An exploratory parallel-group randomised controlled trial of antenatal Guided Self-Help (plus usual care) versus usual care alone for pregnant women with depression: DAWN trial

BACKGROUND

Depression is a common antenatal mental disorder associated with significant maternal morbidity and adverse fetal outcomes. However, there is a lack of research on the effectiveness or cost-effectiveness of psychological interventions for antenatal depression.

METHODS

A parallel-group, exploratory randomised controlled trial across five hospitals. The trial compared Guided Self-Help, modified for pregnancy, plus usual care with usual care alone for pregnant women meeting DSM-IV criteria for mild-moderate depression. The trial objectives were to establish recruitment/follow-up rates, compliance and acceptability, and to provide preliminary evidence of intervention efficacy and cost-effectiveness. The primary outcome of depressive symptoms was assessed by blinded researchers using the Edinburgh Postnatal Depression Scale at 14-weeks post-randomisation.

RESULTS

620 women were screened, 114 women were eligible and 53 (46.5%) were randomised. 26 women received Guided Self-Help - 18 (69%) attending ≥4 sessions - and 27 usual care; n = 3 women were lost to follow-up (follow-up rate for primary outcome 92%). Women receiving Guided Self-Help reported fewer depressive symptoms at follow-up than women receiving usual care (adjusted effect size -0.64 (95%CI: -1.30, 0.06) p = 0.07). There were no trial-related adverse events. The cost-effectiveness acceptability curve showed the probability of Guided Self-Help being cost-effective compared with usual care ranged from 10 to 50% with a willingness-to-pay range from £0 to £50,000.

CONCLUSIONS AND LIMITATIONS

Despite intense efforts we did not meet our anticipated recruitment target. However, high levels of acceptability, a lack of adverse events and a trend towards improvements in symptoms of depression post-treatment indicates this intervention is suitable for talking therapy services.

Preventing excessive gestational weight gain: a systematic review of interventions

Women who gain excessive weight during pregnancy have an increased risk of post-partum obesity, and retention of gestational weight gain (GWG) post birth is a strong predictor of maternal overweight/obesity a decade or more after the birth. The aim of the current review was to identify, and evaluate the effect of key variables designed to modify risk factors for excessive weight gain in pregnant women that have been targeted in interventions over the last decade. The 10 interventions focused primarily on behavioural changes in relation to physical activity and/or to eating. While six studies reported significantly less weight gain in the intervention women, only three showed that women in the intervention were significantly more likely to gain within recommended guidelines. GWG was reduced in only normal-weight, low-income, obese, or overweight women, or not at all. Only one study reported a reduction in GWG in women with body mass indexes spanning the normal, overweight and obese categories. The findings were inconsistent in relation to what factors need to be targeted in intervention programmes to reduce GWG. Consideration of psychological factors relevant to pregnancy, in addition to behavioural changes in relation to eating and physical activity, is suggested for future intervention studies.

Measuring preterm cumulative stressors within the NICU: the Neonatal Infant Stressor Scale

BACKGROUND

Stress experiences, while pervasive, are less likely than painful experiences to be managed in still-hospitalised preterm infants.

AIM

We aimed to quantify the severity of common stressors for preterm infants with a view to providing a tool to manage presumed accumulated infant stress.

METHODS AND SUBJECTS

Seventeen doctors and 130 nurses who work in Neonatal Intensive and Special Care Nurseries rated the perceived stress severity of 44 acute events and 24 chronic living conditions for preterm infants at three ages (<28 weeks, 28-32 weeks, >32 weeks post-conceptional age) and for themselves. Acute items (such as heel lance) were organised into nursing, peripheral venous access, peripheral arterial access, central vascular access, ventilation, nutrition, medical procedures, surgery, radiology and miscellaneous categories. Chronic living conditions included items such as receiving intranasal oxygen and having a systemic infection.

RESULTS

Doctors and nurses perceived nearly all items to be stressful to infants to some degree and to be equally stressful across ages. The degree of stress experienced by clinicians themselves was generally low and moderately correlated with presumed infant stress for the same items. Presumed infant stress was inversely related to clinician age.

CONCLUSION

Based on these results we developed the Neonatal Infant Stressor Scale to help track, measure and manage presumed accumulated stress in preterm neonates.

Impact of education on women with perinatal depression

OBJECTIVE

To assess the impact that education through participation in a depression screening program has on mental health literacy and help seeking behavior in perinatal women.

METHODS

Responses to a hypothetical case of depression, help seeking behavior, and screening levels for risk of depression using the Edinburgh Postnatal Depression Scale were compared between two groups of postnatal women; one group who had participated in a screening program and the other who had not. Those who participated in the screening program were also asked to evaluate the educational material they had received.

RESULTS

A total of 1309 women, broadly representative of postnatal women, answered one or more questionnaires. Those who had participated in the screening program were better able to recognize depression in a hypothetical case, and also assess their own mental state more appropriately. Those women who had been part of the program and did not score high on the EPDS were less likely to seek help, were more satisfied when they did and tended to benefit more from the educational booklet.

CONCLUSIONS

Participation in a screening program with educational material had significant benefits for mental health literacy and the health service use for perinatal women at risk for depression.

Health professional's knowledge and awareness of perinatal depression: results of a national survey

INTRODUCTION

Postnatal depression affects 14% of women, occurring also antenatally, with potential long-term consequences, making it an important disorder to detect and manage early. In this study we sought to examine knowledge and awareness of perinatal depression in health professionals involved in perinatal care throughout Australia prior to the implementation of a comprehensive screening program, aimed at improving detection and access to appropriate management.

METHODS

A random sample of General Practitioners (GPs) and Maternal Child Health Nurses (MCHNs) and Midwives, in regions throughout Australia to be subsequently targeted by a screening and education program, were invited to participate. Responses to a hypothetical vignette and a knowledge questionnaire, as well as details of experience were completed.

FINDINGS

Questionnaires were completed by 246 GPs, 338 MCHNs and 569 midwives, with overall response rates; GP's 23%; MCHN's 55% and midwives 57%. Although knowledge level was similar among professional groups, MCHNs had higher levels of awareness of perinatal depression. Both GPs and MCHNs were more likely than midwives to recognize the need for providing help to women with emotional distress. Depression was more likely to be considered postnatally than antenatally in all groups, with GPs most likely to provide this diagnosis. GPs had a significant propensity to recommend antidepressants, and midwives to select non-specific medications.

CONCLUSIONS

Health professionals responding to this survey had a high awareness and similar knowledge base. Further education on antenatal depression and the safety risks and alternatives to medication is important for all groups, but particularly important for midwives and GPs. The latter is especially relevant given the preference for women with perinatal depression not to use pharmacological interventions to treat their emotional distress.

Breaking the bad news: dilemmas in shared decision-making in medical practice

In a review of the literature, very little empirically based research was uncovered to guide the practice of health professionals who need to tell their patients bad news and help them to decide on their preferred treatment option. Various practising styles and guidelines are presented, and ethical and crosscultural challenges discussed. An enormous amount of research still needs to be done to discover the least stressful ways of dealing with these issues in health care settings.

Psychiatric illness in women: a review of the function of a specialist mother-baby unit

OBJECTIVE

The aim of this paper is to describe a specialist program in a psychiatric mother-baby unit and to review the characteristics (including mothering skills) and outcomes on discharge of 36 women consecutively admitted to the unit over an intensive 6-month observation period. Changes in admissions to the same unit over 10 years were also compared.

METHOD

Consecutive admissions were studied in terms of demographics, ethnicity, diagnosis, psychiatric history, psychiatric information and mother-infant data.

RESULTS

The majority of women admitted suffered from schizophrenia or other psychotic disorders, with the second largest diagnostic criteria being depression. For 20 mothers, this was the first psychiatric admission and most admissions were voluntary. The mean length of stay was 21.7 days, representing a highly significant decrease in stay when compared to the past 10 years in the same unit. Mothering skills were found to be incompetent or only passable in 57% of women. A small improvement occurred by discharge, and the majority of women were not separated from their infants.

CONCLUSIONS

The critical need to support these women and their infants in the long term was highlighted, with recommendations of outpatient and day programs, as well as supported accommodation.

Group treatment for postpartum depression: a pilot study

OBJECTIVE

There are few reports on the efficacy of treatment programs for women with postpartum depression, despite the long-term nature of this disorder. This study describes a pilot evaluation of a treatment program with educational, social support and cognitive-behavioural components.

METHOD

Ten women with persistent depression originating in the postpartum period were offered a 10-week group treatment program and compared to a wait-list control group.

RESULTS

Following treatment, a significant improvement in depression was demonstrated on the Edinburgh Post-Natal Depression Scale, Beck Depression Inventory, and Profile of Mood States. Several common factors in women suffering from postpartum depression were also identified, as were drop-out characteristics.

CONCLUSION

These results are encouraging and suggest that a cognitive-behavioural group program might be effective as a treatment for depression in the postpartum period. However, further detailed studies are required to conform this pilot study.

Do infants of depressed mothers cry more than other infants?

OBJECTIVE

This study compared the crying behaviour of infants of depressed and non-depressed mothers at 3 and 6 months of age.

METHODOLOGY

Twenty-nine depressed and 44 non-depressed mothers, their infants and partners participated in this study. Mothers were asked to complete 24-hour diaries of the amount their infants cried for 1 week.

RESULTS

The diurnal variations in crying patterns of infants of depressed and non-depressed mothers were not significantly different. However, infants of depressed mothers were found to cry significantly more in total per day than infants of non-depressed mothers at 3 months of age, but not at 6 months. The results could not be explained by differences in infant temperament.

CONCLUSION

Maternal depression may be a contributory factor to infant crying at 3 months of age.

Mother-infant interactions in postpartum depression: an early intervention program

This paper examines the role of postnatal intervention in the prevention of the negative consequences of postpartum depression on developing mother-infant relationships. It is argued that, once difficulties in these interactions have been identified, direct attempts to modify the interactions must occur within a framework that includes maternal, paternal, partnership/marital and social variables. An intervention program that may be instituted by nurses is described. The Baby Happiness, Understanding, Giving and Sharing (HUGS) Programme is an attempt to integrate direct intervention in mother-infant interactions into a systemic framework which takes into account contextual variables such as cognitive style and social support.