Huynh-Nhu Le

Review of screening instruments for postpartum depression

SummaryThis paper presents a review and discussion of eight self-report measures used to assess for depressive symptoms in the postpartum period. Because postpartum depression is a significant mental health problem, there is a need for reliable and valid screening instruments. Published psychometric data (e.g., reliability, sensitivity, specificity, positive predictive value, concurrent validity) of each self-report instrument are presented and critiqued. Results suggest that the Edinburgh Postnatal Depression Scale is the most extensively studied measure with postpartum women with moderate psychometric soundness. This review illustrates the need for more research in this area. Issues involved in the selection of measures are considered. Implications for clinical practice, research, culture and language are discussed.

Randomized controlled trial of a preventive intervention for perinatal depression in high-risk Latinas.

OBJECTIVE A randomized controlled trial was conducted to evaluate the efficacy of a cognitive-behavioral (CBT) intervention to prevent perinatal depression in high-risk Latinas. METHOD A sample of 217 participants, predominantly low-income Central American immigrants who met demographic and depression risk criteria, were randomized into usual care (UC; n = 105) or an 8-week CBT group intervention during pregnancy and 3 individual booster sessions during postpartum (n = 112). Participants completed measures assessing depressive symptoms (Center for Epidemiological Studies Depression Scale at baseline; Beck Depression Inventory, Second Edition [BDI-II]) and major depressive episodes (Mood Screener) at 5 time points throughout the perinatal period. RESULTS Intent-to-treat analyses indicated that intervention participants had significantly lower depressive symptoms and fewer cases of moderate depression (BDI-II ≥ 20) at Time 2 than UC participants. These effects were stronger for women who fully participated in the intervention (≥ 4 classes). The cumulative incidence of major depressive episodes was not significantly different between the intervention (7.8%) and UC (9.6%) groups. CONCLUSIONS A CBT intervention for low-income, high-risk Latinas reduced depressive symptoms during pregnancy but not during the postpartum period. Low levels of depressive symptoms and lower than expected rates of clinical depression in both groups may partially be due to methodological issues. As perinatal depression is a significant public health problem, more work is needed to prevent perinatal depression in low-income, ethnically diverse women.

Impact of stress reduction instructions on stress and cortisol levels during pregnancy.

This pilot study examined whether giving stress reduction (SR) instructions to pregnant women would be effective in regulating stress, mood, and cortisol levels during pregnancy. Forty-one predominantly low-income Latina women, receiving prenatal services at a public county hospital, completed measures of stress and mood (depressive symptoms, positive and negative affect) and provided morning and evening saliva samples to measure cortisol prior to and after receiving SR instructions. We hypothesized that adherence to these SR instructions would result in lower levels of stress, negative mood states, and cortisol levels when compared to baseline values. Repeated measures ANOVA analyses demonstrated significantly lower levels of stress (P < 0.001), lower symptoms of depression and negative affect (P < 0.001), and lower levels of morning cortisol (P = 0.01) under the SR condition, compared to baseline. Health behaviors that were engaged in during the SR condition and implications for prenatal health interventions are discussed.

A comparison of three screening tools to identify perinatal depression among low-income African American women

BACKGROUND The purpose of the current study was to determine the sensitivity, specificity, and positive predictive value of three depression screening tools among a low-income African American population of pregnant and recently delivered women enrolled in home visitation programs in a low-income urban community. METHODS Ninety-five women enrolled in home visitation programs-32 who were pregnant and 63 with a child <6 months comprise the study sample. Each woman completed a structured clinical interview and three depression screening tools-the Edinburgh Postnatal Depression Scale (EPDS), Center for Epidemiologic Studies Depression Scale (CES-D), and Beck Depression Inventory II (BDI-II). RESULTS Over a quarter of women (28.4%) were experiencing major depression. Each screening tool was highly accurate in detecting major depression and major or minor depression among prenatal and postpartum women, with areas under the curve (AUCs) >0.90. Sensitivities of all screening tools were improved when using cutoffs lower than those considered standard by instrument developers. LIMITATIONS Participants were recruited from home visitation programs in an urban context which may limit generalizability to other populations of low-income African American women. Given that no women during pregnancy met criteria for minor depression, it was not possible to determine optimal prenatal cutoff scores. CONCLUSIONS Three depression screening tools-the EPDS, CES-D, and BDI-II-appear to be reliable and brief assessments of major and minor depression among low-income African American perinatal women. Providers using these tools should consider using lower cutoff scores to most effectively identify women in need of depression treatment.

Estimating Intervention Effects of Prevention Programs: Accounting for Noncompliance

Individuals not fully complying with their assigned treatments is a common problem encountered in randomized evaluations of behavioral interventions. Treatment group members rarely attend all sessions or do all “required” activities; control group members sometimes find ways to participate in aspects of the intervention. As a result, there is often interest in estimating both the effect of being assigned to participate in the intervention, as well as the impact of actually participating and doing all of the required activities. Methods known broadly as “complier average causal effects” (CACE) or “instrumental variables” (IV) methods have been developed to estimate this latter effect, but they are more commonly applied in medical and treatment research. Since the use of these statistical techniques in prevention trials has been less widespread, many prevention scientists may not be familiar with the underlying assumptions and limitations of CACE and IV approaches. This paper provides an introduction to these methods, described in the context of randomized controlled trials of two preventive interventions: one for perinatal depression among at-risk women and the other for aggressive disruptive behavior in children. Through these case studies, the underlying assumptions and limitations of these methods are highlighted.

Identifying Risk for Onset of Major Depressive Episodes in Low-Income Latinas during Pregnancy and Postpartum.

This study aimed to identify subgroups of pregnant women at imminent (1 year) risk for major depressive episodes. Participants were 84 low-income, predominantly Mexican women using public sector obstetrics services who participated in monthly interviews during pregnancy and up to 6 months postpartum. Participants were designated a priori as “more vulnerable” or “less vulnerable” to future perinatal depression based on evidence of mood regulation problems defined as (a) a self-reported history of major depressive episodes, (MDE) and/or (b) high current depressive symptom scores on a continuous depression scale. Two definitions of a major depressive episode based on meeting 2 or 3 DSM-IV MDE criteria, were used to measure the incidence of a new major depressive episode. Results suggest that more vulnerable groups (i.e., with the greatest mood regulation problems) had a higher incidence of major depressive episodes than less vulnerable groups. Implications for screening and developing preventive interventions for postpartum depression are discussed.

Interpersonal factors and perinatal depressive symptomatology in a low-income Latina sample.

Interpersonal factors are among the risk factors that predispose women to experiencing mood disturbances during the childbearing years. This study investigates the trajectory of change in depressive symptomatology over the course of the perinatal period as related to interpersonal risk factors (marital quality and social support) in a sample of 69 low-income, mostly immigrant Latina mothers at high and low risk for depression. We found a significant linear change in depressive symptomatology from baseline (pregnancy) through the postpartum period. This decline was steeper for high-risk women who reported high levels of social support compared with those who reported low levels of social support. In addition, a greater decline in depressive symptom scores was found for women who reported better postnatal marital quality, irrespective of risk group status. The results suggest the importance of considering marital quality and social support in estimations of risk for depression. These findings also have implications for targeting social support and marital quality in preventive interventions for perinatal depression in Latinas.

Recruiting Latino women in the U.S. and women in Mexico in postpartum depression prevention research

The negative consequences of untreated depression on the health and well-being of women and their children are well-documented, underscoring the need to develop effective interventions to prevent the onset of major depression during the perinatal period. This article describes recruitment data from two randomized controlled trials of preventive interventions for postpartum depression: one conducted with immigrant Latinas in Washington, DC, United States, and the other with women in Mexico City, Mexico. In both countries, pregnant women met a priori eligibility criteria and were randomized into an 8-week theory-based group intervention. Two hundred and seventeen Latinas in the U.S. and 377 women born and raised in Mexico were enrolled in their respective countries. The recruitment rates (i.e., the number of participants who met eligibility criteria, consented, and randomized into the study) were 70% in the U.S. and in Mexico. Issues and recommendations related to recruiting Hispanic women into preventive intervention trials for postpartum depression are discussed.

Unintended pregnancy and perinatal depression trajectories in low-income, high-risk Hispanic immigrants

Perinatal depression is a prevalent and detrimental condition. Determining modifiable factors associated with it would identify opportunities for prevention. This paper: 1) identifies depressive symptom trajectories and heterogeneity in those trajectories during pregnancy through the first-year postpartum, and 2) examines the association between unintended pregnancy and depressive symptoms. Depressive symptoms (BDI-II) were collected from low-income Hispanic immigrants (n=215) five times from early pregnancy to 12-months postpartum. The sample was at high-risk for perinatal depression and recruited from two prenatal care settings. Growth mixture modeling (GMM) was used to identify distinct trajectories of depressive symptoms over the perinatal period. Multinomial logistic regression was then conducted to examine the association between unintended pregnancy (reported at baseline) and the depression trajectory patterns. Three distinct trajectory patterns of depressive symptoms were identified: high during pregnancy, but low postpartum (“Pregnancy High”: 9.8%); borderline during pregnancy, with a postpartum increase (“Postpartum High”: 10.2%); and low throughout pregnancy and postpartum (“Perinatal Low”: 80.0%). Unintended pregnancy was not associated with the “Pregnancy High” pattern, but was associated with a marginally significant nearly four fold increase in risk of the “Postpartum High” pattern in depressive symptoms (RRR=3.95, p<0.10). Family planning is a potential strategy for the prevention of postpartum depression. Women who report unintended pregnancies during prenatal care must be educated of their increased risk, even if they do not exhibit antenatal depressive symptoms. Routine depression screening should occur postpartum, and referral to culturally appropriate treatment should follow positive screening results.

Excavating Culture: Disentangling Ethnic Differences From Contextual Influences in Parenting

Historically, much of the research on parenting has not disentangled the influences of race/ethnicity, SES, and culture on family functioning and the development of children and adolescents. This special issue addresses this gap by disentangling ethnic differences in parenting behaviors from their contextual influences, thereby deepening our understanding of parenting processes in diverse families. Six members of the Parenting Section of the Study Group on Race, Culture, and Ethnicity (SGRCE) introduce and implement a novel approach toward understanding this question. The goal of this project is to study culturally related processes and the degree to which they predict parenting. An iterative process was employed to delineate the main parenting constructs (warmth, psychological and behavioral control, monitoring, communication, and self-efficacy), cultural processes, and contextual influences, and to coordinate a data analytic plan utilizing individual datasets with diverse samples to answer the research questions.