Depression after childbirth: the views of medical students and women compared

In Their Own Words: A Qualitative Investigation of the Factors Influencing Maternal Postpartum Functioning in the United States

During the first twelve months postpartum, infants require intensive care and mothers are susceptible to physical and mental health concerns as they undergo a period of tremendous psychological and physiological adjustment. The mother’s level of postpartum functioning not only impacts her experience as a mother but also the infant and family unit. However, efforts to bolster functioning are lacking, and previous literature has identified a gap between what experts recommend and what mothers desire during the postpartum period. To address this, we conducted structured interviews with a diverse sample of 30 postpartum mothers to identify factors that mothers report are most influential to their postpartum functioning. In total, we identified 23 clinically actionable factors, all of which are backed by existing literature. In addition to an in-depth presentation of the qualitative findings, we also present a heat map to visualize the relevance of these factors to each of seven established domains of maternal functioning. Lastly, based on our findings, we offer a taxonomy of interventional strategies that could bolster maternal functioning during this critical period.

Re-examination of perinatal mental health policy frameworks for women signalling distress on the Edinburgh Postnatal Depression Scale (EPDS) completed during their antenatal booking-in consultation: a call for population health intervention

BACKGROUND

Globally, anxiety and depression are the most common complications of the perinatal period (conception to 1 year postpartum). It is now recognised that anxiety and depression are more commonly found antenatally than postnatally and represent the greatest risk factor for developing postnatal depression. Research in this space has focused on treatment of postnatal depression, with limited attention paid to preventative strategies for women signalling distress, who are subthreshold for diagnosable illness.

MAIN TEXT

The Edinburgh Postnatal Depression Scale (EPDS) was introduced in 1987 and has since been validated as a depression screening tool in the Australian and international setting. The EPDS has been embedded as a depression screening tool within a broader psychosocial assessment for women who receive their maternity care in the public system in Australia. Owing to perceived service restrictions, an EPDS score must reach a threshold of 13 or more to warrant specific assessment or intervention. Current policy frameworks focus on tertiary prevention models, and those women scoring 10 to 12, who could reasonably be considered as signalling distress or early signs of illness, are not currently offered intervention. The consequences of undetected or untreated perinatal mood or anxiety disorder (often co-morbid) include maternal psychological, social, occupational and physical dysfunction, and extend to deleterious infant and child life-course effects. This provides a strong justification to explore the role of preventative programs for women who are distressed. A range of low-resource, population-based interventions are available and effective. We explore the evidence for a selection of these programs. Further research is needed to decipher their effectiveness as a secondary prevention approach in women who are currently signalling distress during antenatal assessment.

CONCLUSION

The burden of perinatal mood disorders, and their potential for prolonged impact, justify the exploration of preventatively-focused programs in women who signal distress during antenatal care.

National survey on psychosocial obstetrics and gynecology curriculum in US medical schools

INTRODUCTION

This study sought to identify how psychosocial topics related to women's health are taught and assessed in the obstetrics/gynecology program of American medical schools, and what issues may prevent or promote their instruction.

METHODS

A questionnaire was distributed to the ob/gyn clerkship director of every US medical school. Directors were asked whether each of four recommended topics were covered in their curricula. They were also asked about barriers to instructing topics not taught, and the importance of these topics.

RESULTS

Out of 136 US medical schools, 57 questionnaires were returned (response rate = 40.4%). In all, 27 schools (48%) include formal training in pregnancy-related mood disorders, 33 (58%) include pre-menstrual syndrome/pre-menstrual dysphoric disorder, 29 (51%) include female sexual dysfunction and 45 (79%) include violence against women. Six schools (12%) listed none of these topics as taught. All but three of the clerkship directors agreed that psychosocial topics are important. The most common reason given for lack of instruction was insufficient time allotted.

CONCLUSIONS

Despite agreement on their importance, many US medical schools do not teach psychosocial aspects of women's health. Addressing the barriers to teaching these topics would help provide medical students with more opportunities to learn about these issues.

The process of developing and implementing a telephone-based peer support program for postpartum depression: evidence from two randomized controlled trials

BACKGROUND

A randomized controlled trial evaluated the effect of telephone-based peer support on preventing postpartum depression (PPD) among high-risk mothers. The results indicated that support provided by peer volunteers may be an effective preventative strategy. The purpose of this paper is to outline the process of developing, implementing, maintaining, and evaluating the peer support program that we used in this PPD prevention trial.

METHODS

The peer support program had been used successfully in a pilot trial and a previous breastfeeding peer support trial. Based on our experience and lessons learned, we developed a 4-phase, 12-step approach so that the peer support model could be copied and used by different health providers in various settings. We will use the PPD prevention trial to demonstrate the suggested steps.

RESULTS

The trial aim to prevent the onset of PPD was established. Peer volunteers who previously experienced and recovered from self-reported PPD were recruited and attended a four-hour training session. Volunteers were screened and those identified as appropriate to provide support to postpartum mothers were selected. Women who scored more than 9 on the Edinburgh Postnatal Depression Scale within the first two weeks after childbirth were recruited to participate in the trial and proactive, individualized, telephone-based peer support (mother-to-mother) was provided to those randomized to the intervention group. Peer volunteers maintained the intervention, supported other volunteers, and evaluated the telephone-based support program. Possible negative effects of the intervention were assessed. An in-depth assessment of maternal perspectives of the program at 12 weeks postpartum was performed.

CONCLUSIONS

The 4-phase, 12-step approach delineated in this paper provides clear and concise guidelines for health professionals to follow in creating and implementing community-based, peer-support interventions with the potential to prevent PPD.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN68337727.

The effect of telephone-based interpersonal psychotherapy for the treatment of postpartum depression: study protocol for a randomized controlled trial

BACKGROUND

Substantial data indicate potential health consequences of untreated postpartum depression (PPD) on the mother, infant, and family. Studies have evaluated interpersonal psychotherapy (IPT) as treatment for PPD; however, the results are questionable due to methodological limitations. A comprehensive review of maternal treatment preferences suggests that mothers favor 'talking therapy' as a form of PPD treatment. Unfortunately, IPT is not widely available, especially in rural and remote areas. To improve access to care, telepsychiatry has been introduced, including the provision of therapy via the telephone.

METHODS/DESIGN

The purpose of this randomized controlled trial is to evaluate the effect of telephone-based IPT on the treatment of PPD. Stratification is based on self-reported history of depression and province. The target sample is 240 women. Currently, women from across Canada between 2 and 24 weeks postpartum are able to either self-identify as depressed and refer themselves to the trial or they may be referred by a health professional based on a score >12 on the Edinburgh Postnatal Depression Scale (EPDS). Following contact by the trial coordinator, a detailed study explanation is provided. Women who fulfill the eligibility criteria (including a positive diagnostic assessment for major depression) and consent to participate are randomized to either the control group (standard postpartum care) or intervention group (standard postpartum care plus 12 telephone-based IPT sessions within 12 to 16 weeks, provided by trained nurses). Blinded research nurses telephone participants at 12, 24, and 36 weeks post-randomization to assess for PPD and other outcomes including depressive symptomatology, anxiety, couple adjustment, attachment, and health service utilization. Results from this ongoing trial will: (1) develop the body of knowledge concerning the effect of telephone-based IPT as a treatment option for PPD; (2) advance our understanding of training nurses to deliver IPT; (3) provide an economic evaluation of an IPT intervention; (4) investigate the utility of the EPDS in general clinical practice to identify depressed mothers; and (5) present valuable information regarding PPD, along with associated couple adjustment, co-morbid anxiety and self-reported attachment among a mixed rural and urban Canadian population.

TRIAL REGISTRATION

Current Controlled Trials Ltd. ISRCTN88987377.

Peer support for postpartum depression: volunteers' perceptions, recruitment strategies and training from a randomized controlled trial

A randomized controlled trial evaluated the effect of telephone-based peer support (mother-to-mother) on preventing postpartum depression among high-risk mothers. This paper reports volunteers' perceptions, which showed that peer support is an effective preventative intervention. Two-hundred and five (205) volunteers were recruited and trained to provide peer support to 349 mothers randomized to the intervention group. Volunteers' perceptions were measured at 12 weeks using the Peer Volunteer Experience Questionnaire, completed by 69% (121) of the 175 volunteers who provided support to at least one mother. Large majorities felt that the training session had prepared them for their role (94.2%), that volunteering did not interfere with their lives (81.8%) and that providing support helped them grow as individuals (87.8%). Over 90% stated that they would become a peer volunteer again, given the opportunity. Recruitment and retention of effective volunteers is essential to the success of any peer-support intervention. Results from this study can assist clinicians and program planners to provide effective training, sufficient on-going support and evaluation and appropriate matching of volunteers to mothers who desire peer support and are at high risk of postpartum depression.

Immigrant and refugee women's post-partum depression help-seeking experiences and access to care: a review and analysis of the literature

ACCESSIBLE SUMMARY

• This literature review on post-partum depression (PPD) presents an analysis of the literature about PPD and the positive and negative factors, which may influence immigrant and refugee women's health seeking behaviour and decision making about post-partum care. • A critical review of English language peer-reviewed publications from 1988 to 2008 was done by the researchers as part of a qualitative research study conducted in a western province of Canada. The overall goal of the study is to raise awareness and understanding of what would be helpful in meeting the mental health needs of the immigrant and refugee women during the post-partum period. • Several online databases were searched: Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, MEDLINE (Ovid), EBM Reviews - Cochrane Database of Systematic Reviews. • Review of the literature suggests: 1 Needs, issues and specific risk factors for PPD among immigrant and refugee women have been limited. 2 Descriptive accounts regarding culture and PPD are found in the literature but impact of cultural factors upon PPD has not been well studied. 3 Few studies look at how social support, gender, and larger institutions or organizational structures may affect immigrant and refugee women's help-seeking and access to mental health care services. 4 More research is needed to hear the immigrant and refugee women's ideas about their social support needs, the difficulties they experience and their preferred ways of getting help with PPD.

ABSTRACT

This review and analysis of the literature is about the phenomenon of post-partum depression (PPD) and the barriers and facilitators, which may influence immigrant and refugee women's health seeking behaviour and decision making about post-partum care. As part of a qualitative research study conducted in a western province of Canada a critical review of English language peer-reviewed publications from 1988 to 2008 was undertaken by the researchers. The overall goal of the study is to raise awareness and understanding of what would be helpful in meeting the mental health needs of the immigrant and refugee women during the post-partum period. Several online databases were searched: Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, MEDLINE (Ovid), EBM Reviews - Cochrane Database of Systematic Reviews. Findings suggest: (1) needs, issues and specific risk factors for PPD among immigrant and refugee women have been limited; (2) descriptive accounts regarding culture and PPD are found in the literature but impact of cultural factors upon PPD has not been well investigated; (3) few studies examine how social support, gender, institutional and organizational structures present barriers to the women's health seeking behaviour; and (4) additional research is required to evaluate immigrant and refugee women's perspectives about their social support needs, the barriers they experience and their preferred support interventions.

Effect of peer support on prevention of postnatal depression among high risk women: multisite randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of telephone based peer support in the prevention of postnatal depression.

DESIGN

Multisite randomised controlled trial.

SETTING

Seven health regions across Ontario, Canada.

PARTICIPANTS

701 women in the first two weeks postpartum identified as high risk for postnatal depression with the Edinburgh postnatal depression scale and randomised with an internet based randomisation service.

INTERVENTION

Proactive individualised telephone based peer (mother to mother) support, initiated within 48-72 hours of randomisation, provided by a volunteer recruited from the community who had previously experienced and recovered from self reported postnatal depression and attended a four hour training session.

MAIN OUTCOME MEASURES

Edinburgh postnatal depression scale, structured clinical interview-depression, state-trait anxiety inventory, UCLA loneliness scale, and use of health services.

RESULTS

After web based screening of 21 470 women, 701 (72%) eligible mothers were recruited. A blinded research nurse followed up more than 85% by telephone, including 613 at 12 weeks and 600 at 24 weeks postpartum. At 12 weeks, 14% (40/297) of women in the intervention group and 25% (78/315) in the control group had an Edinburgh postnatal depression scale score >12 (chi(2)=12.5, P<0.001; number need to treat 8.8, 95% confidence interval 5.9 to 19.6; relative risk reduction 0.46, 95% confidence interval 0.24 to 0.62). There was a positive trend in favour of the intervention group for maternal anxiety but not loneliness or use of health services. For ethical reasons, participants identified with clinical depression at 12 weeks were referred for treatment, resulting in no differences between groups at 24 weeks. Of the 221 women in the intervention group who received and evaluated their experience of peer support, over 80% were satisfied and would recommend this support to a friend.

CONCLUSION

Telephone based peer support can be effective in preventing postnatal depression among women at high risk.

TRIAL REGISTRATION

ISRCTN 68337727.

Evidence-based recommendations for depressive symptoms in postpartum women

Postpartum depression is a serious health issue affecting 13% of women from diverse cultures. Despite the well-documented consequences of postpartum depression, it remains difficult to identify, and diverse practices relate to its prevention and treatment. Evidence-based interventions are essential to improve both maternal and infant health outcomes associated with pregnancy. This article describes the development process of an evidence-based practice guideline for postpartum depression and highlights the practice recommendations related to the confirmation, prevention, and treatment of depressive symptoms in postpartum mothers.

Canadian Mothers’ Perceived Support Needs During Postpartum Depression

OBJECTIVE

To assess the support needs, support resources, barriers to support, and preferences for support intervention for women with postpartum depression.

DESIGN

Multisite, exploratory, descriptive study in which qualitative data were collected on support needs, the availability of resources, perceived barriers to support, and preferences for support of women who have experienced symptoms of postpartum depression.

PARTICIPANTS AND SETTING

Conducted in Alberta and New Brunswick; mothers were interviewed individually (Alberta, n= 24; New Brunswick, n= 17) and in groups (Alberta, n= 5; New Brunswick, n= 6).

RESULTS

For most mothers, one-on-one support was preferred when postpartum depression is recognized. Group support should be available once the mothers start to feel better and are able to comfortably interact with other mothers in a group format. This suite of alternatives needs to be underpinned by concerted public education efforts.

Global and relationship-specific perceptions of support and the development of postpartum depressive symptomatology

BACKGROUND

A lack of social support has consistently been demonstrated to be an important modifiable risk factor for postpartum depression. As such, a greater understanding of specific support variables may assist health professionals in the development of effective preventive interventions. The purpose of this paper was two-fold: (1) to determine if women discriminated between global and relationship-specific perceptions of support, and (2) to examine the influence of global and relationship-specific perceptions of support in the immediate postpartum period on the development of depressive symptomatology at 8 weeks postpartum.

METHODS

As part of a longitudinal study, a diverse sample of 594 mothers completed questionnaires that included the Edinburgh Postnatal Depression Scale (EPDS) and global and relationship-specific (e.g., partner, mother, and other women with children) measures of support.

RESULTS

Mothers clearly discriminated between global and relationship-specific perceptions of support and those with depressive symptomatology at 8 weeks had significantly lower perceptions of both global and relationship-specific support at 1-week postpartum. Using discriminant function analysis, four variables, reliable reliance from partner, nurturance from partner, attachment to other women with children, and EPDS score at 1-week postpartum, differentiated between mothers who experienced depressive symptomatology at 8 weeks and those who did not.

CONCLUSION

Relationship-specific interventions may be beneficial if they include strategies that target a positive partner relationship through preceptions of reliable alliance and feeling needed and provide opportunites for interaction with other mothers. Maternal mood at 1 week postpartum was the largest predictor of depressive symptomatology at 8 weeks.

When giving life starts to take the life out of you: women's experiences of depression after childbirth

OBJECTIVE

To capture the missing voices of mothers who are suffering postnatal depression.

DESIGN

Qualitative methodology using in-depth interviews.

SETTING

Melbourne, Victoria, Australia.

PARTICIPANTS

10 women who had been clinically diagnosed and admitted to a large hospital mother and baby unit in Australia.

FINDINGS

Stigma is frequently attached to women who are unhappy after the birth of their child, because they are not coping with the demands of motherhood or do not instantly bond with, and love, their baby. As a result, postnatal depression can be a terrifying and isolating experience for women. It is also a complex illness with varying degrees, reasons for onset and medical treatments.

IMPLICATIONS FOR PRACTICE

In this study, we have captured the emotions and feelings of women first hand, allowing us and health-care practitioners who are treating women to truly understand this debilitating illness. It is hoped that, in making the wider community aware of depression after childbirth, fewer women will suffer in silence.

Postpartum depression help-seeking barriers and maternal treatment preferences: a qualitative systematic review

BACKGROUND

Despite the well-documented risk factors and health consequences of postpartum depression, it often remains undetected and untreated. No study has comprehensively examined postpartum depression help-seeking barriers, and very few studies have specifically examined the acceptability of postpartum depression treatment approaches. The objective of this study was to examine systematically the literature to identify postpartum depression help-seeking barriers and maternal treatment preferences.

METHODS

Medline, CINAHL, and EMBASE databases were searched using specific key words, and published peer-reviewed articles from 1966 to 2005 were scanned for inclusion criteria.

RESULTS

Of the 40 articles included in this qualitative systematic review, most studies focused on women's experiences of postpartum depression where help seeking emerged as a theme. A common help-seeking barrier was women's inability to disclose their feelings, which was often reinforced by family members and health professionals' reluctance to respond to the mothers' emotional and practical needs. The lack of knowledge about postpartum depression or the acceptance of myths was a significant help-seeking barrier and rendered mothers unable to recognize the symptoms of depression. Significant health service barriers were identified. Women preferred to have "talking therapies" with someone who was nonjudgmental rather than receive pharmacological interventions.

CONCLUSIONS

These results suggest that women did not proactively seek help, and the barriers involved both maternal and health professional factors. Common themes related to specific treatment preferences emerged from women of diverse cultural backgrounds. The clinical implications outlined in this review will assist health professionals in addressing these barriers and in developing preventive and treatment interventions that are in accord with maternal preferences.

Detection of postpartum depression and anxiety in a large health plan

To determine the prevalence of diagnosed and/or treated postpartum depression and anxiety, records were extracted for 1 year after delivery from databases of outpatient diagnoses and prescriptions, for women in a health maintenance organization who had delivered a child from July 1997 through June 1998. For comparison, telephone interviews were conducted 5 to 9 months after delivery with random samples of women who delivered at 2 facilities from June 1998 through January 1999. Of the women interviewed, 11% met criteria for major depression during the first 4 months postpartum, and an additional 13% met criteria for probable depression at 5 to 9 months postpartum. In contrast 7.0% of the large cohort had a visit or prescription for depression. The 1-year prevalence rate for diagnosed and/or treated anxiety without depression was 3.8%; the rate at time of interview was 14.7%. Overall, less than 33% of women with substantial depression or anxiety symptoms were detected.

The effect of peer support on postpartum depression: a pilot randomized controlled trial

OBJECTIVE

To evaluate the effect of peer support (mother-to-mother) on depressive symptomatology among mothers identified as high-risk for postpartum depression (PPD).

METHOD

Forty-two mothers in British Columbia were identified as high-risk for PPD according to the Edinburgh Postnatal Depression Scale (EPDS) and randomly assigned to either a control group (that is, to standard community postpartum care) or an experimental group. The experimental group received standard care plus telephone-based peer support, initiated within 48 to 72 hours of randomization, from a mother who previously experienced PPD and attended a 4-hour training session. Research assistants blind to group allocation conducted follow-up assessments on diverse outcomes, including depressive symptomatology, at 4 and 8 weeks postrandomization.

RESULTS

Significant group differences were found in probable major depressive symptomatology (EPDS > 12) at the 4-week (chi 2 = 5.18, df = 1; P = 0.02) and 8-week (chi 2 = 6.37, df = 1; P = 0.01) assessments. Specifically, at the 4-week assessment 40.9% (n = 9) of mothers in the control group scored > 12 on the EPDS, compared with only 10% (n = 2) in the experimental group. Similar findings were found at the 8-week assessment, when 52.4% (n = 11) of mothers in the control group scored > 12 on the EPDS, compared with 15% (n = 3) of mothers in the experimental group. Of the 16 mothers in the experimental group who evaluated the intervention, 87.5% were satisfied with their peer-support experience.

CONCLUSIONS

Telephone-based peer support may effectively decrease depressive symptomatology among new mothers. The high maternal satisfaction with, and acceptance of, the intervention suggests that a larger trial is feasible.