Sensitivity and specificity of the three Whooley and Arroll questions for detecting perinatal depression in Mexican women / Sensibilidad y especificidad de las tres preguntas de Whooley y Arroll para detectar depresión perinatal en mujeres mexicanas

Abstract: Objective: To evaluate the sensitivity and specificity of the Two Whooley questions and the Arroll question, using the SCID, The Structured Clinical Interview (SCID-I) as the gold standard for detecting perinatal depression. Materials and methods: We interviewed 210 women during pregnancy and 6 months postpartum. Results: The criterion with the greatest sensitivity was responding positively to either Whooley question (pregnancy= 94.7 %; postpartum=100.0%), while the most specific criterion was responding positively to the two Whooley questions plus the Arroll question (Pregnancy=90.0% Postpartum = 85.7%). Conclusion: The Whooley and Arroll questions have adequate psychometric properties to detect possible cases of depression during the perinatal period. They can be applied during prenatal check-ups and postpartum consultations. Timely detection of women at risk of perinatal depression can contribute to their treatment for reducing their adverse consequences in mothers and infants.

Resumen: Objetivo: Evaluar la sensibilidad y la especificidad de la Escala de las dos preguntas de Whooley y la pregunta de Arroll para detectar riesgo de depresión perinatal, usando la SCID como estándar de oro. Material y métodos: Se entrevistó a 210 mujeres durante el embarazo y 6 meses después del parto. Resultados: El criterio con mayor sensibilidad fue responder positivamente a cualquiera de las Preguntas de Whooley (embarazo = 94.7%; posparto = 100.0%) y, el más específico, responder positivamente a las preguntas de Whooley más la de Arroll (embarazo = 90.0% , Posparto = 85.7%). Conclusiones: Las preguntas de Whooley y Arroll tienen propiedades psicométricas adecuadas para detectar posibles casos de depresión durante el periodo perinatal. Pueden aplicarse durante las citas de control prenatal y consultas en el postparto. Detectar de manera oportuna a mujeres en riesgo de depresión perinatal puede ayudar a su atención para reducir sus consecuencias adversas en madres e infantes.

Correlation between intake of omega-3 fatty acids and depressive and anxiety symptoms during pregnancy / Correlación entre la ingesta de ácidos grasos omega-3 y los síntomas de depresión y ansiedad en el embarazo

Abstract: Introduction: Anxiety and depression during pregnancy are disabling disorders associated to complications during the pregnancy, delivery, and postpartum period, with a significant prevalence, between 9 and 20%, hence its importance. Nutritional factors, such as omega-3 fatty acids (ω-3FA) deficiency, have been related with both disorders during pregnancy, especially docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). Objective: To evaluate the association between dietary intake of EPA and DHA, and anxiety symptoms (AS) and depressive symptoms (DS) in Mexican pregnant women. Method: The sample consisted of 151 women in the second trimester of pregnancy. Instruments included a Food Frequency Questionnaire, the Trait Anxiety Inventory, and the Edinburgh Postnatal Depression Scale. Results: A daily intake of DHA and EPA of 70 mg/d and 30 mg/d, respectively, was found. The prevalence of AS was 44.4%, and 17.9% for DS. We also found the correlation negatively moderate between dietary intake of DHA and EPA and AS (p = .003, p = .017) and DS (p = .001, p = .020) in the group of women who had a severely insufficient intake of ω-3FA. Discussion and conclusion: The statistical significance shows a negative correlation between variables and the dietary intake of ω-3FA explains in a very small percentage the variability of AS and DS, according to their coefficient of determination. These results suggest the need for an investigation of this relationship through interventional studies.

Resumen: Introducción: La prevalencia de ansiedad y depresión en el embarazo oscilaentre 9 y 20%. Poseen una gran importancia al ser trastornos incapacitantes asociados a complicaciones durante el embarazo, parto y postparto. Factores nutricionales, como la deficiencia de ácidos grasos omega-3 (AGω-3), se han relacionado con ambos trastornos durante el embarazo, especialmente el ácido docosahexaenoico (DHA) y el ácido eicosapentaenoico (EPA). Objetivo: Evaluar la asociación entre la ingesta dietética de EPA y DHA y los síntomas de ansiedad (SA) y depresión (DS) en mujeres embarazadas mexicanas. Método: Se entrevistó a 151 gestantes fueron entrevistadas en el segundo trimestre de embarazo. Los instrumentos de medición utilizados fueron: un Cuestionario de Frecuencia de Consumo de Alimentos, el Inventario de Ansiedad-Rasgo y la Escala de Depresión Postnatal de Edimburgo. Resultados: Se encontró una correlación negativa moderada entre la ingesta de DHA y EPA y los SA (p = .003, p = .017) y SD (p = .001, p = .020) en el grupo de mujeres con ingesta gravemente insuficiente. Se encontró una ingesta dietética diaria de DHA y EPA de 70 mg y 30 mg, respectivamente. La prevalencia de SA fue 44.4% y de SD, 17.9%. Discusión y conclusión: Aunque la significancia estadística mostró una correlación negativa entre variables, de acuerdo con el coeficiente de determinación, la ingesta dietética de AGω-3 explica en un escaso porcentaje la variabilidad de los SA y SD. Estos resultados sugieren la necesidad de investigar dicha relación por medio de estudios de intervención.

Psychometric Properties of the Resilience Inventory for Pregnant Mexican Women / Propiedades Psicometricas del inventario de Resiliencia para Mujeres embarazadas Mexicanas

La resilencia ha estado relacionada a la salud mental durante el período perinatal. Sin embargo, hasta donde sabemos, no hay intrumentos para medir la resilencia que hayan sido validados en esta población. El propósito de este estudio fué examinar las propiedades psicométricas del Inventario de Resilencia en mujeres embarazadas mexicanas. Se evaluó una muestra de 280 mujeres usando el Inventario de Resilencia, el Cuestionario de Salud del Paciente y un cuestionario de situaciones de estrés. El coeficiente de confiabilidad del Inventario de Resilencia fué de 0.88 para la escala completa. El análisis factorial exploratorio resultó en una estructura de resilencia de tres factores (capacidad personal, religiosidad y actitud positiva) para mujeres embarazadas. La validez consistente fué respaldada por correlaciones negativas con síntomas prenatales depresivos y situaciones de estrés. El Inventario de Resilencia podría ser potencialmente una medida fiable válida. Es necesario continuar explorando el rol de la resilencia en el período perinatal e identificar los factores que la determinan.

Resilience has been related to mental health during the perinatal period. However, to our knowledge, there are no instruments for measuring resilience that have been validated in this population. The purpose of this study was to examine the psychometric properties of the Resilience Inventory in Mexican pregnant women. A sample of 280 women was evaluated using the Resilience Inventory, Patient Health Questionnaire and a stressful life events questionnaire. The reliability coefficient of the Resilience Inventory was 0.88 for the complete scale. Exploratory factor analysis resulted in a three-factor structure of resilience (personal competence, religiosity and positive attitude) for pregnant women. Concurrent validity was supported by negative correlations with prenatal depressive symptoms and stressful life events. The Resilience Inventory could potentially be a valid reliable measure. It is necessary to continue exploring the role of resilience in the perinatal period and identify the factors that shape it.

Association between depressive symptoms and psychosocial factors and perception of maternal self-efficacy in teenage mothers / Asociación entre sintomatología depresiva y factores psicosociales y percepción de eficacia materna en madres adolescentes

Abstract Introduction Teenage pregnancy is a national health priority. Having to deal with pregnancy during adolescence can cause the mother, at an already vulnerable age, to doubt her maternal capacity to cope with a challenge of this magnitude. The teenage mother's assessment of her maternal self-efficacy is associated with her performance, in other words, the way she relates and responds to the needs of her infant, which has major implications for the latter's development. Objective To study the association between personal (depressive symptoms, self-esteem) and environmental characteristics (social support, partner satisfaction) and those of the infant (problems with infant care, the infants's temperament) and the perception of maternal self-efficacy (PME) in adolescent mothers. Method Cross-sectional study. The following instruments were applied: Center for Epidemiologic Studies Depression Scale (CES-D), Post-partum Depression Predictors Inventory-Revised (PDPI-R), and Maternal Efficacy Questionnaire to 120 mothers under 20 during the first six months postpartum. Bivariate lineal regression and hierarchical linear regression analyses were used for the data analysis. Results When adjusting for other variables, symptoms of depression and difficult infant temperament were associated with lower PME. Social support was only associated with increased PME in the bivariate analysis. Discussion and conclusion These findings contribute to the limited literature on the subject and provide elements for designing strategies to improve adolescent mothers' PME to encourage behaviors that are more relevant and sensitive to infants' physical and emotional needs.

Resumen Introducción El embarazo adolescente es una prioridad nacional para la salud. Enfrentar un embarazo durante la adolescencia puede hacer que la madre, a una edad de por sí vulnerable, dude de su capacidad materna ante un reto de esta magnitud. La valoración que hace de su eficacia materna se asocia con su desempeño, esto es, con la manera de relacionarse y responder a las necesidades de su infante, misma que tiene consecuencias determinantes en el desarrollo de éste. Objetivo Estudiar la asociación entre características personales (síntomas depresivos, autoestima), ambientales (apoyo social, satisfacción con la pareja) y del infante (problemas con el cuidado del infante, temperamento infantil) con la percepción de eficacia materna (PEM) en madres adolescentes. Método Estudio transversal. Se aplicaron: Escala de Depresión del Centro de Estudios Epidemiológicos (CES-D), Inventario de Predictores de Depresión Posparto Revisado (PDPI-R) y Cuestionario de Eficacia Materna a 120 madres menores de 20 años durante el primer semestre posparto. Para los análisis de datos se usaron regresiones lineales bivariadas y análisis de regresión lineal jerárquica. Resultados Al ajustar por otras variables, los síntomas de depresión y el temperamento infantil difícil se asociaron con más baja PEM. El apoyo social se asoció con mayor PEM sólo en los análisis bivariados. Discusión y conclusión Estos hallazgos contribuyen a la escasa literatura sobre el tema y proveen elementos para el diseño de estrategias que mejoren la PEM en madres adolescentes para favorecer conductas más pertinentes y sensibles ante las necesidades físicas y emocionales de los infantes.

Childhood abuse increases the risk of depressive and anxiety symptoms and history of suicidal behavior in Mexican pregnant women

Objective:To explore the relationship between individual and co-occurring childhood sexual, physical, and verbal abuse, prenatal depressive (PDS) and anxiety symptoms (PAS), and history of suicidal behavior (HSB) among Mexican pregnant women at risk of depression.Methods:A sample of 357 women screened for PDS was interviewed using the Childhood Experience of Care and Abuse Questionnaire (CECA-Q), the Beck Depression Inventory (BDI-II), the anxiety subscale of the Hopkins Symptoms Checklist (SCL-90), and specific questions on verbal abuse and HSB.Results:Logistic regression analyses showed that women who had experienced childhood sexual abuse (CSA) were 2.60 times more likely to develop PDS, 2.58 times more likely to develop PAS, and 3.71 times more likely to have HSB. Childhood physical abuse (CPA) increased the risk of PAS (odds ratio [OR] = 2.51) and HSB (OR = 2.62), while childhood verbal abuse (CVA) increased PDS (OR = 1.92). Experiencing multiple abuses increased the risk of PDS (OR = 3.01), PAS (OR = 3.73), and HSB (OR = 13.73).Conclusions:Childhood sexual, physical, and verbal abuse, especially when they co-occur, have an impact on PDS and PAS and lifetime HSB. These findings suggest that pregnant women at risk for depression should also be screened for trauma as a risk factor for perinatal psychopathology.

Acceptability and barriers to treatment for perinatal depression: An exploratory study in Mexican women / Aceptación y barreras al tratamiento para depresión perinatal: Estudio exploratorio en mexicanas

Background Depression is frequently experienced during the perinatal period. In Mexico, it has received very little attention from researchers and health service providers. It is well known that untreated depression is one of the leading causes of disability in women. Objective This study seeks to explore: 1. the recognition of perinatal depression among pregnant and postpartum women; 2. the acceptance of various modalities of treatment for depression, and 3. the perception of the barriers to receive treatment. Material and methods For this descriptive, exploratory study, 41 women in the third trimester of pregnancy and 30 women between the fourth and sixth postpartum weeks were interviewed. The study was conducted at a health center and a general hospital. The interview included demographic and obstetric data; depressive symptomatology (PHQ-2); open questions on the recognition of perinatal depression and scales relating to the acceptance of treatment modalities and barriers to access health services. Results Almost all the women had heard of the term postpartum depression, while one quarter did not know the causes of this disorder, which was attributed to an inability to face new challenges, emotional and hormonal changes, and lack of social support. The majority considered that it is not easy to speak about their unhappiness or discomfort, and that people would not understand if pre- or post-partum women felt sad or depressed in this period. Individual psychotherapy was the treatment with the highest level of acceptance, while medication, during pregnancy or breastfeeding, was the least accepted. The main barriers to treatment were: lack of time; institutional procedures; being unable to afford care and not having anyone to look after the children. Conclusions These results constitute a preliminary approach to the care needs for depression during the perinatal period. Women's awareness that help is required may not suffice to encourage them to seek assistance due to instrumental barriers and attitudes to treatment. In order to ensure effective care, it is necessary for the official norms regulating the health care for women and babies in this period to include treatment for mental disorders.

Antecedentes La depresión es un estado frecuente en el periodo perinatal. En México ha recibido muy poca atención por parte de investigadores y prestadores de servicios. Se sabe que la depresión no tratada es una de las causas más importantes de discapacidad en las mujeres. Objetivo Explorar: 1. el reconocimiento de la depresión perinatal en embarazadas y puérperas, 2. la aceptación de diferentes modalidades de atención para la depresión y 3. la percepción de las barreras para asistir a tratamiento. Material y métodos En este estudio descriptivo y exploratorio se entrevistó a 41 mujeres en el tercer trimestre del embarazo y a 30 entre la cuarta y sexta semanas del posparto. El estudio se llevó a cabo en un centro de salud y en un hospital general. La entrevista incluyó: datos demográficos y obstétricos; sintomatología depresiva (PHQ-2); preguntas abiertas sobre el reconocimiento de la depresión perinatal y escalas relativas a la aceptación de diversas modalidades de tratamiento y barreras para acudir a servicios de salud. Resultados Casi todas habían escuchado el término depresión posparto; una cuarta parte desconocía las causas de este trastorno, el cual fue atribuido a no saber enfrentar los nuevos retos, cambios emocionales, cambios hormonales y falta de apoyo social. La mayoría consideró que no es fácil hablar de tristeza o malestar en este periodo y que la gente tampoco lo entendería. La psicoterapia individual fue el tratamiento con mayor aceptación; los medicamentos, durante el embarazo o lactancia, los menos aceptados. Las principales barreras al tratamiento fueron: la falta de tiempo, los trámites institucionales, la imposibilidad de pagarlo y la carencia de cuidado para los hijos. Conclusiones Estos resultados constituyen una primera aproximación a los requisitos de atención de la depresión en el periodo perinatal. El reconocimiento de la necesidad de ayuda por parte de las mujeres puede no ser motivo suficiente para que acudan a buscarla debido a las barreras instrumentales y las actitudes hacia el tratamiento. Para poder brindar una atención efectiva es necesario que las normas oficiales, que regulan el cuidado de la salud de mujeres e infantes en este periodo, incluyan una atención a los trastornos mentales.

Detección de depresión en mujeres embarazadas mexicanas con la CES-D / Depression screening in Mexican pregnant women with the CES-D

Prenatal depressive symptoms, due to their high prevalence (22% to 37%) and negative consequences on the health of the mother, the baby and the course of pregnancy, require early detection to provide support and treatment. The CES-D is a scale to identify symptoms of depression that is easy and quick to apply and has adequate validity among expectant mothers. The purpose of the study was to analyze the validity and reliability of the CES-D in pregnant Mexican women, as well as its sensitivity, specificity and predictive values using the SCID as the gold standard. Method The study was based on the secondary analysis of data. A sample of 98 pregnant women attending antenatal care in health center was selected because they displayed depressive symptoms or previous depression. Results The internal consistency of the CES-D was α=0.81. Factor analysis, which assessed the construct validity, yielded four interpretable factors (depressive affect, lack of energy/somatic symptoms, interpersonal relationships and positive affect), which accounted for 49.10% of the variance. The ROC curve analyses, showed an AUC of 0.81; for a cutoff point of >16, showed 100% sensitivity and 19.6% specificity; and sensitivity of 80.0% and specificity of 76.1% for a >28 cut-off point. Conclusions The CES-D showed excellent internal and construct validity in Mexican pregnant women and appeared to be a suitable tool for detecting depressive symptoms -a requisite for implementing preventive actions. However, it was less accurate, but still acceptable, when diagnosing major depression according to DSM-IV criteria with a score of >28.

La sintomatología depresiva prenatal, por su alta prevalencia (22% a 37%) y consecuencias negativas sobre la salud de la madre, el producto y el curso del embarazo, requiere de detección oportuna para proporcionar apoyo y tratamiento adecuados. La CES-D es una escala para identificar síntomas de depresión, de fácil y rápida aplicación y con validez adecuada en gestantes. El objetivo del trabajo fue analizar la validez y confiabilidad de la CES-D en mujeres mexicanas embarazadas, así como la sensibilidad, especificidad y valores predictivos usando el SCID como estándar de oro. Método El estudio se basó en un análisis secundario de datos. Se obtuvo una muestra de 98 mujeres embarazadas en la sala de espera de un centro de salud que proporcionaba atención prenatal. Fueron seleccionadas por presentar sintomatología depresiva (CES-D>16) o historia de depresión. Resultados La consistencia interna de la CES-D fue de α=0.81. El análisis factorial, que valoró la validez de constructo, mostró que cuatro factores pudieron ser interpretados (afecto depresivo, falta de energía/síntomas somáticos, relaciones interpersonales y afecto positivo), que explicaron 49.10% de la varianza. En el análisis de la curva COR, se obtuvo un ABC de 0.81; para punto de corte >16, mostró 100% de sensibilidad y 20.9% de especificidad y para la puntuación >28, sensibilidad de 80.0% y especificidad de 76.1%. Conclusiones Se encontró que la CES-D tiene excelente validez interna y de constructo en gestantes mexicanas y que es una herramienta adecuada para la detección de sintomatologia depresiva (CES-D>16) -requisito indispensable para instrumentar acciones preventivas-, sin embargo fue menos precisa, aunque adecuada para diagnosticar depresión mayor según criterios del DSM-IV aun en el punto de corte más parsimonioso (>28).

Factores asociados a la percepción de eficacia materna durante el posparto / Factors associated to maternal perceptions of efficacy in the postpartum

The objective was to study maternal efficacy at two moments during the postpartum: at 6 weeks, and at between 4 and 6 months after delivery and its relationship with various socio-demographic and psychological factors in Mexican postpartum women. Maternal self-efficacy (MSE) is a concept that alludes to the mother's ability to perform her maternal role. It is defined as the judgment that the mother formulates concerning her own competence and the effectiveness with which she copes with the demands and needs of the infant. Some studies show that mothers who perceive themselves as possessing high self-efficacy exhibit more effective behaviors, as well as a greater ability to adapt and a capacity to respond and interpret the needs of the infant, as well as to encourage and stimulate him or her. Some of the factors that influence the perception of self-efficacy are social support, especially when provided by significant others, and when the support networks reinforce the belief that the task is being carried out adequately. Educational attainment and living with a partner ad similarly. On the other hand, variables that have a negative effect include depression and high stress levels. In one way or another, MSE affects child rearing practices: those who perceive themselves to be effective are more involved in the activities of their children, in their cognitive stimulation at home during the pre-school period. Thus, MSE during the postpartum period exerts an influence on the mother-child relationship and the development of the latter, with long-term consequences. In short, the study of the perception of maternal self-efficacy is not only of theoretical interest, but also, knowledge of the manner in which it takes place and the factors that act upon it opens up the possibility of influencing the MSE, improving the maternal role and the infants'well-being. In Mexico, we were unable to find published data on this subject, which is why it is particularly important to study it. Materials and methods Participants. The study is a secondary data analyses from a research directed toward evaluating a psycho-educational intervention during pregnancy. The sample included women attending prenatal care at three health care institutions in Mexico City. Participants were interviewed at 6 weeks (n= 149) and at between 4-6 months postpartum (n = 156). Inclusion criteria were being >18 years of age, not being <26 weeks pregnant, having completed primary school and having depressive symptomatology and/or a prior history of depression. Exclusion criteria were presenting bipolar disorder or substance abuse. The sample was taken as a sole group, independent of whether the participants had taken part in intervention (eight psycho-educational group sessions oriented toward preventing postpartum depression)or control conditions (treatment as usual provided by the institution), because no differences were found between these groups in terms of relevant variables (e.g. symptoms of depression). Instruments. These included measurements in the following areas: 1. socio-demographic information; 2. the Maternal Self-Efficacy Questionnaire; 3. the Beck Depression Inventory second edition (BDI-II); 4. Social Support Rate Scale (SSRS) and the Family Adaptation, Partnership, Growth, Affection, and Resolve (Family APGAR); 5. Anxiety scale, the Hopkins Symptoms Check List-90 (HSCL-90); 6. the Coopersmith Self-Esteem Inventory, and 7. stressing events, with a 12 item scale. Procedure. After selection of participants based on inclusion criteria, these were assigned randomly to either the control or the intervention group. After delivery, the aforementioned instruments were applied to participants by means of an interview at the two moments of the postpartum period. Two logistic regression analyses were conducted (one for each postnatal point) to evaluate the relationship between socio-demographic (age, schooling, civil status, number of pregnancies) and psychological (symptoms of depression and anxiety, self-esteem, stressing events, social support) variables on MSE. Additionally, pertaining to the intervention and control condition was introduced in the analyzes in order to control for the possible effect of participation in the intervention. Results With respect to sample characteristics, there was a similar number of women <26 (47.3%) than women aged >26 years (52.7%); the majority had > 1 0 years of schooling (66.7%), had a partner (married or cohabitating) (86%), and had less than one pregnancy (62.7%). Logistic regression analyzes for 6 weeks postpartum showed that not having a partner (Odds ratio [OR] = 1.98), postpartum depressive symptomatology (OR = 2.39), stressful events (OR = 2.18), and belonging to the control group (OR=4.37) were related to a low maternal self-efficacy; for the period of 4-6 months postpartum, not having a partner (OR = 2.97), less schooling (OR = 2.18), and postpartum depressive symptomatology (OR=3.97) were associated with the variable under study. Discussion Postnatal depressive symptomatology and not having a partner predicted low perception of maternal self-efficacy at 6 weeks and at 4-6 months postpartum, which indicates that its effect is more chronic. The repercussion of depression can be explained by the reduction of the sensation of maternal capacity that it produces, while not having a partner, which is one of the most important supports for the adaptation of the women to maternity, renders maternal performance difficult. The presence of stressful events at 6 postnatal weeks also hampers the perception of self-efficacy in the care of the infant, which is explicable because of the great demands to which the mother is submitted due to the baby's young age during this period. For its part, limited schooling exerted adverse effects 4-6 months after delivery. It has been documented that this variable is closely associated with mental health in general; it reduces the resources for coping with stress and deteriorates self-esteem. Finally, being part of the control group, that is, not having participated in the psycho-educational intervention, negatively influenced maternal self-efficacy, but had no effect at 4-6 months postpartum. This result that shows that in a first instance participating in a certain condition affected the dependent variable plus the fact that the selection criterion for the main study was that they all scored in depressive symptoms restricts the generalization of these findings. The implications of these findings are that perception of maternal self-efficacy could be improved through specific programs directed toward women displaying limited educational attainment, lack of a partner, postpartum depressive symptoms, and stressing events. The benefit would not only translate into a more positive feeling of the mother with respect to her abilities, but also, theoretically, into a better performance of her maternal role, and consequently, into the well-being and development of their infants.

El objetivo es estudiar la percepción de la eficacia materna (PEM) en el posparto y su relación con diversas variables sociodemográficas y psicológicas. La PEM se define como el juicio que la madre formula sobre su propia competencia y efectividad para enfrentar las demandas y necesidades del infante. Conocerla facilita la comprensión de su actitud y sus respuestas frente a los requerimientos de los hijos. Evaluar los factores que la afectan abre la posibilidad de influir sobre la misma para mejorar el desempeño materno y, por ende, el bienestar de los infantes. Método Participantes. El estudio es un análisis secundario de datos de una investigación dirigida a evaluar una intervención psicoeducativa durante el embarazo. La muestra incluyó a mujeres que asistían a atención prenatal en tres instituciones de salud de la Ciudad de México. Fueron entrevistadas a las seis semanas (N = 149) y entre los cuatro y seis meses posparto (N = 156). Un criterio de inclusión fue presentar síntomas de depresión. La muestra se tomó como un solo grupo independiente- mente de que las participantes hubieran tomado parte en la condición de intervención (ocho sesiones psicoeducativas orientadas a prevenir la depresión posparto) o control (tratamiento regular de la institución), por no encontrarse diferencias entre las mismas en las variables relevantes (por ejemplo, síntomas de depresión). Instrumentos. Se incluyeron las siguientes áreas: 1. Información sociodemográfica, 2. Cuestionario de Eficacia Materna [Maternal Efficacy Questionnarié), 3. Inventario de Depresión de Beck (IDB-II), 4. Apoyo social [Social Support Apgar), 5. Escala de Ansiedad [Hopkins Symptoms Check Lisf-90¡, 6. Inventario de Autoestima (Coopersmith) y 7. Sucesos estresantes. Se condujeron dos análisis de regresión logística (uno para cada punto de medición posnatal) para evaluar la relación de las variables sociodemográficas (edad, escolaridad, estado civil, número de embarazo) y psicológicas (síntomas de depresión y ansiedad, autoestima, sucesos estresantes, apoyo social) sobre la percepción de eficacia materna. Adicionalmente, la pertenencia al grupo de intervención o control se introdujo en los análisis para evaluar el posible su efecto sobre la variable dependiente. Resultados A las seis semanas posparto dicho análisis mostró que no tener pareja y presentar sintomatología depresiva y sucesos estresantes, así como pertenecer al grupo control, se relacionaron con baja percepción de eficacia materna. En el periodo de cuatro a seis meses posparto, no tener pareja, una menor escolaridad y sintomatología depresiva fueron las que se relacionaron con dicha variable. Discusión La sintomatología depresiva posparto y no tener pareja predijeron baja percepción de eficacia materna en ambos momentos en que se midieron, lo que indica que su efecto es más crónico. Los síntomas de depresión influyen en la sensación de capacidad de la madre, mientras que, al ser la pareja uno de los apoyos más importantes en este momento, su ausencia dificulta su desempeño, al recaer sobre ella todas las responsabilidades. Los sucesos estresantes a las seis semanas posnatales también dificultan la percepción de eficacia ya que se conjuntan con las grandes demandas a las que la madre está sometida por la corta edad del bebé. Pertenecer al grupo de intervención y control sí tuvo un efecto sobre la eficacia a las seis semanas: pertenecer al segundo tuvo uno menos favorable sobre la variable en estudio. Este resultado, ¡unto con el hecho de que la muestra del estudio primario tenía como requisito para su conformación que las mujeres presentaran síntomas de depresión, restringe la generalización de los mismos. Una de las implicaciones de estos datos es que la percepción de eficacia materna podría mejorarse con programas dirigidos a mujeres que presenten baja escolaridad, que no tengan pareja y padezcan síntomas de depresión posnatales o sucesos estresantes.

Retention rates and potential predictors in a longitudinal randomized control trial to prevent postpartum depression / Tasas de retención y variables que la predicen en un estudio aleatorio controlado longitudinal para prevenir la depresión posparto

Perinatal depression is increasingly recognized as a significant public mental health problem; consequently, there is a major interest in developing strategies to prevent postpartum depression that may help reduce its detrimental consequences. However, the unique experiences associated with the perinatal period make it more difficult to recruit participants at this stage and to retain them over time when assessing prevention interventions. The aim of the study is to examine retention rates and predictors of retention in a longitudinal, randomized controlled trial (RCT) to prevent postnatal depression. Method Participants: Pregnant women (N = 377) at risk of depression were randomized to intervention or usual care condition and assessed during pregnancy and at 6 weeks and 4-6 months postpartum. Intervention: The intervention was designed by modifying a previously evaluated one and includes information on normal pregnancy and the postpartum period, from psychoanalytic and risk factors perspectives. It attempts to reduce depression levels by increasing positive thinking and pleasant activities, improving self-esteem, increasing self-care, learning skills to strengthen social support, and exploring unrealistic expectations about pregnancy and motherhood. It is delivered in eight two-hour weekly group sessions during pregnancy. Measures: Depressive symptoms were measured using the second edition of the Beck Depression Inventory (BDI-II); anxiety symptoms with the corresponding subscale of the Hopkins Symptoms Checklist (SCL-90) and social support with the Social Support Apgar (SSA). A short form of 12 items representing potential stressors was used as a measurement of stressful life events and the Abbreviated Version of the Dyadic Adjustment Scale (A-DAS) measured partner relationship. Results Retention rates -defined in three ways- were: (1) Total retention (percentage of participants completing the 4-6 month postpartum interview) was 41.7% (31.2% intervention and 61.4% control); (2) Retention from randomization to (a) completion of initial evaluation and attendance of > 1 intervention sessions was 42.4%; and (b) completion of initial evaluation (control) was 82.2%; and (3) Follow-up retention: (a) intervention participants attending > 1 sessions that completed the intervention as well as the 4-6 months postpartum interview was 73.5%; and (b) control participants assesses in this period was 66.6%. For those who came to at least one intervention session 83% completed the intervention. The predictors of total retention were: being single, more educated, and poor partner relationship quality. For the intervention condition, predictors of (a) retention from randomization to attendance to > 1 sessions were anxiety and stressful life events, and (b) for follow-up retention was being employed. Conclusions In the present study, retention of participants was even lower than what has been found in similar interventions. However, attendance rates of the course, once the participants had attended one session, were very good. In terms of predictors of retention, women at high risk of depression (single, with poor partner quality relationship, more stressful life events and high anxiety) were more committed to participating in the study. Consequently, in order to increase retention rates, future interventions should target women that present such risk factors. Nevertheless, those with low educational attainment and homemakers, who are a vulnerable group, were difficult to retain and thus remain a challenge in postpartum depression prevention studies. We conclude that rates and predictors of retention differed depending on points of measurement, suggesting different strategies to optimize participation.

La depresión perinatal cobra cada día mayor reconocimiento como un problema importante de salud mental pública; en consecuencia, ha crecido el interés por desarrollar estrategias para prevenir la depresión posparto, que lleven a evitar sus consecuencias adversas. Sin embargo, las peculiaridades del periodo perinatal dificultan tanto el reclutamiento como la retención de esta población a lo largo del tiempo, cuando se evalúan intervenciones preventivas. El objetivo del estudio es examinar las tasas de retención y las variables que predicen las mismas en un estudio longitudinal aleatorio controlado (EAC) para prevenir la depresión posparto. Método Participantes: Trescientas setenta y siete embarazadas que mostraron riesgo de depresión fueron aleatorizadas a grupos de intervención y control y evaluadas durante el embarazo y a las 6 semanas y a los 4-6 meses después del parto. La muestra se tomó de salas de espera de tres instituciones que proporcionan atención prenatal. Intervención: La intervención se desarrolló a partir de modificar una anterior dirigida a mujeres con depresión para incluir información sobre el embarazo y puerperio normales desde una perspectiva psicoanalítica y de factores de riesgo de depresión posparto. Pretende reducir la depresión al reforzar los pensamientos positivos y las actividades agradables, mejorar la autoestima y el autocuidado, desarrollar habilidades que fortalezcan el apoyo social y explorar las expectativas poco realistas sobre el embarazo y la maternidad. Se imparte en ocho sesiones grupales durante el embarazo, dos horas por semana. Instrumentos: Los síntomas de depresión se midieron con la segunda versión del Inventario de Depresión de Beck (IDB-II), los de ansiedad con la correspondiente subescala del Hopkins Symptom Check List 90 (SCL-90) y el apoyo social con la escala de Apoyo Social Apgar (SSA). Una selección de 12 reactivos sobre estresores potenciales y dificultades persistentes se usó para medir sucesos vitales y la Escala de Ajuste Diádico (A-DAS) para evaluar la satisfacción con la relación de pareja. Resultados Las tasas de retención definidas de tres maneras fueron: 1. La retención total (participantes aleatorizadas que concluyeron con todo el procedimiento hasta la entrevista a los 4-6 meses posparto) fue de 41.7% (31.2% intervención y 61.4% control). 2. La retención desde la aleatorización hasta (a) completar la entrevista inicial y asistir a > 1 sesión de intervención fue de 42.4% y (b) completar la evaluación inicial (control) fue de 82.2% (c). 3. La retención hasta el seguimiento: (a) proporción que inició y completó la intervención, esto es, que asistió a > 4 sesiones, así como a la entrevista a los 4-6 meses posparto fue de 73.5% y (b) participantes del grupo control que fueron entrevistadas en este periodo fue de 66.6%. Para quienes asistieron a por lo menos una sesión, la tasa de asistencia a la intervención fue de 83%. Las variables que predijeron la retención totalfueron: ser soltera, tener mayor nivel de escolaridad y la mala relación de pareja. En el grupo de intervención, las variables que predijeron (a) la retención desde la aleatorización hasta asistir a > 1 sesión de intervención fueron la presencia de ansiedad y de sucesos estresantes, y (b) la retención hasta el seguimiento aumentó en mujeres que estaban o habían estado empleadas los últimos seis meses. Conclusiones Los resultados son consistentes con los de trabajos anteriores respecto a la dificultad para retener mujeres embarazadas y en el puerperio en ensayos a lo largo del tiempo. En el presente estudio la tasa de retención fue aún más baja de lo que han encontrado otros autores, sobre todo debido a la enorme pérdida de participantes que firmaron el consentimiento informado y fueron aleatorizadas y no asistieron a ninguna sesión de la intervención. Al mismo tiempo, es interesante notar que la tasa de asistencia a la intervención, una vez que las participantes se presentaron a una primera sesión, fue muy alta. Esto habla de la alta aceptación que ésta tuvo entre las participantes. En cuanto a los factores que predijeron la retención, las mujeres con alto riesgo de depresión (sin pareja, con una relación mala con la pareja, con más sucesos estresantes y síntomas de ansiedad) fueron las más comprometidas en participar en el estudio. Por lo tanto, una manera de mejorar la tasa de retención es a través de dirigirla a mujeres que presenten estos factores de riesgo. Por otro lado, fue difícil retener a aquellas con bajo nivel de escolaridad y a las amas de casa, que también son una población vulnerable. Saber cómo mejorar la retención de este grupo sigue siendo un reto para estudios posteriores de prevención de la depresión posparto. Podemos concluir que las tasas y los factores que predicen la retención varían dependiendo de la manera en que se definan, lo que sugiere que las estrategias para optimizar la retención deben adecuarse a cada una de estas definiciones.

Ideación y comportamiento suicida en embarazadas / Suicidal ideation and suicidal behavior in pregnancy

The aim is to explore the occurrence of suicide ideation and behavior in pregnant women receiving prenatal care and to analyze the motives behind these behaviors. Although there are very few studies evaluating the prevalence of the suicide phenomenon (suicide, intentional injuries with or without the aim of taking one's own life, ideas of harming oneself or death) during the prenatal period, it has been reported that pregnancy complications due to suicide attempts occur in 0.4 out of every 1 000 patients discharged from hospitals in the state of California in the United States and in one out of every 283 pregnant women in specialized mental health services. Suicide ideation occurs in 1.4% of English expectant mothers, 0.5% of Finnish ones and 27.8% of US pregnant women with psychiatric disorders. In Latin America, it is estimated to occur in 1 6.7% of pregnant teenagers. Although suicide ideation and suicide attempts during pregnancy are less frequent than at other times in life, they have major consequences, increasing the risk of death and affecting fetal development and pregnancy itself. Method Participants: The interviewees comprised 120 pregnant women who came in for prenatal care at 1.a state Health Center providing primary health care and 2. three Health Homes that provide basic medical services, run by the Health Secretariat in Mexico City. Three of the 120 questionnaires were rejected due to incomplete information, which left a total of 117. Sample characteristics include: mean age, 23.2 years (DS = 5); mean monthly income, $3,876 (SD = $239); schooling, 69% had completed junior high school while 31% had completed senior high school; 71% were housewives while 29% were also engaged in paid employment. Marital status: 18% married, 19% single and 63% cohabiting. Instrument: A structured questionnaire with the following areas: 1. Socio-demographic information (age, schooling, etc.). 2. Indicators of suicidal ideation and behavior: a) Have you thought a lot about death, whether your own, someone else's or death in general? b) Have you wished to die ? c) Have you ever been about to take your own life? and d) Have you ever intentionally hurt, cut, poisoned or harmed yourself in order to take your own life? 3. Timing and motives. If the event occurred sometime in their life, the interviewer explored whether the event took place during the current pregnancy as well as the reasons why it happened. Procedure: In the waiting room at the Health Center, expectant mothers were told about the purpose of the study and the informed consent form. In the Health Homes, final year medical students did the same and arranged appointments for the interviews. The same researcher conducted the interviews in the two settings. Results Suicidal ideation: Thinking a lot about death at some time in their lives was reported by 29 subjects (24.8%) and during pregnancy by 44 (37.6%). The reasons for these thoughts during this last period are: separation from one's partner, death of a child, fear of childbirth, fear of accidents or sickness and interest in the subject of death. Realizing one is pregnant, feeling lonely, the death or illness of someone close and family problems are among the reasons for thoughts about death as well as the desire to die. Desire to die: This was expressed by 29 subjects (24.8%) in the past and by nine (7.7%) during pregnancy. Among the latter group, the reasons were: realizing one is pregnant, the death or illness of someone close and family problems. They also mentioned problems with their partners and parents. Suicidal intention: Thirteen said that they had been about to take their own lives at some stage (11.1%), while three (2.6% said that they had done so during pregnancy. During this period, this had been caused by problems with their partners. Suicide attempts: Ten women mentioned suicide attempts (8.5%) at some time in their lives, while one (0.9%) did so during pregnancy. This particular case mentioned problems with her partner as being the cause. Discussion Thinking a lot about death is the most common indicator. It may be explained by disadvantageous social conditions, but also by the particular conditions of pregnancy. In this respect, there are various fears common to expectant mothers who are apprehensive about the well-being of the future baby and anticipate a difficult childbirth. As one would expect, suicide attempts are less common than suicide intentions and the desire for and ideas about death. The desire to die, suicide intentions and attempts are less frequent during pregnancy than at other times in a person's life. This may be due to the future mother's feeling of responsibility, or a possible hormonal effect, which act as protective factors. Problems with one's partner are a risk factor for suicide intention and attempts. This is hardly surprising, since marital problems adversely affect women's mental health at different times in their lives, but during pregnancy, they intensify their insecurity at a time of great transition, making them fearful of the future and leading them to wonder about whether getting pregnant was the right thing to do. These observations should be treated with caution due to methodological limitations, such as the small sample size and restricted scope of the research.

Los objetivos son investigar la ocurrencia de la ideación y comportamiento suicida en embarazadas que acuden a atención prenatal y analizar los motivos de las conductas. Hay pocos estudios que evalúen la prevalencia del fenómeno suicida en el periodo perinatal. Algunos señalan que las complicaciones en el embarazo por intento de suicidio se reportan en 0.4 de cada mil pacientes dadas de alta de hospitales y en una de cada 283 embarazadas en servicios especializados de salud mental. La ideación suicida se presenta entre 0.5 y 1.4% de las embarazadas y en 27.8% de este grupo con trastornos psiquiátricos. Método Participantes: Se entrevistó a 120 embarazadas que acudieron a control prenatal: 1. a un Centro de Salud que brinda atención primaria y 2. a tres Casas de Salud que proveen servicios médicos básicos en la Ciudad de México. Se excluyeron tres de los 120 cuestionarios debido a información incompleta, lo que dejó un total de 11 7. Instrumento: Un cuestionario estructurado con las siguientes áreas: 1. Información sociodemográfica. 2. Indicadores de ideación y comportamiento suicida: a) ¿Ha pensado mucho en la muerte, ya sea en la suya, en la de alguien más o en la muerte en general?, b) ¿Ha deseado morir?, c) ¿Ha estado a punto de quitarse la vida? y d) ¿Alguna vez, a propósito, se ha herido, cortado, intoxicado o hecho daño con el fin de quitarse la vida? 3. Momento en que ocurrió y motivos. Si la conducta ocurrió alguna vez en la vida, se indagó si fue durante el embarazo y las razones para hacerlo. Procedimiento: Una psicóloga aplicó el instrumento por medio de una entrevista en la sala de espera del Centro de Salud y en un consultorio en las Casas de Salud. Asistió en días fijos varias veces por semana hasta completar el tamaño de la muestra. Resultados Ideación suicida: Pensar mucho en la muerte lo manifestaron 29 (24.8%) alguna vez en la vida y 44 (37.6%) durante la gestación. Los motivos para este último periodo son: separación de la pareja, muerte de un hijo, miedo al parto, temor a accidente o enfermedad e interés en el tema de la muerte. Saberse embarazada, sentirse sola, la muerte o la enfermedad de una persona cercana y tener problemas familiares son razones para los pensamientos de muerte, pero también para el deseo de morir. Deseo de morir: Lo expresaron 29 (24.8%) en el pasado y en nueve (7.7%) ocurrió en la preñez. En ésta, los motivos fueron: saberse embarazada, la muerte o la enfermedad de una persona cercana y tener problemas familiares. También aludieron a problemas con la pareja y con los padres. Intención suicida: Trece dijeron haber estado a punto de quitarse la vida alguna vez (11.1%) y tres (2.6%), durante el embarazo; los problemas con la pareja son la causa de la intención en este periodo. Intento suicida: Diez mujeres hablaron de intento (8.5%) alguna vez en la vida y una (0.9%), durante el embarazo. Este único caso mencionó, como causa, los problemas con la pareja. Discusión Pensar mucho en la muerte es el indicador más frecuente. Lo anterior se explica quizá por condiciones sociales desventajosas, pero también por las particularidades del embarazo. En este sentido, existen diversos temores comunes en madres gestantes, quienes se muestran aprensivas por el bienestar del futuro bebé y por anticipar un parto difícil. Como era de esperarse, el intento suicida es menos frecuente que la intención y el deseo e ideas de muerte. El deseo de morir, la intención y el intento son a la vez menos frecuentes durante el embarazo que en otro momento de la vida. Esto se debe quizá al sentimiento de responsabilidad de la futura madre o a un posible efecto hormonal, que funcionan como factores protectores. Los problemas con la pareja son un factor de riesgo para la intención y el intento suicida, lo que amerita mayor estudio. Estas observaciones merecen tomarse con cautela debido a limitaciones metodológicas, como el reducido tamaño de la muestra y lo acotado de la indagación.

Síntomas depresivos en el embarazo y factores asociados, en pacientes de tres instituciones de salud de la ciudad de México

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Abstract: Background Depression is a frequent condition in pregnancy, at least as frequent as it is among non-pregnant women. Studies on its prevalence show rates from 2% to 21% of major depression and 8% to 31% of depressive symptomatology. In Mexico, a prevalence of 22% has been estimated on the basis of a self-report scale. Risk factors for depression in pregnancy include previous history of depression, parental separation during childhood, single mother-hood, not wishing to be pregnant, lack of social support and low educational attainment. Objective Due to the consequences of depression on pregnancy and to the scarce studies available in Mexico, the aim of this study was to examine the presence of depression in pregnant women as well as the risk factors associated with the latter. Material and methods Three hundred pregnant women receiving ante-natal care were interviewed in the waiting rooms of three institutions (one third level hospital, a health center and a clinic specializing in women). The instrument included a scale of depression (CES-D) and the following risk factors: previous depression symptoms, parental separation before the age of 11, possible depression and problem-atic alcohol consumption in expectant motliers parents, unplanned pregnancy and lack of social support. Results A total of 30.7% of the interviewees showed significant depressive symptomatology (CES-D > 16). Fifty-nine percent mentioned having suffered from depressive symptomatology in the past. Some degree of disability in the past month was reported by 19% of those that mentioned depression symptoms. The mean number of days they stopped performing their everyday activities was 11.21 (SD = 10.68) with a range of 1 to 30 days. Seven women (21.2%) stated that they could not engage in their activities because of their depression every single day of the past month. As for suicidal ideation at any time in their lives, the following symptoms were displayed: half said that they had thought a great deal about death, a quarter said that they had wanted to die, nearly a fifth had intended to take their own life and 7.7% had injured themselves in order to take their own lives. During the previous month, the frequency of these behaviors had considerably declined, almost to zero, and only "thinking frequently about death" was common (18%). The variables associated with depression symptoms (CES-D) were: previous symptoms of depression (t = -4-40, p > 0.000), separation from the father before the age of 11 (t = -2.68; p > 0.008), possible depression in mother (t = -3.24, p > 0.001), possible depression in father (t = -2.41, p > 0.016), problematic alcohol consumption in father (t= -2.23, p > 0.040), unplanned pregnancy (t=-2.43, p>0-015), lack of emotional social support (t = 2.87, p > 0.005) and lack of practical social support (t = 2.94, p > 0.005). The evaluation of a risk model of these factors on depressive symptomatology through logistic regression (with the step-by-step method) showed that the following variables were significant: possible depression in the mother (of the expec-tant mother) which increases the risk of displaying depression in pregnancy 0.8 times, previous depressive symptomatology, which increases it 1.08 times, lack of practical social support, which increases it 1.71 times and not having a partner, which increases it 1.51 times. Discussion and conclusions The results, as regards mental health, showed that depressive symptoms occured in nearly a third of pregnant women; this percentage is higher than the 22% found in Mexico in previous studies. Although this symptomatology does not necessarily meet the criteria for major depression, it has been considered to be of sufficient clinical importance, as it has been associated with disability, psychiatric and physical co-morbidity; demand for treat-ment for and risk of future depression and in this case, with post-partum depression. A fifth of the subjects displayed more serious symptomatology in terms of disability, as the women mentioned not being able to engage in their everyday activities, working or studying. The mean number of days in which they were unable to carry out their activities was eleven during the previous month. This data suggests that this population with greater pathology should be detected and referred for specialized mental care by antenatal care services. Suicidal ideation during the previous month decreased considerably, in comparison with that reported at any time in theit lives, which agrees with reports that state that self-damaging behaviors and suicide attempts tend to be very low during pregnancy. As for pathological antecedents, 59% considered that they had suffered from depressive symptomatology in the past, in addition to having experienced suicidal ideation to varying degrees. It is significant that nearly 8% had previously attempted suicide. Both, previous depressive symptomatology and suicidal ideation in the past, were associated with current depression symptoms in the expectant mother, as has been reported in other countries. Unplanned pregnancy was also related to depression (CES-D). As literature suggests, not wishing to be pregnant is related to this disorder and although not planning a pregnancy is not synonymous with not wishing for it, according to these data, lack of planning also increases depressive symptoms. Among childhood situations, parental separation or loss of the father before the age of 11 was a significant variable as regards symptomatology in pregnancy; this was similar to what other authors have reported. Separation from the mother was not related to these symptoms, contrary to what other studies have reported in both pregnant and non-pregnant women. Adversity in childhood in the form of parents' mental pathology or substance use has been associated with depression among the general population. The results obtained here show a significant relationship between problematic alcohol consumption in the father and possible depression in the mother or father -as perceived by the interviewee herself- and depression symptoms in the expectant mother. During pregnancy and above all, post-partum, women have a real need to receive both emotional and practical support. This study, like others showed that the lack of this support increased the risk of depression. The construction of a model with some of these variables showed that being a single or divorced mother, having had a mother who may have been depressed, having displayed depressive symptoms in the past and the lack of practical support increased the risk of depressive symptomatology. By way of a conclusion, one can say that although there are similarities between depression in pregnancy and at other moments in women's lives, its presence during this period is particu-larly important due to the new demands the woman has to cope with and the adverse effects it has on the development of pregnancy, and the high risk of experiencing depression during the post-partum. Designing intervention programs for expectant mothers could have an enormous effect on improving the mental health of mothers and their babies, a reason why it is important to take into account the risk factors described in this study.