Elizabeth Boath

The treatment of postnatal depression: A comprehensive literature review

The aim of this comprehensive review was to identify and critically review all published studies of the treatment of postnatal depression, including those who would be excluded from systematic reviews because of their stringent inclusion criteria. A search of the electronic databases Medline, PsychLit, Sociofile, CINAHL, COPAC and that of published books held by the British Library was carried out in 2000, using the key words: postnatal depression; postpartum depression; puerperal depression; and treatment. The search strategy was limited to English language references using human subjects from 1964 to 2000. A very broad definition of postnatal depression was used and papers were included if they had clearly defined their main purpose as the treatment, as opposed to the prevention, of postnatal depression. Studies of postpartum blues and puerperal psychosis were excluded. This search strategy identified 30 articles. Copies of relevant papers were obtained and the authors independently read and critiqued the published articles using critical appraisal criteria designed specifically for this narrative review. The reviews were combined, clarification was sought from authors and disagreements were discussed until agreement was reached. Treatment approaches were categorized as: pharmacological; psychological & psychodynamic; pharmacological & psychological; social support & relaxation; and hormonal. The methodological limitations of these studies means that the efficacy of these treatment approaches have not been clearly established and there is very little good evidence available on which to make policy or practice recommendations; thus, further work in this area is warranted.

Women's views of antidepressants in the treatment of postnatal depression

Little research has been carried out on the treatment of postnatal depression and clinicians must currently rely on general recommendations for the use of antidepressants. Antidepressant medication as the main treatment for depression in general practice has been shown to be effective when used as prescribed. However, research has shown that depressed patients consistently receive either no medication or consistently low doses of medication. This study will investigate womens experiences of taking antidepressant medication for postnatal depression. Thirty-five women with a clinical diagnosis of postnatal depression who had been prescribed antidepressant medication completed a questionnaire detailing their experiences of taking medication. Four open-ended questions and responses were discussed with the women. Of the 35 women who were prescribed medication, 4 chose not to take it because they were breast-feeding. Twenty of the women described finding medication helpful. Although only 4 women directly reported not taking antidepressants as prescribed, the comments made by a further 9 women suggest that compliance may have been poor. This study suggests a need to improve information about medication for postnatal depression. If this information is not provided, women are likely to continue to self-manage medication at a dosage that may be clinically ineffective.

The prevention of postnatal depression: A narrative systematic review

This systematic review assessed the success of randomized controlled trials of preventative interventions for postnatal depression (PND). Outcomes examined were estimates of PND prevalence. Methodological quality was determined through the examination of key components individually with independent data extraction by all three authors. Data sources included Medline, PsycINFO, Sociofile, CINAHL, COPAC, EMBASE, Cochrane library; hand searches and a newsletter requests for unpublished trials to the Marcé Society and Postpartum Support International. Twenty-one RCTs were included in this review. Nine of these trials demonstrated short-term preventative success (seven psychological and supportive interventions, one unpublished antidepressant trial and a calcium carbonate trial) but none provided any evidence of long-term success. Furthermore, the results of three of the psychological intervention trials should be viewed with caution due to a lack of methodological rigour. There is a need for future research into the prevention of PND to be tightly designed and maybe include an exploration of the experience of postnatal depression for multiparous women.

When the cradle falls: the treatment of postnatal depression in a psychiatric day hospital compared with routine primary care

BACKGROUND Postnatal depression affects one in ten women within 6 months of childbirth. The most effective treatment strategy for postnatal depression is not clear. METHODS This prospective, naturalistic study of the treatment of postnatal depression compared 30 women treated at a specialised psychiatric day hospital with 30 women treated using routine primary care (RPC). Clinical, marital and social adjustment were assessed on three occasions over 6 months using: the Edinburgh Postnatal Depression Questionnaire (EPDS); the Clinical Interview schedule (CIS); the Anxiety Subscale of the Hospital Anxiety and Depression Scale; the Dyadic Adjustment Scale (DAS); and the Work Leisure and Family Life Questionnaire-Modified (WLFLQ-M). RESULTS There were no significant differences between the two groups at baseline. However, there were significant differences in outcome at 3 and 6 months follow-up for all outcome measures except the DAS. At 6 month follow-up 21 of the PBDU group were no longer depressed compared with 7 of the RPC group. CONCLUSIONS A specialised day hospital is a more effective treatment setting for postnatal depression than routine primary care. LIMITATIONS OF THE STUDY The study is not an RCT, so systematic bias is possible. The sample size is relatively small and the duration of follow-up relatively short.

When the cradle falls II: the cost-effectiveness of treating postnatal depression in a psychiatric day hospital compared with routine primary care

BACKGROUND This prospective cohort study assessed the cost-effectiveness of treating 30 women with postnatal depression (PND) at a specialised psychiatric Parent and Baby Day Unit (PBDU), compared to 30 women treated using routine primary care (RPC). METHODS Following recruitment, the women were assessed on three occasions (initially, 3- and 6-months), using a variety of social and psychiatric outcome measures. Direct and indirect costs were collated using structured interviews, retrospective analysis of case notes and routinely collated NHS cost data. Sensitivity analysis was also carried out. RESULTS There was no significant difference between the women in the two groups initially in terms of their socio-demographic characteristics, or scores on the outcome measures. However, at 6-months, 21 women in the PBDU group were no longer depressed compared to only seven women in the RPC group. The total cost was 46,211 pounds for the PBDU group and 18,973 pounds for the RPC group. Moving from RPC to a PBDU would involve an additional expenditure of 27,238 pounds (46,211-18,973) whilst delivering 14 more positive outcomes. The move from RPC to PBDU would incur an additional cost per successfully treated woman of 1945 pounds (27,238/14). This compares favourably with the current cost per successfully treated woman in the RPC group of 2710 pounds (18,973/7). CONCLUSIONS RPC is dominated on the grounds of cost-effectiveness by PBDU treatment and so PBDU treatment should be recommended to health care decision-makers. LIMITATIONS OF THE STUDY The results were sensitive to the inclusion of primary care contacts and the costs of medication.

A case-control study of differences between regular and causal adult attenders in general dental practice.

Objectives To assess whether adults attending a dental practice for regular dental care have better oral health than adults attending casually in response to a dental problem, and to explore the barriers to asymptomatic attendance. Methods An observational case-control study comparing the characteristics of 100 regular attenders with 100 casual attenders in one general dental practice in North Staffordshire. All study subjects were aged 18 years or over. Sociodemographic characteristics of the two groups were collated, including age, gender, social class, marital status, employment status and smoking status. The primary outcome measure was the observed number of teeth with dentinal caries diagnosed using bitewing radiographs. Results Regular attenders were observed to have better oral health with respect to dental caries and tooth mobility (p<0.05). This was not explained by the observation that casual attenders were more likely than regular attenders to be male, aged 18–44 years, in social class III or IV. Secondary outcomes, including number of subjects with mobile teeth and teeth with >30% bone-loss, were also significantly worse in the casual attenders. However, the median number of teeth present in both groups was 27. In regular attenders, the most common reason for attending was to ‘keep the teeth’ (96%). In casual attenders, ‘fear/dislike of dental treatment’ was the most frequent indicator of non-attendance (56%). Conclusions In our study, adults who regularly attended general dental practice were shown to have better oral health, including less overall tooth decay, mobility and bone-loss, compared with adults who did not attend on a regular basis. Assuming this result to be externally valid, a challenge for the dental profession in the future will be to develop effective oral health promotion initiatives.

Users' views of two alternative approaches to the treatment of postnatal depression

Postnatal depression (PND) is a major public health concern, yet services are lacking. Most women with PND receive routine primary care from general practitioners, health visitors, and in a few cases community psychiatric nurses. A Parent and Baby Day Unit (PBDU) has been developed in Stoke-on-Trent and attendance at this Unit has a greater therapeutic impact on PND than routine primary care (RPC). This small pilot study elicits user views to understand the role of specialist and routine care in PND treatment and pinpoints which aspects of specialist care are important to women. Thirty women with PND attending the PBDU and 30 receiving RPC completed a questionnaire on their views of the service they received. Written comments were analysed thematically using content analytic techniques. The majority of women attending the PBDU were satisfied with this service, whereas women receiving RPC were dissatisfied with their treatment and a perceived absence of information. The main value of the PBDU seems to be one of social support. Effective communication from primary care professionals is important for women with PND and a perceived lack of information is a major cause of dissatisfaction. Availability of peer and professional support is perceived as valuable, but is insufficient within primary care.

Influencing prescribing in primary care: a collaboration between clinical pharmacology and clinical pharmacy

A study was carried out to determine whether the standard of prescribing in primary care can be improved by a therapeutics advisory service provided by a consultant clinical pharmacologist and a clinical pharmacist.

Meeting the challenges of teenage mothers with postpartum depression: overcoming stigma through support

Objective: This study aimed to elicit and explore the experiences of teenage mothers with postpartum depression focussing on their experiences of being a teenage mother; support needs and the potential for support and education to be delivered by healthcare workers, or peers. Background: Teenage mothers are three times more likely to get postnatal depression than older mothers and are at increased risk of poorer mental health for up to three years postpartum. Method: Fifteen first-time mothers aged 16–19, living in Stoke on Trent, UK, with an infant aged under one year and suffering from postpartum depression were interviewed. Qualitative data were analysed using thematic framework analysis to identify emergent patterns and themes. Results: Four key themes emerged: stigma and perceptions of being judged; social and professional support; knowledge and information; and barriers to utilising support. Conclusion: The results highlighted the stigma, both real and perceived, that teenage mothers experienced as well as the lack of informal support networks for many and the unavailability of relevant and appropriate information targeted at teenage mothers. Some mothers highlighted the positive relationships they had with their health visitor which was essential to them in building a trusting relationship. However, not all had such good experiences, with some reporting that they did not know who their health visitor was. The need for tailored services and innovative methods of delivery are highlighted.

When the bough breaks : Charles Street Parent and Baby Day Unit

Abstract Charles Street Parent and Baby Day Unit (PBDU), is a specialized, multi-disciplinary, psychiatric day hospital in Stoke-on-Trent, Staffordshire, that provides a comprehensive service of high intensity, customized treatment to parents with psychological disorders associated with pregnancy, childbirth, stillbirth, miscarriage and termination (Cox et al., 1993). The unit is the major component in the perinatal psychiatry service, which also involves a liaison psychiatry service to the North Staffordshire Maternity Hospital and an in-patient facility in an acute admission ward. These concentrated efforts led to national recognition in 1992 when the unit was awarded the Hospital Doctor Team of the Year Award. This report briefly outlines the service and the clinical and socio-demographic characteristics of clients referred to the PBDU over a 1-year period.