ratio, to LV or a wait-list control group (WLC). Assessments, conducted at baseline and 8 weeks, evaluated depression, quality of life, and treatment satisfaction.

RESULTS

Depressive severity, depressive symptoms, and quality of life significantly improved among LV recipients as compared with women receiving standard social/health services. Women valued LV as evidenced by their high attendance rates and treatment satisfaction ratings.

CONCLUSIONS

In a stepped model of depression care, LV can provide an accessible, acceptable, and effective first-line treatment option for at-risk women who otherwise are unlikely to receive treatment. (PsycINFO Database Record

Psychodynamic therapies with infants and parents: a review of RCTs on mother-infant psychoanalytic treatment and other techniques

This article critically examines the existent evidence base for Psychodynamic Therapy with Infants and Parents (PTIP), specifically focusing on the available RCTs (Randomized Controlled Trials) in the literature. The author also discusses how these studies influenced the design of an RCT of a related novel treatment method, Mother-Infant Psychoanalytic treatment (MIP). He found that certain types of mothers and infants may be more likely to benefit from MIP. In addition to providing guidance on therapeutic techniques, this article also effectively outlines ways in which PTIP, as well as psychotherapy for emotional issues during pregnancy, can be better integrated into the comprehensive health care system. Local health care units comprised of a nurse group and one therapist may be a better way of handling mother-infant interactional difficulties than centralized, specialized perinatal psychiatry centers.

Attempting to prevent postnatal depression by targeting the mother–infant relationship: a randomised controlled trial

Aim

The purpose of the study was to investigate whether an intervention which focused on enhancing the quality of the mother-infant relationship would prevent the development of postnatal depression (PND) and the associated impairments in parenting and adverse effects on child development.

Background

Recent meta-analyses indicate modest preventive effects of psychological treatments for women vulnerable to the development of PND. However, given the strong evidence for an impact of PND on the quality of the mother–infant relationship and child development, it is notable that there are limited data on the impact of preventive interventions on these outcomes. This is clearly a question that requires research attention. Accordingly, a randomised controlled trial (RCT) was conducted of such a preventive intervention.

Methods

A large sample of pregnant women was screened to identify those at risk of PND. In an RCT 91 were randomly assigned to receive the index intervention from research health visitors, and 99 were assigned to a control group who received normal care. In an adjacent area 76 women at risk of PND received the index intervention from trained National Health Service (NHS) health visitors. The index intervention involved 11 home visits, two antenatally and nine postnatally. They were supportive in nature, with specific measures to enhance maternal sensitivity to infant communicative signals, including items from the Neonatal Behavioral Assessment Scale. Independent assessments were made at 8 weeks, 18 weeks, and 12 and 18 months postpartum. Assessments were made of maternal mood, maternal sensitivity in mother–infant engagement, and infant behaviour problems, attachment and cognition.

Findings

The RCT revealed that the index intervention had no impact on maternal mood, the quality of the maternal parenting behaviours, or infant outcome, although there were suggestions, on some self-report measures, that those with a lower level of antenatal risk experienced benefit. This was also the case for the intervention delivered by trained NHS health visitors. The findings indicate that the approach investigated to preventing PND and its associated problems cannot be recommended.

Depression among postnatal women in an urban Irish community

Objectives:To estimate the prevalence of postnatal depression in a community sample of women in a disadvantaged urban area in West Dublin, and to examine the factors which may be associated with it.

Method: All women who had a live birth in the area over a one year period were identified (944) and the self-rated Edinburgh Postnatal Depression Scale (EPDS) was distributed to those who could be contacted by the public health nurses. Those scoring in the depressed range (> 12) were compared to non-depressed for age, marital status, employment, parity, presence of a confidant, mode of delivery, previous miscarriage and previous psychiatric history.

Results: Contact was made with 596 women and 377 responded. Responders were older and more likely to be first time mothers, but there was no significant difference between responders and eligible population for marital status. One hundred and eight women (28.6%) scored in the depressed range. Ten sociodemographic and clinical variables were entered into a logistic regression. Scores over the threshold (> 12), suggesting clinical depression, were significantly associated with four variables, lower age, absence of a confidant, previous miscarriage and previous treatment for depression by a GP.

Conclusions: A high prevalence of postnatal depression of 28.6% was reported, which may be associated with overall high levels of social disadvantage in this sample. There were implications for the targeting of resources into such areas. The associated factors are discussed.

Prevention and treatment of postnatal depression

Postnatal depression is a common condition that may have a significant negative impact on both infant and mother, often remaining undiagnosed and untreated. Development of effective means of detection, prevention and treatment of postnatal depression is a major health challenge. The objective of this article is to critically review pharmacological, psychological and psychosocial approaches of prevention and treatment for postnatal depression. There is little evidence of short-term success for preventive interventions and some evidence of short-term success for treatment interventions. No preventive or therapeutic studies, however, have provided evidence for long-term success. There is a need for future research into the prevention and treatment of postnatal depression including the assessment of long-term effects on the child's development as well as feasibility in relation to cost-effectiveness.

The course of postpartum depression: a review of longitudinal studies

After participating in this educational activity, the physician should be better able to 1. Identify the risk factors associated with persistence of postpartum depression. 2. Evaluate the limitations of the literature. 3. Determine the implications of the findings on women with postpartum depression and their children.This article aims to critically review studies published between 1985 and 2012 concerning the course of postpartum depression (PPD), as well as factors implicated in PPD with a chronic course. We provide a systematic, qualitative review of studies on the course of PPD, following PRISMA guidelines. The results show that although the majority of women recover from PPD, it becomes chronic in a relatively large subgroup of women. Several studies have identified risk factors predicting a chronic course of PPD. This review also emphasizes and discusses important conceptual and methodological limitations in existing research, which preclude drawing strong conclusions. Finally, the implications of these findings and suggestions for future research and clinical intervention are outlined.