Screening women for distress during pregnancy: the impact of including 'Possibly' as a response option.

OBJECTIVES: To investigate the impact of including the response option of 'Possibly' in the Distress question on the Matthey Generic Mood Questionnaire (MGMQ) during antenatal emotional health screening in English-speaking women. BACKGROUND: Some distress screening questions only allow respondents to choose between 'Yes' or 'No' to the presence of distress. The MGMQ, however, allows respondents to chose between 'Yes', 'Possibly', or 'No', which may be preferable if a participant is reluctant to state she definitely feels distressed. METHOD: In Study 1, women undergoing routine antenatal psychosocial screening were allocated to either completing the MGMQ Distress question with the usual three-option response format of 'Yes, Possibly, No' (N = 960), or just a 'Yes, No' response format (N = 771). The proportion of responses were compared in each group, as were the proportion then screening positive on the MGMQ's Bother question. In Study 2, women (N = 113) attending routine antenatal clinic appointments were asked about their preference between these response formats. RESULTS: Including 'Possibly' resulted in only a slight increase in the proportion giving a positive response to the Distress question, and then also screening positive on the Bother question. In Study 2, a substantial majority of women (80%) preferred having 'Possibly' in the response options. CONCLUSION: While the impact of including 'Possibly' is small, it allows for more women to communicate how they are feeling on the full MGMQ. Given the large majority of women preferring having 'Possibly' included, we believe that the Distress Question is enhanced by having this as a response option.

Opening the door: midwives' perceptions of two models of psychosocial assessment in pregnancy- a mixed methods study.

BACKGROUND: One in five women experience psychological distress in the perinatal period. To support women appropriately, Australian guidelines recommend routine depression screening and psychosocial risk assessment by midwives in pregnancy. However, there is some evidence that current screening processes results in higher rates of false positives. The Perinatal Integrated Psychosocial Assessment (PIPA) Project compared two models of psychosocial assessment and referral - Usual Care and the PIPA model - with a view to improving referral decisions. This paper describes midwives' perspectives on psychosocial assessment, depression screening and referral at the antenatal booking appointment and compares midwives' experiences with, and perspectives on, the two models of care under investigation. METHODS: A two-phase, convergent mixed methods design was used. Midwives providing antenatal care completed a self-report survey in phase one prior to implementation of the new model of psychosocial assessment (n = 26) and again in phase two, following implementation (n = 27). Sixteen midwives also participated in two focus groups in phase two. Quantitative and qualitative data were compared and integrated in the presentation of results and interpretation of findings. RESULTS: Midwives supported psychosocial assessment believing it was a catalyst for 'Opening the door" to conversations with women. Midwives were comfortable asking the questions and tailored their approach to build rapport and trust. Overall. midwives expressed favourable views towards the PIPA model. A greater proportion of midwives relied mostly or entirely on the suggested wording for the psychosocial questions in the PIPA model compared to Usual Care (44.4% vs 12.0%, χ2=5.17, p=.023, φ =-.36). All midwives reported finding the referral or action message displayed at the end of the PIPA psychosocial assessment to be 'somewhat' or 'very' helpful, compared to 42.3% in Usual Care (χ2 = 18.36, p < .001, φ = -.64). Midwives were also more likely to act on or implement the message often or all of the time) in the PIPA model (PIPA = 69.2% vs Usual Care = 32.0%, (χ2 = 5.66, p < .017, φ = -.37). CONCLUSION: The study identified benefits of the new model and can inform improvements in psychosocial screening, referral and related care processes within maternity settings. The study demonstrates that psychosocial assessment can, over time, become normalised and embedded in practice.

Measuring perinatal mental health risk.

The purpose of this review was to critically analyse existing tools to measure perinatal mental health risk and report on the psychometric properties of the various approaches using defined criteria. An initial literature search revealed 379 papers, from which 21 papers relating to ten instruments were included in the final review. A further four papers were identified from experts (one excluded) in the field. The psychometric properties of six multidimensional tools and/or criteria were assessed. None of the instruments met all of the requirements of the psychometric properties defined. Some had used large sample sizes but reported low positive predictive values (Antenatal Risk Questionnaire (ANRQ)) or insufficient information regarding their clinical performance (Antenatal Routine Psychosocial Assessment (ARPA)), while others had insufficient sample sizes (Antenatal Psychosocial Health Assessment Tool, Camberwell Assessment of Need-Mothers and Contextual Assessment of Maternity Experience). The ANRQ has fulfilled the requirements of this analysis more comprehensively than any other instrument examined based on the defined rating criteria. While it is desirable to recommend a tool for clinical practice, it is important that clinicians are made aware of their limitations. The ANRQ and ARPA represent multidimensional instruments commonly used within Australia, developed within large samples with either cutoff scores or numbers of risk factors related to service outcomes. Clinicians can use these tools, within the limitations presented here, to determine the need for further intervention or to refer women to mental health services. However, the effectiveness of routine perinatal psychosocial assessment continues to be debated, with further research required.

A psychosocial risk assessment model (PRAM) for use with pregnant and postpartum women in primary care settings.

Recognition of high rates of mental health morbidity and mortality that affect women during the perinatal period has prompted the development of psychosocial risk assessment programs. Designed to identify women, at risk, during routine health checks and delivered by primary care health service providers, these fit within a primary prevention and early intervention strategic approach to the reduction of perinatal mental illness and reflect an integrated approach to perinatal health services delivery. This paper describes the development and use of the psychosocial risk assessment model (PRAM) at the Royal Hospital for Women in Sydney, Australia. Data is presented on 2,142 women who attended the Antenatal Midwives Clinic between 2002 and 2005. The PRAM guides primary care staff to quickly identify women experiencing emotional distress and/or psychosocial problems during pregnancy or postnatal checks. Measures used in pregnancy are the symptom-based Edinburgh Depression Scale and the psychosocial risk-based Antenatal Risk Questionnaire. In postnatal setting the Postnatal Risk Questionnaire is used. Scores can be used to compute a Psychosocial Risk Index (PRI) to guide individualized care planning, define needs for referral and classify groups for clinical and research purposes. Based on the PRI, among 2,142 women assessed in pregnancy 70.6% were classified as low/no risk (no interventions indicated currently), 24.1% as medium risk (in need of monitoring), and 5.3% as high risk (complex). The PRAM offers a conceptual framework, methods and measures for brief psychosocial assessment with clinical and research applications. Postpartum follow up studies of women assessed during pregnancy have commenced. Randomized controlled trials and cross-cultural studies are now indicated to strengthen the evidence base for the model.

Brief antenatal cognitive behaviour therapy group intervention for the prevention of postnatal depression and anxiety: a randomised controlled trial.

BACKGROUND: The majority of randomised controlled trials examining the effectiveness of antenatal group interventions at preventing postnatal depression in "at risk" women have used a "psychoeducational" intervention. The aim of the present study is to evaluate the effectiveness of an antenatal cognitive behavioural group intervention in a primary care setting for pregnant women identified with mild to moderate symptoms in pregnancy and/or at risk of developing depression or anxiety in the perinatal period. METHOD: Subjects were randomised to a CBT group intervention or control condition (information booklet) and administered the EPDS and STAI at pre (Time 1) and post intervention (Time 2), and at 2 months (Time 3) and 4 months postpartum (Time 4). MINIs were administered at Times 1, 3 and 4. RESULTS: Of the 774 women approached, 277 accepted and were suitable; thus 191 were randomised to the CBT intervention and 86 to the control condition. The subsequent 52% drop-out left 89 women "completing" the CBT groups and 43 in the control group; these two groups were well matched on demographic variables. Intention to treat analyses revealed relatively low mean baseline EPDS scores (means 6.88 -8.16) with no reduction in EPDS scores in either group from Time 1 to Time 4. MINI depression criteria were fulfilled by 19% of all participants at Time 1 but there was no reduction in depression in either group; in contrast those with MINI anxiety diagnoses reduced from 28% in late pregnancy to 16% at four months postpartum in the CBT group with similar reductions in the control group. Analyses on the 132 "completers" showed significant symptomatic improvement over time for both the CBT group and control condition. Depression scores in the most symptomatic women (EPDS>12; N=19) decreased steadily by over 50% over the total time course but there were no differences in improvement between the CBT and control groups. LIMITATIONS: A number of methodological factors may have obscured our results including a tendency to natural remission in mildly symptomatic subjects and the possibility that our control condition was therapeutic in itself. CONCLUSION: While a modest reduction in depression scores was noted in study "completers", both the CBT group intervention control condition were equally beneficial. The reasons for this finding include the low symptom level at baseline; the potential effectiveness of the control condition; and the brevity of the intervention.

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.

Actions taken to cope with depression in patients seeking specialist care.

OBJECTIVE: To assess the rates and perceived effectiveness of actions used to cope with depression and the factors influencing these in an outpatient sample seeking help for depression. METHOD: One hundred and seventy-six patients (74 male, 102 female) aged 16-82 years (M = 42, SD = 14.4 years) with a major depressive episode (DSM-IV criteria) were assessed using a number of measures that covered sociodemographics, history of psychiatric illness, actions taken to alleviate depression and their perceived effectiveness. Logistic regression analyses assessed age, gender and illness characteristics associated with the use and perceived effectiveness of strategies adopted to manage depression. RESULTS: Medical interventions were used and perceived to be effective in alleviating depressive symptoms by most of the sample, as were self-help and complementary therapies. Sociodemographic and illness-related characteristics had a significant influence, with younger age and having experienced an episode of anxiety disorder found to be the strongest predictors for the use of coping strategies. Being female was the strongest predictor for their effectiveness. CONCLUSION: A range of actions for depression, including medical and complementary interventions, were used and found to be helpful in a sample that had sought professional help for depression. Gender, age, depression and anxiety factors were all found to predict the use and perceived effectiveness of these strategies.

Antenatal screening for the prediction of postnatal depression: validation of a psychosocial Pregnancy Risk Questionnaire.

OBJECTIVE: To assess the predictive value of an antenatal index of risk for postnatal depression (PND). METHOD: Participants returned the Pregnancy Risk Questionnaire (PRQ; 18 antenatal items) and the Edinburgh Depression Scale (EDS) at a mean of 32 weeks gestation; the EDS was then mailed out at 2 and 4 months postpartum to ascertain those women who were screened positive (score>2), i.e. probable cases of depression. Only those returning the EDS at 2 and/or 4 months were included in the study (n=1296). Women who screened positive (n=322; 24.8%) were contacted and of these, 245 completed the Auto-Composite International Diagnostic Interview (CIDI) and form the basis of our primary analyses. RESULTS: A CIDI diagnosis of major depression was found in 5.3% women at either 2 or 4 months. In this population, the optimal PRQ cut-off was >or=46 at which point sensitivity was 44% and specificity 92%. At this cut-off 9.9% tested positive (for risk of PND) on the PRQ with a positive predictive value (PPV) of 23.5%. Of 1079 women who scored below 46 on the PRQ, 3.2% were cases of CIDI depression while of those 119 scoring 46 or above, 23.5% were CIDI cases at 2 or 4 months postpartum, yielding an odds ratio of 9.18. CONCLUSION: Using a cut-off of >or=46, the PRQ is better than previously reported tools in the antenatal prediction of PND with respect to sensitivity and specificity, while like other studies PPV remains limited. The PRQ allows identification of high and low risk groups and thus has applicability in both the research and clinical settings.

Clinical issues in perinatal mental health: new developments in the detection and treatment of perinatal mood and anxiety disorders.

OBJECTIVE: This paper presents evidence of new developments in the detection and treatment of perinatal mood and anxiety disorders that have relevance for clinicians. METHOD: An electronic search was conducted in MEDLINE, CINAHL, PsychINFO and The Cochrane Library Database for the interval 1995-2005 for papers published in English. RESULTS: New developments were identified as follows: i) Broadening frames of reference within perinatal mental health. ii) Impact of disorders upon offspring. iii) Identifying women at risk of mental health problems. iv) Prevention and early intervention strategies. v) Treatments. CONCLUSION: Perinatal mental health is a rapidly expanding field that impacts upon the health and wellbeing of all members of families with infants and young children. An evidence base for best practice is slowly emerging but considerable work is still needed in relation to the identification of women at risk, standardisation of diagnostic procedures, reduction of adverse outcomes for women and infants, prevention, early intervention, and treatment of clinical disorders.

Progressing a spectrum model for defining non-melancholic depression.

OBJECTIVE: To further develop a 'spectrum model' for non-melancholic disorders that encompasses underlying personality styles and clinical patterning. METHOD: In a sample of patients with non-melancholic depression, we studied four personality constructs influencing risk to depression, assessing associational strength and specificity between personality scores and symptom and coping response patterns. RESULTS: Analyses refined four personality dimensions (anxious worrying, irritability, social inhibition, and self-centredness) for testing the model. For all dimensions, personality style was specifically linked with a mirroring 'coping' response. Quantification of specific links allowed development of a spectrum model for the non-melancholic depressive disorders in which underpinning personality style showed some specific links with the clinical 'pattern' of symptoms and coping repertoires. CONCLUSION: The model has the capacity to assist clinical assessment, identify aetiological personality influences and allow specific treatment effects for the heterogeneous non-melancholic depressive disorders to be determined.

Antenatal screening and early intervention for "perinatal" distress, depression and anxiety: where to from here?

Recent developments in the study of mental health issues surrounding childbirth, have brought about a shift from the narrow concept of "postnatal depression" (PND) to a consideration of the spectrum of depressive and anxiety disorders arising in the "perinatal" period - which in the mental health context is defined as encompassing pregnancy and the first year postpartum. This shift has been associated with a growing recognition of the potential for prevention and early intervention in the perinatal period. In this article, the difficulties of antenatal screening with the aim of predicting PND are highlighted and contrasted with the potential benefits of antenatal screening aimed at identifying psychological morbidity - whether pre-existing risk factors and/or current symptoms - which may have bearing across the entire perinatal period. The literature on randomized controlled trials of "targeted" antenatal interventions to reduce PND and "indicated" interventions in postnatally depressed women are also reviewed. Future clinical and research directions in the field of early intervention for perinatal mood and anxiety disorders are identified.

Gender differences in response to differing antidepressant drug classes: two negative studies.

BACKGROUND: A recent US study presented data suggesting that depressed women are more likely to respond to selective serotonin reuptake inhibitor (SSRI) than tricyclic (TCA) antidepressant drug therapies. We have undertaken replication studies in two independent databases. METHOD: We have examined for gender differences in SSRI and TCA antidepressant response in both retrospective and prospective naturalistic uncontrolled studies, and in subsets of melancholic and non-melancholic depressed subjects. As the US study had indicated that women under the age of 40 years were particularly likely to show a differential response to SSRIs, we examined for age, gender and interactional effects. In addition, we examined for differential SSRI and TCA responsiveness in a subset of patients who had received drugs from both classes. RESULTS: We failed to find evidence of women having a preferential response to SSRI medication or, conversely, of men having a superior response to TCA medication. Older age, however, was associated with a superior TCA response and younger age with a superior SSRI response. CONCLUSION: As few studies have examined for differential gender and age effects in response to narrow action and broad action antidepressant drugs across major depressive subtypes, gender differential effects remain to be established.

An Australian validation study of the temperament and character inventory.

OBJECTIVE: To assess the validity of the temperament and character inventory (TCI) measure in an Australian sample. METHOD: A sample of depressed subjects completed the TCI and a measure assessing personality disorder constructs (PDCs), while family members and psychiatrists also returned PDC ratings. RESULTS: Factor analyses generally supported the TCI constructs, when the temperament and character scales were analysed separately. Self-reported PDC scores were validated against corroborative witness ratings and used to assess the TCIs concurrent validity. Validation analyses supported all TCI temperament scales, but the Self-transcendence Character scale was unassociated with PDC scores. The remaining two character scales (i.e. cooperativeness and self-directedness) were non-specifically associated with all PDC scores. CONCLUSION: Study results support the validity of the TCI scales, but question the best model for conceptualizing the TCI. It is suggested that two character scales quantify disordered functioning, while temperament scales quantify style, constructs that may be inter-related or independent in individual subjects.

Targeted group antenatal prevention of postnatal depression: a review.

OBJECTIVE: To review the efficacy of antenatal group interventions aimed at reducing postnatal depression (PND) in 'at risk' women. METHOD: Medline, Psyclit, HEALTHSTAR, EMBASE, Cochrane library, UK National Research Register and CINHAL searches were performed from 1960 to December 2001 focussing on randomized controlled trials (RCTs). RESULTS: As statistical synthesis of the studies was not feasible, a qualitative review is provided. All five studies reviewed suffer from substantial limitations including small numbers; unrealistic effect sizes; large attrition rates; lack of a systematic approach in identifying those 'at risk' and thus clinically heterogenous samples. Three of the studies used unvalidated interventions that were educational or supportive in approach. While one such study reported a benefit of intervention, the largest study using a structured intervention, reported no effect. A very small study using interpersonal therapy, was promising but needs replication with an adequate sample size. CONCLUSION: There is currently little evidence from RCTs to support the implementation of antenatal group interventions to reduce PND in 'at risk' women. Further studies addressing the significant methodological limitations are recommended before concluding that antenatal targeted interventions have no place in maternity care.

Antenatal screening for postnatal depression: a systematic review.

OBJECTIVE: To describe the screening properties of the antenatal tools which have been developed to predict depression after birth and to summarize the implications of the findings for antenatal screening. METHOD: Systematic review and secondary analysis of published papers. RESULTS: Sixteen studies including sufficient data for the calculation of screening properties were identified. The majority developed a study-specific screening instrument. Outcome assessments used the Edinburgh Postnatal Depression Scale or standardized diagnostic psychiatric interviews, or both. In the two largest population-based studies, the proportion of women screening as positive ('at risk' of postnatal depression) was 16 and 52%, respectively, and of these only 35 and 8% actually developed depression after birth. CONCLUSION: No screening instrument(s) met the criteria for routine application in the antenatal period. Factors that may have affected poor sensitivity and positive predictive values include the exclusion of key domains in predicting risk, particularly personality, a past history of abuse and postnatal events, the contribution of which may be being under-estimated in studies evaluating antenatal risk prediction tools.

What interventions may reduce postpartum depression.

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

Early and late onset depression in old age: different aetiologies, same phenomenology.

BACKGROUND: Phenomenological differences between older patients with early onset (EO; onset of first major depressive episode before 60 years) and late onset (LO) depression have been inconsistent but, if real, may reflect differences in aetiology. We aimed to compare aetiological factors, phenomenology and cognitive function in older patients with depression by age of onset. METHODS: Subjects were all patients > or =60 years old (n=73) from 407 consecutive attenders to a Mood Disorders Unit, diagnosed with DSM-III-R Major Depressive Episode, at or close to the nadir of their episode. Putative risk factors were assessed by structured interview. Psychological morbidity and depressive symptoms were assessed by the 21-item Hamilton Rating Scale for Depression, CORE rating of psychomotor disturbance, Newcastle Endogeneity Scale, Zung Depression Scale and General Health Questionnaire. Cognition was assessed by tests of memory, attention, executive function and motor speed. RESULTS: Personality abnormalities, a family history of psychiatric illness and dysfunctional past maternal relationships were significantly more common in EO depression. The two age of onset groups were essentially similar in terms of depressive sub-type and severity, phenomenology, history of previous episode, and in neuropsychological performance. LIMITATIONS: Use of self-report data, moderate sample size, sample not age-matched, tertiary referral patients. CONCLUSIONS: EO and LO depression are similar phenotypically, but differ aetiologically. The pursuit of mechanisms which predispose depressive episodes may be heuristically more valuable than further investigation of individual depressive features in distinguishing early from late onset depression.

The clinical features of bipolar depression: a comparison with matched major depressive disorder patients.

BACKGROUND: Despite a resurgence of interest in the treatment of bipolar depression, there have been few controlled studies of the clinical characteristics of this condition. Identification of any distinctive clinical "signatures" of bipolar depression would be helpful in determining treatment options in the clinical setting. METHOD: From a cohort of 270 inpatients and outpatients assessed in detail during a DSM-IV major depressive episode, 39 bipolar I disorder patients were identified and closely matched with 39 major depressive disorder patients for gender, age, and the presence or absence of DSM-IV melancholic subtype. Patients were compared on a broad range of parameters including the Hamilton Rating Scale for Depression (depression severity), 54 depressive symptoms, the Newcastle Endogenous Depression Diagnostic Index, 3 family history items, 2 physical health items, the CORE scale (psychomotor disturbance), and 5 history items. RESULTS: Although the bipolar patients were no more severely depressed than the major depressive disorder controls, they were more likely to demonstrate psychomotor-retarded melancholic and atypical depressive features and to have had previous episodes of psychotic depression. These findings were largely duplicated even when the population was confined to those with DSM-IV melancholia. CONCLUSION: The clinical admixture of psychomotor-retarded melancholic signs and symptoms, "atypical" features, and (less frequently) psychosis may provide a "bipolar signature" in clinical scenarios when there is uncertainty concerning the polarity of a depressive presentation.