Jeannette Milgrom

Risk factors for antenatal depression, postnatal depression and parenting stress

BackgroundGiven that the prevalence of antenatal and postnatal depression is high, with estimates around 13%, and the consequences serious, efforts have been made to identify risk factors to assist in prevention, identification and treatment. Most risk factors associated with postnatal depression have been well researched, whereas predictors of antenatal depression have been less researched. Risk factors associated with early parenting stress have not been widely researched, despite the strong link with depression. The aim of this study was to further elucidate which of some previously identified risk factors are most predictive of three outcome measures: antenatal depression, postnatal depression and parenting stress and to examine the relationship between them.MethodsPrimipara and multiparae women were recruited antenatally from two major hoitals as part of the beyondblue National Postnatal Depression Program [1]. In this subsidiary study, 367 women completed an additional large battery of validated questionnaires to identify risk factors in the antenatal period at 26–32 weeks gestation. A subsample of these women (N = 161) also completed questionnaires at 10–12 weeks postnatally. Depression level was measured by the Beck Depression Inventory (BDI).ResultsRegression analyses identified significant risk factors for the three outcome measures. (1). Significant predictors for antenatal depression: low self-esteem, antenatal anxiety, low social support, negative cognitive style, major life events, low income and history of abuse. (2). Significant predictors for postnatal depression: antenatal depression and a history of depression while also controlling for concurrent parenting stress, which was a significant variable. Antenatal depression was identified as a mediator between seven of the risk factors and postnatal depression. (3). Postnatal depression was the only significant predictor for parenting stress and also acted as a mediator for other risk factors.ConclusionRisk factor profiles for antenatal depression, postnatal depression and parenting stress differ but are interrelated. Antenatal depression was the strongest predictor of postnatal depression, and in turn postnatal depression was the strongest predictor for parenting stress. These results provide clinical direction suggesting that early identification and treatment of perinatal depression is important.

Non-psychotic mental disorders in the perinatal period

Mental disorders are among the most common morbidities of pregnancy and the postnatal period, and can have adverse effects on the mother, her child, and family. This Series paper summarises the evidence about epidemiology, risk factors, identification, and interventions for non-psychotic mental disorders. Although the phenomenology and risk factors for perinatal mental disorders are largely similar to those for the disorders at other times, treatment considerations differ during pregnancy and breastfeeding. Most randomised controlled trials have examined psychosocial and psychological interventions for postnatal depression, with evidence for effectiveness in treating and preventing the disorder. Few high-quality studies exist on the effectiveness or safety of pharmacological treatments in the perinatal period, despite quite high prescription rates. General principles of prescribing of drugs in the perinatal period are provided, but individual risk-benefit analyses are needed for decisions about treatment.

A randomized controlled trial of psychological interventions for postnatal depression

OBJECTIVES First, to establish the efficacy of psychological interventions versus routine primary care for the management of postnatal depression (PND). Secondly, to provide a direct comparison of cognitive-behavioural therapy (CBT) versus counselling and, finally, to compare the relative value of group and individual delivery formats. DESIGN The study involved 192 depressed women drawn from a large community screening programme in Melbourne, Australia and allocated to cognitive behaviour therapy, counselling, or routine primary care. Baseline and post-intervention measures of depression and anxiety were collected in the form of validated self-report inventories. METHOD Women were screened in the community and diagnosis of depression confirmed with a standardized psychiatric interview. Interventions were of 12 weeks duration, including three partner sessions, and adhered to a structured manual. RESULTS Psychological intervention per se was superior to routine care in terms of reductions in both depression and anxiety following intervention. CONCLUSIONS For those women with PND, psychological intervention is a better option than routine care, leading to clinically significant reduction of symptoms. Counselling may be as effective as group cognitive behaviour therapy. The benefits of psychological intervention may be maximized by being delivered on a one-to-one basis.

Preventing excessive gestational weight gain: a systematic review of interventions

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

Depression and anxiety through pregnancy and the early postpartum: An examination of prospective relationships

BACKGROUND The aim of this study was to explore the prospective relationship between depressive symptoms and anxiety across pregnancy and the early postpartum. METHODS Participants (N=207) completed the State-Trait Anxiety Inventory Trait subscale, Beck Depression Inventory, and social support and sleep quality measures at two time points during pregnancy and once in the early postpartum period. RESULTS After accounting for the relative stability of anxiety and depression over time, depressive symptoms earlier in pregnancy predicted higher levels of anxiety in late pregnancy and anxiety in late pregnancy predicted higher depressive symptomatology in the early postpartum. A bi-directional model of depression and anxiety in pregnancy was supported. LIMITATIONS Data were based on self-reports and participating women were predominantly tertiary educated with high family incomes. CONCLUSION Our findings suggest that depressive symptoms precede the development of higher levels of anxiety and that anxiety, even at non-clinical levels, can predict higher depressive symptoms. Clinicians are advised to screen for anxiety and depression concurrently during pregnancy.

Correlates of ante- and postnatal depression in fathers: A systematic review

BACKGROUND Contemporary research findings suggest that depression during the ante- and postnatal periods is a significant problem not only for women but also for many men. This paper provides a conceptual and methodological review of the literature on cross-sectional and prospective correlates of depressive symptoms in men during both pregnancy and the postpartum period. METHODS The search, via several electronic databases, was limited to English papers published between January 1996 and August 2009, and identified 30 relevant articles. RESULTS The most common correlate of paternal depressive symptoms pre- and post birth was having a partner with elevated depressive symptoms or depression; poor relationship satisfaction was also frequently associated with elevated depressive symptoms or depression in men. LIMITATIONS There were significant methodological limitations of existing studies, including small sample sizes; the use of cross-sectional designs; varied measures of depression; focus on depression in the postpartum only; and in the few longitudinal gestational studies, the inclusion of only one assessment point. The limitations of the current systematic review include the inclusion of only papers written in English and potential publication bias, where studies with null findings are less likely to be published. CONCLUSION The scientific study of predictors of mens depressive symptoms pre and post birth remains in its infancy. Given the implications of clinical depression in men both during the gestational and postpartum periods, further systematic investigation of direct and indirect predictors of elevated depressive symptoms in men during this time is warranted.

Group treatment for postpartum depression: a pilot study.

Objective: There are few reports on the efficacy of treatment programs for women with postpartum depression, despite the long-term nature of this disorder. This study describes a pilot evaluation of a treatment program with educational, social support and cognitive-behavioural components. Method: Ten women with persistent depression originating in the postpartum period were offered a 10-week group treatment program and compared to a wait-list control group. Results: Following treatment, a significant improvement in depression was demonstrated on the Edinburgh Post-Natal Depression Scale, Beck Depression Inventory, and Profile of Mood States. Several common factors in women suffering from postpartum depression were also identified, as were drop-out characteristics. Conclusion: These results are encouraging and suggest that a cognitive-behavioural group program might be effective as a treatment for depression in the postpartum period. However, further detailed studies are required to confirm this pilot study.

Early Sensitivity Training for Parents of Preterm Infants: Impact on the Developing Brain

After birth, preterm infants face a stressful environment, which may negatively impact early brain development and subsequent neurobehavioral outcomes. This randomized controlled trial involving 45 women with infants <30-wk gestation, assessed the effectiveness of training parents in reducing stressful experiences. Intervention consisted of 10 sessions in the Neonatal Intensive Care Unit (NICU). Postintervention, at term-equivalent (40-wk postmenstrual age), magnetic resonance imaging (MRI) was performed to evaluate brain structure and development. Quantitative volumetric techniques were used to estimate overall and regional brain volumes for different tissue types including CSF, CGM, DNGM, UWM, and MWM. DTI was used to evaluate the integrity and maturation of white matter by ADC and FA. Maturation and connectivity of white matter, characterized by diffusion MR measures of ADC and FA, were significantly enhanced in the intervention group, who displayed greater restriction in ADC and increase in FA. There were no significant effects on either brain volumes or on short-term medical outcomes. Thus, sensitivity training for parents in the NICU is associated with improved cerebral white matter micro-structural development in preterm infants.

Sleep quality and depression during pregnancy: a prospective study

For the first time, the relationship between depressive symptoms and sleep quality was explored prospectively during pregnancy. Participants (n = 273) completed the Pittsburgh Sleep Quality Index and Beck Depression Inventory at three 8‐week intervals, starting from 15–23 weeks gestation. In addition to sleep quality and depression remaining relatively stable during pregnancy, findings revealed that sleep quality earlier in pregnancy predicted higher levels of depressive symptoms at later stage in pregnancy (after controlling for prior depression levels). In contrast, there was no evidence to suggest that depressive symptoms earlier in pregnancy impacted on sleep quality later on. Given that depressive symptomatology can lead to major depression and given the prevalence of pre‐ and postnatal depression, our findings suggest that screening for sleep problems during pregnancy may be of clinical significance.

The relationship between depression and body dissatisfaction across pregnancy and the postpartum : a prospective study

The overall aim of this study was to examine the relationship between depression and body dissatisfaction across pregnancy and the first 12 months postpartum. During pregnancy, womens (N = 116) perceived attractiveness and strength/fitness remained stable, while feeling fat and salience of weight/shape decreased in late pregnancy. During the postpartum, feeling fat and salience of weight/shape increased. Depression and body dissatisfaction scores were correlated with each other concurrently and across multiple time points. However, in baseline-controlled prospective analyses, only a model of greater depression late in pregnancy predicting body dissatisfaction at six weeks postpartum and feeling fat throughout the postpartum was supported.