Can We Prevent

Postpartum Depression?

Cindy-Lee Dennis, PhD Professor in Nursing and Psychiatry, University of Toronto

Canada Research Chair in Perinatal Community Health

Shirley Brown Chair in Women’s Mental Health, Women’s College Hospital

Clinical Importance of Depression

• Depression is one the most common health problems women experience

• It is estimated that 20-25% of women will experience depression during their lifetime

• Further, for 30-50% of women who do experience depression, it is estimated to become a chronic recurring condition

Perinatal Depression

• Perinatal depression is an episode of

depression with an onset either during

pregnancy or the first 12 months

postpartum

• Antenatal depression is an episode of

depression with an onset during

pregnancy

• Postpartum depression is an episode of

depression the first 12 months postpartum

Prevalence

Antenatal Depression

• Prevalence across pregnancy: 12.7% (18.4% with minor depression) (Gavin et al, 2005)

Postpartum Depression (PPD)

• Prevalence in the first 12 weeks postpartum: 13% (O’Hara & Swain,

1996)

→ For women with a history of depression, 35% PPD rate

→ For women with depression during pregnancy, 50% PPD rate

Most frequent

form of maternal morbidity

following childbirth

Persistence of PPD

• For the majority of mothers, PPD starts within the first 12

weeks postpartum

• National Canadian data suggest 8% of mothers will

continue to experience PPD past the first 5 months

postpartum and into the following year (Dennis, et al 2012)

→ this rate is more than 4 times the 1.4% point prevalence for

depression among women found in the Canadian Community Health

Survey

Inability to enjoy things that she used

to

Anxiety

Irritability

Worry Inability to sleep, even

when the baby is sleeping

Inability to concentrate or make decisions

Exhaustion

Feeling heavy

Fear of harming self

or baby

Uncontrollable crying

Common Symptoms

Next Steps?

Maternal PPD Risk Factors

• Depression during pregnancy

• Prenatal anxiety

• Previous history of depression

• Childcare stress

• Life stress

• Lack of social support

• Marital dissatisfaction/conflict

• Low self-esteem

• Low socio-economic status

• Single marital status

• Unwanted/unplanned pregnancy

Unfortunately, PPD occurs at a time when the infant is:

− Maximally dependent on parental care

− Highly sensitive to the quality of the interaction

• Given the persistence of PPD and its association with

recurrent depressive episodes (Copper et al 2003; Nylen et al 2010),

concern for child development is warranted as maternal

depression can:

1. Be incompatible with good parenting cognitions and behaviours

2. Cause significant distress for children due to a stressful home

environment (Goodman &Gotlib 1999)

Health Promotion Consequences

• Research suggests maternal health promotion behaviours

are diminished as mothers with PPD are less likely than

non-depressed mothers to:

− Breastfeed

− Attend well-child visits

− Complete immunizations

− Use home safety devices

− Put infants to sleep on their back

− Engage in enriching activities (e.g., reading, singing, outdoor

activities)

(Zajicek-Farber 2009; Cadzow et all 1999)

Child Developmental Consequences

• Mothers with PPD also have children with poorer

developmental trajectories

• Risk transmission through altered maternal-child

interaction (Rishel, 2012)

What are the effects of maternal-child interaction

difficulties on child development?

• Cognitive development

− General consensus that PPD predicts poorer language and IQ

development in children and that this effect is found across

childhood into adolescence

• Behavioural development

− Meta-analysis of 193 studies→ small but significant association

between maternal depression and child behavioural outcomes

• Emotional development

− Meta-analyses → consistent associations between PPD and

insecure attachment and difficulty in establishing effective self-

regulation skills (Martins and Gaffan, 2000; Atkinson et al., 2000; Campbell et al., 2004)

Intergenerational Effect

• Point prevalence rates for psychiatric disorders among

children of depressed mothers are 2 to 5 times above

community populations (Beardslee et al, 1998)

→ signifying a strong intergenerational effect

Costs of Perinatal Mental Health Problems

• 2014 Report released by London School of Economics

and Centre for Mental Health, UK

• This report– for the first time in the published literature –

provides comprehensive estimates of the costs of

perinatal mental health problems, including the adverse

effects on the child as well as the mother

• Taken together, perinatal depression, anxiety and

psychosis carry a total long-term cost to society of about

£8.1 billion for each one-year cohort of births in the UK

• Nearly three-quarters (72%) of this cost relates to adverse

impacts on the child rather than the mother

Postpartum

Depression:

A Family Affair

Paternal PPD Prevalence

• A recent meta-analysis suggests that approximately 10.4% of fathers will experience depression in the first year postpartum

• Growing evidence that PPD in fathers begins later, often following the onset in mothers and with the rate increasing over the first year postpartum

• Risk factor → maternal PPD

(Paulson et al. 2010)

PPD = Major Childhood Adversity

International experts have clearly identified maternal

depression as a major childhood adversity and that effective

interventions to address this condition are one of the most

important public health preventive strategies we can

implement to reduce the long-term negative outcomes

among children

Not only focus on individual treatment

but also include preventive approaches

to the management of PPD

Preventive Approach

• Moving beyond a model where we wait for a mother to

develop major depressive symptoms and then provide

evidence-based treatment

A NEW Philosophy

• FOCUS on the long-term healthy development of mothers and their

children

• PROACTIVELY provide resources to support this healthy

development

Cochrane Systematic Review

Psychosocial and Psychological Interventions for the Prevention of

Postpartum Depression:

An Update

Dennis, C-L., Dowswell, T. (2013). Psychosocial and psychological interventions for preventing postpartum depression. The Cochrane Database of Systematic Reviews, Issue 2.

Primary Objective

• To assess the effects of psychosocial and psychological

interventions compared with usual antepartum,

intrapartum, or postpartum care to reduce the risk of PPD

Secondary Objectives

1. the effectiveness of specific types of psychosocial interventions

2. the effectiveness of specific types of psychological interventions

3. the effects of intervention provider (professionally-based versus lay-based)

4. the effects of intervention mode (e.g. individual versus group-based interventions)

5. the effects of intervention duration (e.g. single-contact

interventions versus multiple-contact interventions)

6. the effects of intervention onset (e.g. antenatal-only,

versus antenatal and postnatal interventions, versus

postnatal-only interventions)

7. the effects of sample selection criteria (e.g. interventions

targeting women with specific risk factors versus the

general population).

Types of Studies

• All published and unpublished studies were eligible if

they fulfilled the following criteria:

− Were a randomised controlled trial

− Evaluated a psychosocial or psychological intervention in which

the primary or secondary aim was a reduction in risk to develop

PPD

• Quasi-randomised trials were excluded from the analysis

Types of Participants

• Pregnant women and new mothers less than 6 weeks

postpartum, including those at no known risk and those

identified as at-risk to develop PPD

• Trials where > 20% of participants were depressed at trial

entry were excluded

Types of Interventions

• A psychosocial or psychological intervention incorporated a variety of non-pharmaceutical strategies including:

−Psycho-educational sessions

−Cognitive behavioural therapy

−Interpersonal psychotherapy

−Non-directive counselling

−Psychological debriefing

−Various supportive interactions

• Excluded interventions that solely evaluated an educational intervention

Electronic Search

• Searched the Cochrane Pregnancy and Childbirth Group Trials

Register by contacting the Trials Search Co-ordinator

• Register contains trials identified from:

−quarterly searches of the Cochrane Central Register of Controlled Trials

(CENTRAL);

−weekly searches of MEDLINE;

−handsearches of 30 journals and the proceedings of major conferences;

−weekly current awareness alerts for a further 44 journals plus monthly BioMed

Central email alerts.

• Trials published in all languages were considered

Risk of Bias Assessment

• Based on recommendations by the Cochrane Collaboration the

following were examined:

− Generation of Allocation Sequence (selection bias)

− classified as low risk if based on computer generated numbers, tables of random

numbers, or similar

− Allocation Concealment (selection bias)

− classified as low risk if based on central randomisation, sealed envelopes, or similar

− Blinding (performance bias)

− classified as low risk if a blinded outcome assessment was conducted

− Completeness of Follow up Data (attrition bias)

• Did not exclude studies based on rate of incomplete data – sensitivity analysis was

completed if a < 80% follow-up rate was achieved

Review Characteristics

• 28 trials

• Almost 17,000 women

• Published between 1995 and 2010

• Conducted primarily in Australia and the UK

• Five trials were conducted in the USA

• One trial was conducted in the follow countries: Canada,

China, Germany, and India

Summary

• Overall psychosocial and psychological interventions

may decreased the risk of developing PPD by

approximately 22%

• There is beginning evidence to suggest the importance of:

1. Additional professional support initiated postnatally

2. Telephone-based peer support initiated postnatally

3. Interpersonal psychotherapy (IPT)

• Interventions are more likely to be beneficial if they are:

− Initiated postnatally

− Individually-based

− Include multiple contacts

− Target ‘at risk’ women

• Postnatal interventions that were successful

→administered Edinburgh Postnatal Depression Scale

(EPDS) early in the postpartum period to identify

depressive symptomatology

• Secondary preventive interventions

Postpartum Depression

Peer Support Trial (Dennis et al . BMJ 2009)

Funded by Canadian Institutes of Health Research (CIHR)

Purpose

• To evaluate the effect of peer (mother-to-mother) support

on the prevention of PPD among mothers identified as

high-risk

Design Overview

• A randomized controlled trial with stratification based on previous history of depression including PPD was conducted

• Seven Ontario health regions participated in the trial:

− Halton

− Ottawa

− Peel

− Sudbury

− Toronto

− Windsor

− York

Trial Schema

Outcomes at 24 weeks

Outcomes at 12 weeks

Usual Postpartum Care

Outcomes at 24 weeks

Outcomes at 12 weeks

Evaluation of Peer Support

Usual Postpartum Care

Plus Peer Support

Randomization

Eligibility Assessment

Consent

Verbal consent for further contact

Contact details to DCC

EPDS > 9

No further contact

EPDS < 10

PHN Screening

Randomization

• 701 mothers randomized using web-based randomization

(www.randomize.net)

− 349 mothers – intervention group (usual care plus telephone-

based peer support)

− 352 mothers – control group (usual care)

• No significant differences between groups on baseline

variables

Peer Volunteers

• Peer volunteer selection criteria was:

− Ability to speak and understand English

− Self-reported history of and recovery from PPD

− Not currently suffering from depression

• Over 205 peer volunteers were recruited and attended a 4-hour training session

• Provided with a training manual and a list of local community resources for new mothers

Intervention Dosage

• Mothers received a mean of 8.8 (SD=6.0) contacts with

their peer volunteer

• 49.5% were telephone conversations initiated by the peer

volunteer

• The mean duration of these discussions was 14.1 minutes

(SD=18.5)

• 33.4% of contacts were messages were left on mothers’

answering machines

• Only 6.5% contacts were initiated by the mothers

• 2.3% were email interactions

Postpartum Depression: EPDS > 12 at 12 weeks

Peer

n (%)

Control

n (%) χ2 p OR 95% CI

40 (14%) 78 (25%) 12.5 0.0004 2.11 1.38-3.20

Number needed to treat = 8

Relative risk reduction = 0.46 (0.24-0.62)

Summary

• Telephone-based peer support may be effective in

preventing PPD among high-risk mothers

• Mothers who received peer support were at half the risk

to develop PPD

Underlying Mechanisms of Peer Support

• Peer support can:

− Increase social networks

− Reinforce help-seeking behaviours

− Decrease barriers to care

− Encourage effective coping

− Promote social comparisons

− Increase self-efficacy

− Aid self-esteem

NICE Guideline for Depression

Management

of Perinatal

Depression

Case Identification

• The first step in the management of PPD is case

identification

• Research consistently demonstrates that informal

surveillance is imprecise with less than 50% of mothers

with perinatal depression identified despite various

interactions with health professionals (Yawn et al 2012; Goodman &

Tyer-Viola, 2010)

Antenatal Screening

• You can screen antenatally but most effective if it is to

identify women with current depressive symptoms

needing intervention → decreased predictive validity

when trying to identify asymptomatic women at risk

of developing PPD

• Flag women at high risk to develop PPD − History of depression

− Elevated anxiety

− History of abuse

− Migrant status

− Poor marital relationship

Postnatal Screening

Edinburgh Postnatal Depression Scale

(EPDS)

• 10-item self-report instrument

• Scores range from 0 to 30

• Cut-off 12/13 (> 12) – probable PPD

• Cut-off 9/10 (> 9) – possible PPD

• Widely available and free

EPDS

• Validated for antenatal use

• Translated and psychometrically tested in many non-

English populations – over 30 different languages

• Surveys of large samples of perinatal women have found

acceptability to be high (80-90%)

• Critical factor

• Provides a common language

• Enables comparability of clinical and research results

Does perinatal depression screening

increase the number of mothers

who recover?

Research is Clear

Screening alone is insufficient

to ensure the provision of appropriate treatment

and thus ultimately improving clinical outcomes

• The U.S. Preventive Services Task Force recommends screening adults for depression in clinical practices that have systems in place to assure:

1. Accurate diagnosis

2. Effective treatment

3. Follow-up

Effective Treatment Tools

Pharmacological

Psychological

−Interpersonal psychotherapy

(IPT)

−Cognitive behavioural therapy

(CBT)

−Mindfulness-based strategies

Psychosocial

−Peer support /support groups

−Non-directive counselling

Alternative

−Relaxation/Massage

−Exercise

−Yoga

−Bright light therapy

• Pharmacological interventions are a very effective

treatment

• Many mothers are reluctant to take antidepressant

medication due to concerns about breast milk transmission

or potential side-effects

Maternal Treatment Preferences

• The majority of mothers prefer “talking therapies” → especially if they are breastfeeding

• Interpersonal psychotherapy (IPT) is a common and effective ‘talking therapy’ for depression

• IPT is a brief, highly structured, manual-based psychotherapy that addresses interpersonal issues in depression such as: conflict, role disputes, social isolation, prolonged grief

• Intervention teaches:

− More effective communication with family and friends

− Skills for obtaining social support

− Effective coping techniques to use during times of need and during life

changes

• Unfortunately, IPT is not widely available, especially in rural

and remote areas

• There are often long wait-times to receive IPT from a trained

psychiatrist or psychologist

• Therapy is typically provided face-to-face in a clinic/hospital

setting

• PPD treatment has unique barriers (e.g. childcare issues) and high

attrition rates in group or clinic-based PPD treatment programs

Telepsychiatry

• To improve access to care, telepsychiatry has been introduced and includes the provision of psychiatric/mental health services via telephone

• Telepsychiatry can play an important adjunct role within an integrated health care system

• It is predicted to become an increasingly acceptable alternative to traditional face-to-face services

• The provision of IPT by trained nurses can also increase the clinical utility and feasibility of this treatment option

Interpersonal Psychotherapy Trial

Telephone-Based Interpersonal Psychotherapy for the

Treatment of Postpartum Depression

Funding: Canadian Institutes of Health Research

Design Overview

• Randomized controlled trial to evaluate the effect of telephone-based IPT by trained nurses among clinically depressed mothers (SCID positive)

• 36 health regions across Canada from 6 provinces:

− Nova Scotia

− Ontario

− Manitoba

− Saskatchewan

− Alberta

− British Columbia

Randomization

• 241 mothers randomized using web-based randomization

(www.randomize.net)

• 120 mothers → IPT group

• 121 mothers → Control group (standard care)

• No significant differences between groups on baseline

variables

Intervention

• Mothers received 12 weekly 1-hour IPT sessions at a

regularly scheduled time based on maternal convenience

• IPT nurse and mother never met

• Nurses completed an activity log per participant to

document all IPT session details

• All telephone sessions were digitally recorded and

emailed to the trial coordinator

−Guide supervision

−Ensure intervention fidelity

IPT Nurses

• 7 Toronto-based nurses hired and trained by two

psychiatrists (Ravitz & Grigoriadis) to provide IPT

– 3 nurses with psychiatric experience

– 2 public health nurses

– 1 pediatric nurse

– 1 ER nurse

Clinical Depression:

SCID Positive

Weeks

Follow-up

IPT

Group

n (%)

Control

Group

n (%)

χ2 p OR 95% CI

12 weeks

(N = 204)

11

(10.6)

35

(35) 17.41 <.001 4.55 2.16-9.62

24 weeks

(N = 202)

11

(10.9)

34

(33.7) 15.13 <.001 4.15 1.96-8.79

Maternal Evaluation

• Mothers felt the IPT nurses were competent and well-trained

• Telephone-based IPT was convenient and met their needs

• There was only one negative comment – would like more sessions

• Overall, mothers were highly satisfied and would recommend it to

a friend

Conclusion

• Mothers who received IPT were significantly more likely to have a

reduction in depressive symptoms

• Nurses can effectively deliver telephone-based IPT among

clinically depressed mothers

• The remission remained across time to 6 months post-treatment

• Significant ↓ in anxiety and ↑ in relationship quality with partner

• Technology plays a

major role in the

development and

evolution of our lives

• It has percolated into

all aspects including

education, banking,

and business

management

E-Health

• The implementation of technology in

the health sector, popularly known

as eHealth, is emerging as one of the

most rapidly growing areas in

healthcare today

• It encompasses a whole range of

purposes from purely administrative

through to health care delivery

E-Mental Health

• E-Mental health has tremendous potential to address the gap

between the identified need for mental health services and the

limited capacity to provide conventional care

• Applications can address four areas of mental health service

delivery:

1. Information provision

2. Screening, assessment, and monitoring

3. Intervention

4. Social support

• Primarily based on its ability to improve “reach”

Technologies Transforming Mental Health

Foster Collaboration

Increase Access to Services

Engage Individuals

Internet-based

Treatment

Online Peer Support Groups Telepsychiatry

Mobile Therapy

Outstanding Clinical Problem

While effective treatment tools exists for PPD……

Adequate treatment = treatment to remission

Maternal treatment preference

History of psychiatric treatment

Severity

Cultural

Factors

Barrier to treatment

accessibility

New treatment approaches are

required to address the GAP

between the existence and uptake of

effective PPD treatment tools

Collaborative Care

• “Collaborative care” is an approach

to treatment that is highly effective

for the management of general

depression

• In a collaborative care model, case

identification occurs at the

primary care level

• A depression care manager directs

individuals to appropriate treatment

and monitors progress – all in

collaboration with a mental health

specialist

Treatment Follow-Up

• Part of the success of this approach is that it actively

promotes treatment initiation and adherence while

addressing patient preferences and perceived barriers

• Also ensures appropriate follow-up and treatment to

remission

Evaluating Collaborative Care for Postpartum

Depression in Primary Care Settings

Funded by CIHR

Design Overview

• Randomized controlled trial

• Telephone-based collaborative care intervention for PPD

• Diverse maternal and infant outcomes

• Mothers between 0 to 6 months postpartum with

depressive symptomatology (EPDS >9)

• Identified during well-child visits in eight primary care

practices across Toronto

1. A multi-professional approach to care

2. Structured management plan

3. Scheduled patient follow-ups

4. Enhanced inter-professional communication

Summary

• Importance of clinical depression for women

• Prevalence and risk factors

• Impact on child development - cost

• Postpartum depression is a family affair

• Need to be proactive – prevent first then treatment if necessary

• Psychosocial and psychological interventions for prevention

• Peer support a simple yet effective secondary intervention

• Identification (screening) and treatment (talking therapy)

• Nurse-provided telephone-based IPT and the use of technology

• New approach to management – collaborative care

• Ensure treatment to remission to improve child development

Cindy-Lee Dennis, PhD Professor and Canada Research Chair

University of Toronto

cindylee.dennis@utoronto.ca

www.cindyleedennis.ca