Tanya Meade

Maternal mental health in Australia and New Zealand: A review of longitudinal studies

AIM The aim of this paper is to describe the factors that impact on the mental health of Australian and New Zealand (NZ) women in the perinatal period (pregnancy and the year following birth), and to determine the impact of perinatal mental health on womens subsequent health by summarising findings from prospective longitudinal studies conducted in Australia and NZ. METHODS A systematic search was conducted using the databases, Scopus, Medline, PsychInfo and Health Source to identify prospective longitudinal studies focused on womens social and emotional health in the perinatal period. Forty-eight papers from eight longitudinal studies were included. RESULTS The proportion of women reporting depressive symptoms in the first year after birth was between 10 and 20% and this has remained stable over 25 years. The two strongest predictors for depression and anxiety were previous history of depression and poor partner relationship. Importantly, womens mood appears to be better in the first year after birth, when compared to pregnancy and five years later. Becoming a mother at a young age is by itself not a risk factor unless coupled with social disadvantage. Women report a high number of stressors in pregnancy and following birth and the rate of intimate partner violence reported is worryingly high. CONCLUSION Midwives have an important role in the identification, support and referral of women experiencing mental health problems. As many women do not seek help from mental health services, the potential for a known midwife to impact on womens mental health warrants further examination.

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.

Measuring engagement in deliberate self-harm behaviours: psychometric evaluation of six scales

BackgroundEngagement in Deliberate Self-Harm (DSH) is commonly measured by behavioural scales comprised of specific methods of self-harm. However, there is a scarcity of information about the degree to which the methods relate to the same DSH construct although such scales are routinely used to provide a DSH total score. This study addresses the shortfall by evaluating the dimensionality of six commonly used behavioural measures of DSH.MethodsThe DSH measures were Self-Injury Questionnaire Treatment Related (SIQTR), Self-Injurious Thoughts and Behaviors Interview (SITBI), Deliberate Self-Harm Inventory (DSHI), Inventory of Statements About Self-Injury (ISAS), Self-Harm Information Form (SHIF) and Self-Harm Inventory (SHI). The behavioural scales contained in each measure were administered to 568 young Australians aged 18 to 30 years (62% university students, 21% mental health patients, and 17% community members). Scale quality was examined against the stringent standards for unidimensional measurement provided by the Rasch model.ResultsAccording to the stringent post-hoc tests provided by the Rasch measurement model, there is support for the unidimensionality of the items contained within each of the scales. All six scales contained items with differential item functioning, four scales contained items with local response dependency, and one item was grossly misfitting (due to a lack of discrimination).ConclusionsThis study supports the use of behavioural scales to measure a DSH construct, justifies the summing of items to form a total DSH score, informs the hierarchy of DSH methods in each scale, and extends the previous evidence for reliability and external validity (as provided by test developers) to a more complete account of scale quality. Given the overall adequacy of all six scales, clinicians and researchers are recommended to select the scale that best matches their adopted definition of DSH.

Negotiating policy in practice: child and family health nurses’ approach to the process of postnatal psychosocial assessment

BackgroundThere is growing recognition internationally of the need to identify women with risk factors for poor perinatal mental health in pregnancy and following birth. In the state of New South Wales, Australia the Supporting Families Early policy provides a framework of assessment and support for women and families and includes routine psychosocial assessment and depression screening. This study investigated the approach taken by Child and Family Health Nurses (CFHNs) following birth to assessment and screening as recommended by state policy. This was a qualitative ethnographic study that included 83 CFHN and 20 women. Observations occurred with thirteen nurses; with 20 women, in the home or the clinic environment. An additional 70 nurses participated in discussion groups. An observational tool (4D&4R) and field notes were used to record observations and analysed descriptively using frequencies. Field notes, interview data and discussion group transcripts were analysed thematically.MethodsThis was a qualitative ethnographic study that included 83 CFHN and 20 women. Observations occurred with thirteen nurses; with 20 women, in the home or the clinic environment. An additional 70 nurses participated in discussion groups. An observational tool (4D&4R) and field notes were used to record observations and analysed descriptively using frequencies. Field notes, interview data and discussion group transcripts were analysed thematically.ResultsCFHNs demonstrated a range of approaches to assessment and screening. Psychosocial assessment was conducted in 50% (10 out of the 20) of the interactions observed; however, all the women were screened using the Edinburgh Depression Scale. Four major themes that represent the approach taken to the assessment process were identified: ‘Engagement: getting that first bit right’, ‘Doing some paperwork’, ‘Creating comfort’ and ‘Psychosocial assessment: doing it another way’. Nurses utilised other skills such as observing the women interacting with their baby, taking note of non verbal communication and using intuition to develop a clinical decision.ConclusionOverall, nurses’ took a sensitive and caring approach to assessment and screening, however, there were differences in interpretations of the policy recommendations across the two sites. Nurses adopt a flexible, relationship-based approach to the assessment process; however, they experience tension when required to incorporate structured psychosocial assessment processes. To undertake assessment and screening effectively, CFHNs require ongoing support, training and supervision to maintain this sensitive and emotionally challenging work.

Adolescents’ health-related quality of life (HRQoL) changes over time: a three year longitudinal study

BackgroundAdolescence is a significant developmental stage marked by physical, psychological and social changes. While adolescents are generally perceived to be healthy, this stage of development is also associated with an emergence of risk factors that may have long-term consequences for their wellbeing. The aim of this study was to assess health related quality of life (HRQoL), and possible gender and age differences, in a sample of secondary school-aged adolescents over a three-year time period.MethodsAustralian adolescents (n = 403, aged 12–15 at baseline) across six New South Wales high schools completed the KIDSCREEN-27 Questionnaire at three time points. The KIDSCREEN-27 measures five HRQoL domains (physical wellbeing, psychological wellbeing, autonomy and parents relations, social support and peers, and school environment). Mixed-between-within-subjects ANOVA analyses were employed to examine HRQoL over time and across age and gender.ResultsHRQoL rates were comparable to the European-based KIDSCREEN norms with the exception of psychological wellbeing, which was considerably lower in this study’s sample.Over time, for the total sample, there were significant changes on only one of the five dimensions (social support and peers). However, gender differences were found to be significant across three dimensions (physical wellbeing, psychological wellbeing, and autonomy and parents relations), with females reporting lower scores than males (i.e. lower HRQoL). Females’ scores also declined over the three time points across two of the five HRQoL dimensions (social support and peers, and school environment), indicating reductions in HRQoL over time. Age differences were found across all but one dimension (autonomy and parents relations).ConclusionsAlthough statistically significant, the changes in HRQoL may not be clinically significant, as the effect sizes were small and therefore those changes would not be readily noticeable. Those changes, however, suggest that, while HRQoL is predominantly stable over time, fluctuations and declines, such as those found for females, may be early indicators of physical and psychological vulnerabilities. If such vulnerabilities are detected timely; they may be addressed with preventative measures or appropriate interventions.

Problem-solving versus cognitive restructuring of medically ill seniors with depression (PROMISE-D trial): study protocol and design

BackgroundWith an ageing population in most Western countries, people are living longer but often with one or more chronic physical health problems. Older people in physically poor health are at greater risk of developing clinical depression. Cognitive Behavioural Therapy (CBT) and Problem Solving Therapy (PST) have both been found to be efficacious in treating late-life depression, however patients with “multi-morbidity” (i.e. more than one chronic condition) are often excluded from these trials. The aim of this study is to compare the efficacy of CBT and PST in treating older adults who have one or more chronic physical health conditions and a diagnosable depressive disorder. This study will be the first to explicitly target the treatment of depression in older people in primary care settings presenting with a range of health problems using behavioural interventions.Methods/designThe PROMISE-D study is a randomised controlled trial of two evidence-based treatments for late-life major or minor depression for patients who also have at least one co-morbid chronic health problem. Participants will be randomised to two active interventions (PST or CBT) or enhanced treatment-as-usual (E-TAU). Primary outcomes will be depression diagnostic status and severity of depression (according to the Hamilton Depression Rating Scale and the Geriatric Depression Scale). Secondary outcomes will be anxiety severity, quality of life and health care utilisation. Assessments will be conducted by a researcher who remains blind to the patient’s treatment allocation and will be conducted pre and post-treatment and at six and 12 months follow-up. Health care utilisation will be assessed throughout a two year period following entry to the trial. Executive function, rumination and emotion regulation will also be measured to determine the impact of these factors on treatment response in two treatment groups.DiscussionMulti-morbidity, the experience of two or more chronic health problems, is becoming an increasing problem internationally, particularly amongst the elderly. Evidence-based psychological treatments exist for late-life depression and these have been shown to be effective for participants with individual health problems and depression. However, there are no studies that have compared the two leading psychotherapies shown to be effective in the treatment of late-life depression. In addition, many trials of psychotherapy with older adults exclude those with multi-morbidity. Hence, this trial will confirm whether CBT and PST are efficacious in the treatment of depression in the context of complex medical needs and determine which of these two interventions is most efficacious.Trial registrationACTRN12612000854831

Development of a Draft Core Set of Domains for Measuring Shared Decision Making in Osteoarthritis: An OMERACT Working Group on Shared Decision Making

Objective. Despite the importance of shared decision making for delivering patient-centered care in rheumatology, there is no consensus on how to measure its process and outcomes. The aim of this Outcome Measures in Rheumatology (OMERACT) working group is to determine the core set of domains for measuring shared decision making in intervention studies in adults with osteoarthritis (OA), from the perspectives of patients, health professionals, and researchers. Methods. We followed the OMERACT Filter 2.0 method to develop a draft core domain set by (1) forming an OMERACT working group; (2) conducting a review of domains of shared decision making; and (3) obtaining opinions of all those involved using a modified nominal group process held at a session activity at the OMERACT 12 meeting. Results. In all, 26 people from Europe, North America, and Australia, including 5 patient research partners, participated in the session activity. Participants identified the following domains for measuring shared decision making to be included as part of the draft core set: (1) identifying the decision, (2) exchanging information, (3) clarifying views, (4) deliberating, (5) making the decision, (6) putting the decision into practice, and (7) assessing the effect of the decision. Contextual factors were also suggested. Conclusion. We proposed a draft core set of shared decision-making domains for OA intervention research studies. Next steps include a workshop at OMERACT 13 to reach consensus on these proposed domains in the wider OMERACT group, as well as to detail subdomains and assess instruments to develop a core outcome measurement set.

Clinical characteristics of women with reproductive cycle-associated bipolar disorder symptoms.

Objective: Although there is clear evidence that reproductive cycle events are associated with mood episodes for women with bipolar disorder, few studies have examined for relationships between these and specific clinical characteristics of the disorder. This study aimed to explore the relationship between mood symptoms associated with reproductive cycle events and features of the disorder indicative of a more severe lifetime course. Method: Totally, 158 women of at least 18 years of age participated in the study. Subjects were recruited through a specialist clinic at the Black Dog Institute, Sydney, Australia. Results: In total, 77% of women reported increases in mood symptoms during perimenstrual, postnatal or menopausal periods. These women had an earlier age of onset for depressive and hypo/manic episodes and a greater likelihood of comorbid anxiety disorders, rapid cycling and mixed mood compared to those who did not report such reproductive cycle–associated mood changes. Women who experienced postnatal episodes were also more likely to experience worse mood symptoms perimenstrually and menopausally. Conclusion: First, reproductive cycle event–related worsening of mood was associated with a more severe lifetime course of bipolar disorder, and, second, it appears that some women have a greater propensity to mood worsening at each of these reproductive cycle events. If replicated, these findings provide important information for clinicians treating women with reproductive cycle event mood changes and highlight the need for improved therapeutics for such presentations.

Cognitive Impairment in Rheumatoid Arthritis: A Systematic Review

Rheumatoid arthritis (RA) is not commonly associated with central nervous system and brain changes. However, a number of studies have reported high rates of cognitive impairment in adults with RA. The objective of this systematic review was to identify and explore the rates and types of cognitive impairment in RA.

Toward the development of a core set of outcome domains to assess shared decision-making interventions in rheumatology : results from an OMERACT Delphi survey and consensus meeting

Objective. The aim of this Outcome Measures in Rheumatology (OMERACT) Working Group was to determine the core set of outcome domains and subdomains for measuring the effectiveness of shared decision-making (SDM) interventions in rheumatology clinical trials. Methods. Following the OMERACT Filter 2.0, and based on a previous literature review of SDM outcome domains and a nominal group process at OMERACT 2014, (1) an online Delphi survey was conducted to gather feedback on the draft core set and refine its domains and subdomains, and (2) a workshop was held at the OMERACT 2016 meeting to gain consensus on the draft core set. Results. A total of 170 participants completed Round 1 of the Delphi survey, and 116 completed Round 2. Respondents came from 29 countries, with 49% being patients/caregivers. Results showed that 14 out of the 17 subdomains within the 7 domains exceeded the 70% criterion (endorsement ranged from 83% to 100% of respondents). At OMERACT 2016, only 8% of the 96 attendees were patients/caregivers. Despite initial votes of support in breakout groups, there was insufficient comfort about the conceptualization of these 7 domains and 17 subdomains for these to be endorsed at OMERACT 2016 (endorsement ranged from 17% to 68% of participants). Conclusion. Differences between the Delphi survey and consensus meeting may be explained by the manner in which the outcomes were presented, variations in participant characteristics, and the context of voting. Further efforts are needed to address the limited understanding of SDM and its outcomes among OMERACT participants.