UNIVERSITÀ DEGLI STUDI DI PISA
FACOLTÀ DI MEDICINA E CHIRURGIA
Dipartimento di Medicina Clinica e Sperimentale
SCUOLA DI SPECIALIZZAZIONE IN PSICHIATRIA
Direttore: Prof.ssa Liliana Dell’Osso
TESI DI SPECIALIZZAZIONE
“Perinatal Depression: Prevalence, Risk Factors and Screening Tools”
Results from the Perinatal Depression Research & Screening Unit (PND ReScU) StudyRELATORE:
CANDIDATA:
Prof. Mauro Mauri
Dott.ssa Benedetta Ciaponi
INDEX
ABSTRACT 1
INTRODUCTION 3
CLINICAL FEATURES AND PSYCHIATRIC DISORDERS IN THE PERINATAL PERIOD 5
Maternity blues 9
Perinatal depression 9
Post-partum psychosis 11
Confusional States 11
Anxiety disorders 12
Post traumatic stress disorder 12
PERINATAL DEPRESSION: IMPLICATIONS ON MOTHER AND CHILD 13
PERINATAL DEPRESSION RISK FACTORS 19
Severe risk factors 19
Moderate risk factors 22
Small risk factors 23
STUDY BACKGROUND 26
Discrepancies of clinical trials on perinatal depression 26 The results of meta-analysis: from O'Hara to Gaynes 27
The results of PND-ReScU® I (2004-2007) 29
Role of early perinatal screening 31
The problem of treatment of perinatal depression 36 PND-ReScU II
STUDY AIMS 38
MATERIALS AND METHOD 40
STATISTICAL ANALYSES 49
RESULTS 50
DISCUSSION 54
CONCLUSIONS 56
TABLES, GRAPHICS AND FIGURES 58
ABSTRACT
Perinatal depression (PND) is a mental disorder carrying substantial risk not only for
the mother's and child’s health, but also for the whole family. Depression may emerge
during pregnancy and carry over into the postpartum period, or develop soon after
delivery or even many months later. Several studies have been conducted to determine
the etiology of PND and to identify its risk factors. Several risk factors measured
during pregnancy show a strong relation to PND, and include current and past history
of depression and anxiety disorder, family history of mood disorders, negative stressful
life events, marital discord and poor social support. In preventive trials, most of these
risk factors have been listed into check-list and used to screen perinatal depression
high-risk women during pregnancy. These instruments can be useful as initial items of
discussion during the interview between woman and her healthcare provider, despite
their positive features, there is no single set of criteria for assessing the benefit of
routine perinatal depression screening programs, and this lead to different approaches.
Thus, the aim of this thesis was to assess the effectiveness of an early screening in
reducing prevalence rate of postpartum distress.
Women were enrolled in two different groups (N=555), according to time of
recruitment. In the 1st group women enter the study at the beginning of pregnancy, and
are prospectively followed up to 1 year after delivery; in the 2nd group women are
recruited after the delivery, and prospectively followed up to 1 year after childbirth.
The likelihood of being part of group 1 (N=268) or group 2 (287) was similar.
Women were administered a set of instruments including the Edinburgh Postnatal
Depression Scale (EPDS), the State-Trait Anxiety Inventory (STAI) and the Postpartum
Depression Predictors Inventory-Revised (PDPI-R) at different time intervals. The
diagnostic assessment was conducted using the Structured Clinical Interview for
DSM-IV Axis I Disorders (SCID-I).
For the effectiveness of an early screening, we particularly focused on anxiety and
depressive symptoms.
In the recruited population 48 women (18.8%) reported depressive symptoms
throughout the 1-year follow-up after childbirth and 25 (11.8%) women reported state
anxiety symptoms greater than 90° percentile. In particular, we found that carrying out
an early screening during pregnancy significantly reduce the likelihood of having
depressive (12.0% vs 23.6%; OR=2.26; 95%CI: 1.13-4.52) or anxiety (5.0% vs 18.0%;
OR=4.18; 95%CI: 1.50-11.59) symptoms in the postpartum period.
This analysis suggest that antenatal screening of risk factors for postpartum distress
might be highly effective to reduce postpartum distress features and could be
beneficially implemented in clinical practice.
INTRODUCTION
Pregnancy and childbirth have long been considered normal occurrence in a woman's life, and were not considered as medical illnesses. Over centuries, throughout the history of human race, the process of giving birth has not changed. Instead, we acquired greater understanding of it; in consequence, the experience of being pregnant is now richer than ever before. Hereby, pregnancy is more than a biological process. This phenomenon has the capacity to profoundly change a woman, not only from the physical point of view, but also from the psychological, affective and relational. More than that, it deeply affects both the woman and her partner, and implicitly their relationship. In time, mental health problems during pregnancy began to be extensively studied and are shown to have many adverse effects on both woman and her baby. Maternal depression is the primary cause of maternal morbidity (Glazener et al, 1995). According to the most recent estimates, postpartum depression affects between 6.5% and 12.9% of women in different countries (O'Hara MW & Swain AM, 1996; Gaynes BN et al, 2005), but often goes undetected due to lack of proper screening or because many woman hide their feelings from their social environment (Murray e Cooper, 1999; Milgrom J et al, 1999; Beck C & Gable R, 2000). Untreated postpartum depression can have, on the other hand, adverse long-term effects. For the mother, the episode can be the precursor of chronic recurrent depression. For the children, a mother's ongoing depression can contribute to emotional, behavioral, cognitive and interpersonal problems in later life (Jacobsen, 1999). That is why the early recognition is one of the most difficult challenges regarding this mood disorder. In recent years, research conducted in this area have turned their attention to the gestational period, indicating that pregnancy is not a protective factor for depression, much that a percentage of between 8 .5% and 11% develop in this period episode of major or minor depression (O'Hara MW, Gorman LL, 2004; Gaynes BN et al, 2005). To evaluate the usefulness of screening programs of perinatal depression, health agencies apply different criteria and this has led to the creation of different opinions in
relation to the creation of guidelines (Scottish Intercollegiate Guidelines Network SIGN 2002; National Institute for Health and clinical excellence. The royal college of psychiatrists 2007; British columbia reproductive care program guideline reproductive Mental Health 2003).
To summarize, any woman that is at risk of developing such disorders should be educated with the purpose of preventing the onset and should be offered appropriate support, assessment and intervention. The purpose of this paper is to clarify the risk factors and provide an estimate of incidence, prevalence, recurrence and onset of perinatal depression. It is also important to underline the clinical efficacy of the presence of a valid screening tool during pregnancy, with the goal of reducing the morbidity associated with perinatal depression. To test the effectiveness of interventions for screening, we conducted a longitudinal naturalistic study of an unselected population of women followed from the first trimester of pregnancy through the first year postpartum. The sample was evaluated at different times during pregnancy and postpartum, using the 'Edinburgh Postnatal Depression Scale (EPDS), which is the the most widely used and validated instrument of screening for perinatal depression (Cox 1987). In case of a positive screening for perinatal depression, the section of the Mood of the Structured Clinical Interview for Axis I Disorders (SCID-I, First MB et al, 1995) was administered. Women were therefore subjected to psychiatric examination assessing the risk factors highlighted and the psychiatric diagnosis was confirmed. In the presence of a psychological or a mental disorder, in addition to the psychiatrist and the psychologist, were involved other professionals (general practitioner, midwife, gynecologist, neonatologist, pediatrician), who established a plan to prevent and/or personalized therapy, according to the different lines of action. The results of our study suggest that an early screening of depressive symptoms in the perinatal period and an equally timely therapeutic intervention by a team of different professionals are significant in reducing the incidence of the disorder and its effects on the mother and child.
CLINICAL FEATURES AND PSYCHIATRIC DISORDERS IN THE PERINATAL PERIOD
The association between the postpartum period and mood disturbances has been noted since the time of Hippocrates (Miller, 2002). As early as 400 B.C., in fact, Hippocrates described puerperal fever in postpartum women and noted symptoms such as agitation, delirium, and mania. An 11th century author similarly pondered the postpartum period writing of the womb as too moist, the brain filled with water and the moisture running over to the eyes, compels them to involuntarily tears (Leopold & Zoschnick, 1997). While historical references to postpartum depression were largely anecdotal and non-empirical, during the 1960's researchers began to focus on the postpartum period as an area worth investigating. In this period it is rather frequent occurrence of mild psychological disorders. Converging evidence suggested that women were at increased risk for the development of depression during the postpartum period (Pugh, Jerath, Schmidt & Reed, 1963; Ryle 1961). However, due to poorly defined or inadequate criteria used to assess and diagnose depression, there was little consensus on what constituted postpartum depression. While some measured seeking outpatient psychiatric help (Dalton, 1971), others used self-reported distress as their criterion of depression (Kane, Harmon, Keeler & Ewing, 1968). Extrapolating from the literature, it seems that in the field of mood disorders associated with pregnancy, were gradually outlined three different types of clinics, which are arranged on a continuum differentiable in terms of severity of symptoms, course and prevalence. These included maternity blues, characterized by tearfulness, feelings of dysphoria, and emotional liability (Pitt, 1973); postpartum depression, similar to an untreated clinical depression (Meares, Grimwade, & Wood, 1976); and psychotic depression, often accompanied by delusions (Herzog & Detre, 1976). The Research Diagnostic Criteria (Spitzer, GL et al, 1978) reached similar conclusions, identifying three frameworks for different forms of postpartum depression: the maternity blues, minor
depression (mild, neurotic or atypical) and major depression. To these must be added the puerperal psychosis, a rare but important for severity and outcomes. In recent years it has been reached a certain agreement among researchers regarding the clinical problem of continuity or discontinuity between these various forms. Some authors argue that affective disorders constitute the leitmotif of all disease and puerperal psychosis and indicate the maternity blues like paintings located at the extremes of a continuum that sees in an intermediate position of the so-called minor depression severity or atypical (Gitlin MJ, Pasnau RO, 1989). As a result, a surge of studies in the 1980's began to investigate the prevalence and predictors of postpartum depression (Cutrona, 1983; O'Hara, Neunaber, & Zekoski,1984; Watson, Elliott, Rugg, & Brough, 1984). Additionally, O'Hara (1986) more explicitly quantified postpartum mood disorders into three categories in ascending level of severity: blues, depression, and psychosis. Interest in mild and moderate levels of mood disturbance increased as did the timing of the onset of the mood state (Baker, Handley, Waldron, & Dunn, 1980).
Based on the surge of studies in the 1980 and converging evidence that women were at risk for postpartum depression, this linkage entered official psychiatric nomenclature in 1994. At that time the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition added a postpartum onset specifier within the major depression diagnosis. DSM-IV defined major depression with postpartum onset as episodes of depression beginning within four weeks of giving birth (American Psychiatric Association, 1994). This time frame corresponds to the rapid hormonal changes posited to contribute to vulnerability to depression. However, because psychosocial factors also play a major role in triggering postpartum depression, many researchers have used a working definition of the postpartum period as lasting up to six months post delivery (Miller, 2002). During pregnancy, 8 .5-11% of women develop a clinically significant depressive episode (Gotlib IH, 1989; Elkin I et al, 1989; Gorman LL & O'Hara MW, 2004; Gaynes BN et al, 2005), that in one third of cases is the index episode.
Prenatal depression, which can occur during any trimester, increases of three times the risk of postpartum depression (Steer RA et al, 1992).
Postnatal depression affects a variable extent (10-20%) new mothers in the first six months after childbirth (O'Hara MW & Swain AM, 1996; Gaynes BN et al, 2005) represents a negative prognostic factor for both the pregnancy and for the development of the child. Approximately 50 % of episodes postpartum depression have onset of depression before delivery (Wisner et al. 2013), and to a lesser extent, episodes of puerperal psychosis or postpartum mania can also begin during pregnancy (Brockington et al. 1990).
Postpartum depression may experience spontaneous remission in about two months (Kumar R, 1984), but if left untreated in 25% of cases tends to persist up to one year after childbirth (Brockington I, 1996) and can represent a risk factor for the development of recurrence and chronicity of depressive disorder (Nott PN, 1987; Warner R et al, 1996; Kumar R & Robson KM, 1984; Wisner KL et al, 2002). These discrepancies in the nosology of perinatal episodes have led to confusion in both clinical practice and research, leading to recommendations for revision in DSM-V to modify the postpartum onset specifier within the major depression diagnosis to begin within six months following birth. Considering all these observations the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association 2013), included therefore an updated specifier for depression with peripartum onset, which comprises pregnancy (American Psychological Association. Diagnostic and statistical manual of mental disorders. 5th edn. Washington, DC :American Psychiatric Publishing; 2013). The Peripartum onset specifier can be applied to the current or most recent depressive disorder, bipolar I disorder or bipolar II disorder if the episode occurs during pregnancy or in the 4 weeks during delivery. This definition remain anyhow problematic because a while disagreement with the clinical practice. The addition of the "with peripartum onset" specifier for mood episodes, though significant, failed to distinguish between "prepartum" onset and "postpartum" onset, and obfuscates important differences in
mood episodes that might have distinct etiologies, clinical profiles, and responses to treatment. Moreover, once again limiting the specifier to a period of 4 weeks after the birth potentially excludes many mood episodes that are associated with an onset after childbirth. Currently is widely known that women with a history of major depressive disorder (MDD) have increased risks for postpartum depression but less is known about postpartum mania in this population. The relatively small numbers of studies that have investigated hypomaniac symptoms in the postpartum period have reported rates between 9 and 20% (e.g.: Heron et al. 2005; Lane et al. 1997; Sharma et al. 2009). Hopefully, this change will facilitate early detection and diagnosis, as well as appropriate ans safe treatment of bipolar II postpartum depression. The identification of women with postpartum onset hypomania would also provide an opportunity to identify mothers at risk for developing postpartum depression. Lane et al. (1997), for instance, reported that hypomaniac symptmoms at 3-days post partum predicted depression at 6 weeks postpartum. Recent studies have shown that a substantive proportion of women with a history of MDD may experience first onset of mania/hypomania symptoms in the early postpartum, others may experience first onset during pregnancy (Inglis et Al, 2014). A prospective study carried out on 146 women, recruited between 24 and 28 weeks of pregnancy and followed up to one year postpartum has also recently shown that postpartum period appears to be a time of high risk for a new onset of hypomania in women with major depressive disorder, suggesting a bipolar diathesis (Sharma V. Xie et al, 2014). These results reflect a positive change in the DSM-5, which consists of expanding the scope of the specifier to include hypomanic episodes. Better characterization of a mood episodes allow a more appropriate use of treatments, which is important because many patients with mixed features may show a lack of response to lithium or experience a mood instability while taking antidepressants (Sharma 2013).
Maternity blues (or baby blues or postpartum blues)
Defined as the 'sadness' of the post-partum, this symptomatology is quite frequent (50-80%) in mothers who have just given birth. Often women at risk for postpartum blues have a personal or family history of depression, premenstrual dysphoria relate, recent stressful life events or poor social adjustment, were depressed or anxious during pregnancy, are apprehensive and ambivalent externalize respect to pregnancy (Hamilton JA, 1989; Campbell S et al, 1992; O'Hara MW et al, 1991). The clinical picture is characterized by emotional liability and tearfulness, decline in mood, fatigue, anxiety, irritability, and sometimes associated with slight alterations of cognitive difficulties as memory and concentration (Robertson E et al, 2004; Sit DK & Wisner KL, 2009). This framework, which occurs at the 3rd-4th day after delivery, lasts about a week, mostly resolving spontaneously; sometimes, however, the picture may be complicated, resulting in a real depression or, more rarely, in a puerperal psychosis. 20% of women presenting postpartum blues also can have a depressive episode in the year after giving birth (Kennerley H & Gath D, 1989; Najman JM et al, 2000) and a european study showed that maternity blues is associated with an increased risk of major depression (odds ratio = 3.8) and anxiety disorders (odds ratio = 3.9) in the three months following childbirth (Reck C et al, 2009).
Perinatal depression
The current diagnostic systems do not consider the perinatal depression (PND) as a distinct diagnostic entity (World Health Organisation, 2007; American Psychiatric
Association, 2000), and in clinical studies the term 'postpartum depression' has often been used to describe very heterogeneous affective disorders (Wisner KL et al, 2010). Even if the symptoms of postnatal depression is comparable to that of major depression, symptoms such as weight reduction, and sleep disturbances and loss of energy are often attributed to the physiological consequences of childbirth resulting in potentially serious
underestimated consequences. The previous edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, American Psychiatric Association, 2000), shows that, to make a diagnosis of postpartum depression, it is necessary to persist for a time period of two weeks or greater with at least one symptom of depressed mood or loss of interest and pleasure. In addition to this, there must be five or more of the following symptoms: insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, changes in appetite, feelings of inadequacy and guilt, impaired concentration, and suicidal ideation. One special feature with respect to the clinical major depression can be represented by the polarization of ideational issues related to the child with excessive worries about the health of the child, the ability to feed and take care of him, or the feeling of not loving the child (Cox JL et al, 1993, O'Hara MW et al, 1991). Although the DSM-IV-TR as indicating the onset must occur within four weeks following childbirth, clinical experience suggests that this definition is too limiting, and many researchers agree that postpartum depression can be defined as such if it begins within one year of birth (Gaynes BN et al, 2005). In the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V, 2013) the diagnosis of postpartum depression still utilizes the onset specifier format. However, the specifier has changed it is now titled “with peripartum onset” which is defined as the most recent episode occurring during pregnancy as well as in the four weeks following delivery, includes an update for the presence of the specifier for depression onset in the peripartum, which includes the period of pregnancy, however, remains some disagreement with the clinical research. As noted by O’Hara and McCabe (2013) in a recent review on the status of postpartum depression, the DSM-5 Mood Disorders work group did consider extending the four week specifier from 4 weeks to 6 months. In this review they also aptly note that, indeed in clinical practice and research, regardless of the DSM criteria, women with a depressive disorder onset within 12 months of birth are often classified as having “Major Depressive Disorder, with postpartum onset".
Postpartum psychosis
The puerperal psychosis is the most severe postpartum psychiatric disorders: it has a frequency of 0.1-0.2% (Brockington I, 2004) and psychotic symptoms, in about 80% of cases, occur in the first two weeks following the birth. About 70% of postpartum psychotic episodes represent the psychotic episode of bipolar disorder or major depression (McGorry P & Connel S, 1990; Brockington I, 2004; Yonkers KA et al, 2004).
The clinical manifestations of puerperal psychosis often constitute a psychiatric emergency, requiring hospitalization, because of the potential tragic consequences (5% of women commit suicide and 4% infanticide) (Knopps G, 1993). Clinically puerperal psychosis is characterized by a prodromal phase with sleep disturbance and irritability, which are followed by swings in mood of both polarities and psychotic symptoms, with loss of insight, bizarre behavioral changes in the content and form of though, associated with delirium (spatio-temporal disorientation, amnesia, sensory abnormalities and cognitive disorganization). As in the pictures of the organic type, hallucinatory phenomena can also be tactile and visual, as well as auditory illusions (Winser KL et al, 2003; Robertson E et al, 2004).
The postpartum psychosis has important prognostic implications: in about 2/3 of the cases, in fact, occur in subsequent pregnancies similar events (Schoepf J & Rust B, 1994; Benvenuti P et al, 1992) and in about two thirds of cases may occur subsequent psychotic episodes not related to the puerperium (Schoepf J & Rust B, 1994; Benvenuti P et al, 1992; Videbech P & Gouliaev C, 1995). Among the etiologic factors involved in the genesis of postpartum psychosis, particular emphasis seem to take on the metabolic and genetic predisposition to bipolar disorder (Brockington I, 2004).
Confusional states
In the literature have been described puerperal confusional states, probably of a toxic nature, manifesting quickly after complicated pregnancies (preeclampsia, eclampsia) or particularly
painful deliveries; frequently have been described minimal cognitive impairment associated with memory loss and deficits in attentional capacity, were detected in these clinical conditions. (Hamilton JA, 1989).
Anxiety disorders
Pregnancy appears to have a protective role towards some anxiety disorders such as panic disorder, while it may be the time for the onset of others, such as obsessive-compulsive disorder (Brockington I, 2004). Despite the etiopathogenesis of anxiety disorders, hormonal factors appear to have a prominent role (Cohen LS & Nonacs RM, 2005).
The postpartum may be accompanied by the onset or exacerbation of anxiety disorders sphere. The finding of Panic Disorder (Metz A et al, 1988; Altshuler LL et al, 1998) associated with the fear that might harm their baby: this condition is frequently defined as a 'postpartum panic', accounts for the majority of cases a mild condition which is usually managed in the family environment without the need for specialist intervention.
A phenomenon frequently reported, and that occurs with aspects of the obsessive, is the fear of the 'sudden death' of the newborn. Typically, the mother wakes up constantly during the night to check on the baby's health, tone and breathing rate (Sit DK & Wisner KL, 2009). Other typical features are represented by the obsessions of contamination by cleaning rituals towards the new born and the fear of killing the child. Frameworks of generalized anxiety with excessive anxiety for the health and behavior of the child are also described.
Post-Traumatic Stress Disorder
Traumatic factors, obstetric problems, complicated deliveries, abortion and trauma related to the gestational period seem to compete in the onset of the Post-Traumatic Stress Disease (Ballard CG et al, 1995). The disorder is characterized by the classic signs and symptoms of PTSD and, in secondipara, may be associated with tocofobia (Brockington I, 2004).
PERINATAL DEPRESSION: IMPLICATION IN MOTHERS AND CHILD Pregnancy is a time of great change for women.
This period is characterized by an increase in blood levels of gonadal hormones and major changes in the biological and psychological system of the woman. There is still considerable uncertainty in establishing the extent to which known risk factors contribute in the onset of the disorder and what is the role of social and psychological factors in the genesis of psychopathological perinatal outcomes. Regarding the role of gonadal hormones, we can observe that during the whole period of pregnancy, the concentration of progesterone and estrogen increases rapidly and remains constant until a few days before the birth. By expulsion of the placenta a sudden decrease in placental steroids occurs, with concentrations reaching the lowest level within 3-7 days after the birth, remaining at the same level until the re-establishment of ovarian follicular function. The concentration of estrogen and progesterone is more than 200 times lower than at the end of the first week after birth compared to the level of the final stage of pregnancy. At the same time, there is an increase in the rate of blood prolactin, aimed at supporting breastfeeding. Serum concentrations of prolactin gradually increases during pregnancy, reaching, at the end of it, levels about 10 times higher than those detectable during the menstrual cycle. Also in this period the peptidergic systems directly involved in the mechanism of reproduction (GnRH, prolactin, oxytocin), and others involved in more marginal (thyroid hormones, endogenous opioids and CRF-ATCH) undergo major fluctuations. The path that leads to being a mother is influenced by the experiences of the early days of motherhood, the social support available and the temperament of the new born. The inability to adapt to change can be a stress factor for the mother, who lives at times feelings of inadequacy and inability even when there is an adequate family support (Margison F, 1982, Stuart S et al., 1998). The affective disorders are the most common psychiatric disorders in the perinatal period.
Implications on the child
Depressed mothers are more likely to give birth preterm, with possible adverse health outcomes of their child (Locke R et al, 1997). Recent studies have noticed a correlation between the presence of depressive symptoms in pregnancy and the risk of preterm birth, lower birth weight, smaller head circumference and lower Apgar scores (Uno H et al, 1990; Alves SE et al, 1997).
An altered climate intrauterine appear to affect the neurobehavioral function of the newborn. Moreover, in children born to depressed mother, EEG showed less frontal activity, basal and after stimulation (Dawson G et al, 1992). The mechanisms by which depressive symptoms may influence the development of the newborn are not clear. However, the increased blood levels of cortisol and catecholamines, detected in depressed patients, appear to modify placental function by altering the uterine blood flow and causing uterine irritability (Uno H et al, 1994; Glover V, 1997). Dysregulation of the hypothalamic-pituitary-adrenal axis, often associated with depression, can have an effect on fetal development. According to some animal studies, stress during pregnancy would be associated with a number of abnormalities in the offspring: neuronal death, abnormal development of neuronal structures of the fetal brain and dysfunction of the hypothalamic-pituitary-adrenal axis (Uno H et al, 1994; Alves SE et al, 1997; Uno H et al, 1990).
The presence of depression in pregnancy may cause a reduction in the personal care, impaired nutrition with reduction of appetite and, consequently, increase in body weight lower than expected: these factors have been associated with a negative outcome of pregnancy (Teixeira JM et al, 1999).
Especially in the past, many authors have engaged in assessing how the mother-child relationship may be a factor of vulnerability: the difficult mother-child bond, an altered attachment, a particular temperament of the infant were placed in evidence as risk factors. In particular, several studies indicate that there is a significant difference between depressed
mothers and those who are not in relation to affection towards the child and the answer to his cry (Stanley et al, 2004). Moreover, the interaction through facial expressions and vocalizations is reduced in mothers who suffer from depression (Beck CT, 1996; Righetti-Veltema M et al, 1998; Herrera E et al, 2004).
This unsatisfactory early interaction (CT Beck, 1995) has an impact on long-term development of the child. Longitudinal studies, that followed over time the children of depressed mothers, suggest how it can be negatively affected both cognitive development (Sharp D et al, 1995; Murray L et al, 1996), both the child's emotional and behavioral (Sinclair D & Murray L, 1998; Beck CT, 1999; Essex MJ et al, 2001; Hay DF et al, 2003). Suffice it to say that depression in the mother can double the risk of the child suffering from depression himself (Cornish AM et al, 2005).
Abortion
Until now only a limited number of studies have considered abortion as a risk factor for the development of a depressive disorder: some of these have been limited to analyze the short-term impact of this event, but it is conceivable that abortion represents a significant risk factor or a factor of increased vulnerability for depression in later life.
During the first twenty weeks of pregnancy miscarriages have an incidence ranging between 15% and 20% (Frost M & Condon JT, 1996; Lee C & Slade P, 1996). Some studies have reported that 20-30% of women who lose their child in the perinatal period (neonatal death or death after birth) have a clinically relevant depressive symptoms, which can persist for up to three years after the loss event (Boyle FM et al, 1996; La Roche C et al, 1984; Radestad I et al, 1996). Other studies show that the rate of clinically significant depressive episodes as a result of an abortion ranges between 40 and 55% (Frost M & Condon JT, 1996). Depressive symptoms were observed within the first 4 weeks (Friedman T & Gath D, 1989), but also at a distance of 3 months (Prettyman RJ et al, 1993; Robinson GE et al, 1994) and 6 months (Klier
CM et al, 2000; Jannsen HJ et al, 1996) and even a year after abortion. However, it seems that abortion itself is not associated with psychiatric morbidity if it happens in the first trimester, making it a risk factor only for those mothers who live in specific psychosocial contexts (eg membership in conservative churches or particular cultural background) (Adler NE et al, 1992; Gilchrist AC et al, 1995; Major B et al, 2000).
Despite the depression in pregnancy is a risk factor for the development of various obstetric complication (eg: preeclampsia) (Kurki T, 2000), and it is a strong predictor of depression in the postpartum (Graff LA et al, 1991), fewer than half of depressed pregnant women receive adequate treatment one year after giving birth (Cox JL et al, 1984; Ramsay R, 1993). These women have twice the risk of developing a depressive episode again over the next five years (Cooper PJ et al, 1995) and children show a greater vulnerability to peculiar developmental changes. The postpartum depression can indeed alter the relationship between mother and child (Murray L et al, 1996), and it can affect the development of the behavior of the newborn (Mayberry LJ & Affonso DD, 1993): this has been put in relation with problems related to attachment (Hipwell AE et al, 2000; Murray L, 1992), with an altered emotional development (Cogill SR et al, 1986) and difficulties in subsequent social interactions (Cummings EM & Davies PT, 1994; Murray L et al, 1999).
The children of three years are able to recognize the mood of their mothers and to modulate their responses in relation to this (Cohn JF & Tronick EZ, 1983). Cognitive abilities (Whiffen VE & Gotlib IH, 1989), language development (Cox AD et al, 1987) and levels of attention (Breznitz Z et al, 1988) seem to be negatively affected by maternal depression. It was also noted that children of depressed mothers have, in their lives, behavior disorders at a rate two to five times higher than the norm (Beck CT, 1999; Orvaschel H & Walsh-Allis G, 1988).
themselves, making it difficult to follow the obstetric indications, possible impairment of both maternal and fetal nutrition, increased frequency of preterm births and low body weights at birth, problems in the relationship between the mother and the newborn (Murray L et al, 1996). Depression can also be a cause of ill-treatment or reduced care for the little ones (Buist A, 1998), could also induce or exacerbate marital problems to separation or divorce (Boyce P, 1994). The infant or maternal mortality, as rare, they can represent the dramatic outcome of depression in the postnatal period.
Some data in the literature suggest that early screening can identify women at higher risk of developing a subsequent Major Depressive Episode. For example, in one study it was found that, in a high-risk group, in the 3 months following childbirth, only 8% of women who received a targeted treatment developed depression, compared to 16% of a control group (Murray L et al, 1996).
Despite these elements have been extensively documented, and the public health consequences are enormous and well-known, these disorders are often misunderstood and poorly studied. The social cost of depression is huge, accounting for 5.5% of the costs for diseases of the female sex (WHO 2001): it is known, in fact, that depression affects women with a frequency comparable to that of other diseases in the course chronic, with the exception of heart disease. In 2000, among American women of childbearing age depression was the leading cause of hospitalization for non-obstetric factors and more than 205 thousand women had been discharged from hospital with a diagnosis of depression (Jiang HJ et al, 2002).
In recent years, attention has turned to the possible risk factors of biological and psycho-social perinatal depression, and various studies have been conducted to expand knowledge in this regard. A personal or family history of psychiatric past, poor social support and stressful life events seem to be the major risk factors for the
development of a perinatal depressive disorder.
Over the years we have gained a great deal of information on this disorder , but to date only a few have been developed standardized preventive interventions to reduce the risk. Given data in the literature, in attempt to bridge the gap between the clinical awareness of the severity of depression in the postpartum and results, at the Psychiatric Clinic of the University of Pisa from 2004 to 2007 we conducted a multicenter assessment of the risk of postpartum depression in order to verify the usefulness of a battery of instruments to consider the risk factors for the development of postpartum depression and to investigate, with follow-up visits, the prevalence and incidence of PND and to detect the possible presence of additional risk factors for the PND, in an attempt to point strategies and tools for an effective screening of the disease (Borri C et al, 2008; Banti S et al, 2011). Women were followed from the 3rd month of pregnancy up to one year after childbirth. The results revealed a possible utility of screening carried out in early pregnancy to reduce the prevalence of perinatal psychopathology .
PERINATAL DEPRESSION RISK FACTORS
The etiology of depression in pregnancy, the specific role of individual risk factors in the genesis of the disorder and the same autonomy nosographic of this condition are still a matter of debate. Two important meta-analyzes (O'Hara MW & Swain AM, 1996; Beck CT, 2001), conducted on more than eighty studies that have examined a total of about 12.000 individuals of different nationalities, has allowed to identify the risk factors that appear statistically more significant in the development of depression during pregnancy and postpartum. Estimating the relationship between a specific factor and the possibility of developing postpartum depression, by using the coefficient of Cohen (effect size, Cohen LS, 1988), were distinguished three groups of risk factors: risk factors for severe to moderate, moderate risk factors and weak risk factors.
Severe risk factors
Depression or anxiety during pregnancy
Several studies have shown that the presence of depression or anxiety during pregnancy is an important predictor of risk for depression in the postpartum
(Beck CT., 2001; Robertson E et al, 2004; O’Hara MW & Gorman LL, 2004; Lancaster CA et al, 2010; Banti S et al, 2010). (Beck CT., 2001; Robertson E et al, 2004; O'Hara MW & Gorman LL, 2004; Lancaster CA et al, 2010; Banti S et al, 2011).
Previous psychiatric history
The presence of familiar or personal history for psychiatric disorders is considered to be predictors of morbidity both in pregnancy and in the postpartum (Robertson E et al, 2004; Lancaster CA et al, 2010); as the results of these two meta-analyzes
highlight how the factor of Cohen appears in reality lower than conceivable, however it should be pointed out that, in the studies used, the search for psychiatric familiarity was often methodologically problematic. In contrast, studies that have assessed this risk factor in a more analytical and more thorough investigation showed the close relationship between familiarity and risk of getting it (Steiner M. & Tam W., 1999).
Stressful life events
The relationship between stressful life events and depressive disorder is well known (Robertson E et al, 2004; O'Hara MW & Gorman LL, 2004; Lancaster CA et al, 2010). Experiences such as bereavement, separation, divorce, job loss, may represent stress factors in subjects without a history of depressive disorders. The pregnancy and the birth itself can be considered as important factors of stress. It was found that stressful life events show a correlation variable (strong-moderate) from country to country.
Interpersonal variables and depression
According to a model of depression that arises in relation vulnerability and stressful life events, the interaction between the environment and the psychological mechanism is a potential risk for the development of depression. For pregnancies that occur in a problematic social context, in fact, the risk of developing a depression appears higher. According to a study by Brown et al (1978), the adverse psychosocial experiences lived in pregnancy, they would have the same weight in favor the onset of depression than they would if they lived outside of the pregnancy, in determining the onset of depressive episodes in non-pregnant women.
Although the weight of these stressful factors during pregnancy is well known, their impact in the long term is still little known. In fact, we are not able to establish how
these life events have been implicated in the onset of depression later in life: stressful events experienced during pregnancy may have a negative impact on the mental health of the woman also subsequently, in the course of life. A support for this hypothesis comes from the relief that pregnancy in adolescence and in the absence of a partner is associated with an increased risk of major depression and psychiatric morbidity, usually also in adulthood (Harris T et al, 1987; Harris T et al, 1990; Maughan B, & Lindelow M, 1997).
Social support
Adequate support of partner, family members or friends in stressful life situations represent a protective factor against the development of perinatal depression (Brugha TS, 1998; O'Hara MW & Gorman LL, 2004, Lancaster CA et al, 2010). According to Robertson, there are different types of social support: informational support (during which they are given advice and guidance), a type of instrumental support (practical help, material support) and emotional support (concerns and estimate) (Robertson E et al, 2004).
All the reviewed studies have found a strong correlation between postpartum depression and insufficient emotional support and instrumental during pregnancy (O'Hara MW & Swain AM,1996; Beck CT, 1996; Seguin L et al,1999; Beck CT, 2001).
A study by Graff, carried on a low-income urban population, found that women with lower psycho-social support appeared to have a higher risk of developing a psychiatric disorder in the postpartum, with a prevalence for depressive disorders by 23% (Graff LA et al, 1991).
Moderate risk factors Psychological factors
Cognitive style and personality traits such as neuroticism were identified as risk factors for depression. The term neurotic, no longer used by the current classification systems, is commonly used in questionnaires that assess personality to indicate a condition of psychological stress characterized by tension, insecurity, anxiety, and low self-esteem. Several studies have shown that this variable would represent a risk factor of entities to be weak to moderate (O'Hara MW & Swain AM, 1996; Lee DT et al, 2000; Robertson E et al, 2004). In a study by Johnstone et al (2001), women who were described as nervous, fearful, uncomfortable, or anxious were more likely to develop depression in the postpartum period, as well as those with a negative cognitive style (pessimism, anger, ruminations) (O'Hara MW & Swain AM, 1996).
Role transition
Tentoni and High (1980) have suggested that postpartum depression is in part linked to the loss of the expectations of the female role, a role that in the past sixty years has undergone significant changes (Tentoni SC & High KA, 1980). Some studies have considered, as a predictor of depression, role conflict in which the mother is subjected (Yalom ID et al, 1968; Markham J, 1961; Melges FT, 1968; Brown GW et al, 1972).
In a sample of young mothers has been used a questionnaire that assessed maternal attitudes (Maternal Attitudes Questionnaire) (Warner R et al, 1997) regarding the role changes, the expectations created from maternity leave, those related to the new role of mother. The results showed that women with postpartum depression had a cognitive structure less stable than non-depressed mothers.
particular relevance have 'sexual identity and the role of women in relation to the partner and the modification of the' physical appearance leading to 'weight gain (Nilsson A, Almgren PE, 1970; Brown WA & P Shereshefsky, 1972; Jenkin W & M Tiggemann, 1997).
Some research has shown that depressive symptoms are more represented in mothers with lower levels of self-esteem (Hall LA et al, 1996).
Marital relationship
Several studies have reported an increased risk of postpartum depression in women during pregnancy had marital problems (Kumar R, 1984; O'Hara MW & Swain AM, 1996, Beck CT, 2001; Robertson E et al, 2004; O'Hara MW & Gorman LL, 2004). The separation, divorce, a different chronological age between the two spouses, the 'belonging to a different religion can be a source of emotional distress in women more vulnerable (Gordon RE, Gordon KK, 1967). While remaining difficult to establish a causal relationship between a lack of support and the onset of depression, it is known that the postpartum depression is frequently associated with an unsatisfactory relationship with the partner (Tamminen T, 1990) and that, on the contrary, mothers with a satisfactory social support also perceive as adequate support from their partners (Demyttenaere K, 1995).
Small risk Factors Obstetric factors
Where they occur negative experiences such as the threat of miscarriage, abortion, or other gynecological or obstetric complications, pregnancy may expose the woman to particularly high levels of stress (Lee C & Slade P, 1996; O'Hara MW & Swain AM, 1996; O'Hara MW & Gorman LL, 2004).
(cesarean section, instrumental or premature) were considered potential risk factors for depression in the postpartum. However, the literature shows how these factors prove only weak predictors of depression (O'Hara MW & Swain AM, 1996; Warner R et al, 1996; Forman DN et al, 2000; Jhonstone SJ et al, 2001; Robertson E et al, 2004; Lancaster CA et al, 2010).
A recent study on more than 5000 women underlines the role of obstetric factors of previous pregnancies (permature births and post-term births, abortions) as likely component that can predict risks of depressive symptoms during pregnancies (Koleva H et al, 2011).
As the relationship between cesarean delivery and postpartum depression has been considered a weak predictor, when the cesarean delivery takes place under conditions of urgency, the risk seems to become more significant (Boyce PM & Todd R et al, 1992; Hannah P et al, 1992). Other studies related to caesarean section as a risk factor for postpartum depression have yielded conflicting results: a study of Fisher noted, in fact, that women who had a spontaneous delivery programmable showed good levels of self-esteem and conditions during the euthymic period of gestation; those for which it was necessary to plan a caesarean section showed, however, reduced self-esteem and a lower level of humor; the part of the sample that had planned a normal birth, but had then given birth by cesarean, was situated at intermediate scores (Fisher J et al, 1997).
Results misunderstandings arise from unplanned pregnancies or do not (Beck, CT 2001). Some authors have reported a higher risk for postpartum depression during the first pregnancy compared to subsequent (Yalom ID et al, 1968; Davidson JR, 1972); an additional risk factor would be represented by the period of time between two pregnancies: a too long or too short seems to expose women to greater risk (Herz EK, 1992). Multiparity may increase the risk of postpartum depression (Banti S et al,
2011): caring more children may in fact represent an additional source of stress for the mother.
Socioeconomic status
Unemployment, a low income and a low cultural level have always been considered risk factors for the development of mental disorders and especially for depression (Bartley M, 1994). Some evidence suggests that these factors play a small but significant role in the development of depression in the postpartum (Robertson E et al, 2004). The low income, the presence of financial problems, the state of the business partners, the less high socio-economic status would have a significant relationship with depression in the postpartum and these aspects would remain constant even in different countries and cultures (O'Hara MW & Swain AM, 1996; Warner R, 1996; Seguin L et al, 1999; Lee DT et al, 2000; Patel V et al, 2002). Poverty seems to be associated with a rate two times higher than during the postpartum depression (Graff et al, 1991). The adverse socio-economic conditions, in fact, appear to amplify the negative effects of postpartum depression on child development (Cohen LS et al, 1997).
Hamark et al (1995), in a study conducted in Sweden, it was noticed that the most unfavorable social status, the greater was the likelihood of developing depression. Heitler (1976) pointed out the relationship between the development of depression in young mothers, family and economic situation and employment partner's reliability, noting that the new family contributions to a change in economic conditions of the family and how this may be a factor for negative psychological mother. Lancaster et al (2010), in a recent review , however, seem to reduce the weight of the correlation between socioeconomic status and perinatal depressive symptoms .
STUDY BACKGROUND
Discrepancies of clinical trials on perinatal depression
In recent years public health, given the huge social cost related to depression in pregnancy, promoted to that effect targeted clinical and epidemiological research. The research sought to implement, once verified the presence of predictive factors, estimates standardized interventions to reduce the risk of depression during pregnancy and postpartum. An analysis of the literature using the Pubmed search engine using keywords like post-partum/perinatal depression and clinical trials/epidemiologic studies/metanalysis showed that the studies carried out, although numerous, do not give unique results due to the heterogeneity of the variables under consideration. The meta-analysis conducted by O'Hara MW et al (1996) and Gaynes BN et al (2005), which are currently considered the most reliable, indicate a prevalence rate ranging from l.5% and 13%. However, the use of self-administered assessment tools, the methodology used, the duration of the screening period, the adoption of different diagnostic criteria, have meant that the prevalence rates prove extremely variable and sometimes higher than those revealed by meta-analysis . Also the choice of evaluation tools (Beck Depression Inventory, Research Diagnostic Criteria, Edinburgh Postnatal Depression Scale, Postpartum Depression Screening Scale, etc.), different in terms of sensitivity, specificity and reproducibility, has contributed to the variability in prevalence rates.
Rarely, the clinical diagnosis was established through the use of standardized instruments such as the Structured Clinical Interview for DSM-IV (SCID) (First MB et al, 1995), thus justifying the variability of data on the prevalence rate comorbidity.
The results of meta-analysis: from O'Hara to Gaynes
The estimates of the epidemiological data of perinatal depression are quite variable so that, in literature, values are usually between 5% and 15% in Western countries, with rates reaching 26% in teenage mothers (Troutman BR & Cutrona CE, 1990). This large window seems to be justified in part by the type of depression investigated (major and/or minor), by the method of screening and diagnosis, by the time of the evaluation and the duration of the observation period and, finally, by socio-demographic characteristics of the population (O'Hara MW e Swain AM, 1996; Llewellyn AM et al, 1997; Yonkers KA et al, 2001; Gaynes et al, 2005; Mann et al, 2010).
The first reliable epidemiological data on postpartum depression date back to 1996 when O'Hara and Swain published a meta-analysis of 59 studies, covering a total of 12,810 women. Analyzing the data was found a prevalence of 13%, with a confidence interval rather low (12.3% -13.4%). In addition, the difference between the estimates obtained from self-administered questionnaires (12%) and those obtained through structured interviews (14%) was statistically significant. The main factor that influenced the observed prevalence, as well as the method of assessment, was the duration of the evaluation period: studies that considered temporal windows larger, in fact, reported prevalence rates higher than studies that used narrower windows.
In a subsequent cross-cultural study, the prevalence of postpartum depression was estimated at 12.2%, including major depression (4.2%) and minor (8.0%) (Gorman LL & O'Hara MW, 2004).
In 2005, Gaynes BN et al carried out a review on estimates of prevalence and incidence of depression in the perinatal period, as well as analyzing the sensitivity and specificity of different screening tools and considering the role of therapeutic
intervention early in women at high risk of perinatal depression. Gaynes et al have considered 846 articles published in nglish between January 1980 and March 2004, excluding those who did not have similar characteristics and were not responding to certain criteria.
Epidemiological data were obtained from 30 studies but there were also difficulties because some studies reported punctual prevalencies, others period prevalencies. The values resulting from the study prevalence rates were lower for three reasons: first, were excluded studies that assessed depression based on self-report instruments; second, estimates of major and minor depression (MMD) had been separated from estimates of major depression alone; third, were included more recent studies, using more selective criteria to identify major depression. For major depression, the point prevalence ranges between 3.1% and 4.9% at different times during pregnancy and from 1.0% to 5.9% in the first year postpartum. For the mMD, the estimates of point prevalence ranged from 8.5% to 11.0% during pregnancy and from 6.5% to 12.9% in the first year postpartum. The confidence intervals were wide, however, maintaining levels of uncertainty of these estimates.
From the analysis of 13 studies, it was found an incidence of depression equal to 14.5% during the first three months postpartum; if considered only major depression, the incidence was 7.5% during pregnancy and by 6.5% in the first three months postpartum.
The values found of prevalence and incidence of PND not to differ significantly from those of prevalence in women of similar age who were not pregnant or in the postpartum period (Cooper PJ et al, 1988; Cox JL et al, 1993; O'Hara MW et al, 1990). However, one study reported that the probability of having a new episode of major depression in the first five weeks postpartum appeared three times higher compared to a control group of women of similar age, confirming that after a
psychologically and physiologically stressful event, such as labor and delivery, the risk may be greater than that in women less stressed (Cox JL et al, 1993;). More recently, a longitudinal study on general Danish population showed a greater lifetime risk of onset of major depressive disorder during the first five months postpartum compared to a control population (relative risk = 2.79 the first month, second month = 3.53, from the third to the fifth month = 2.08) (Munk-Olsen T et al, 2006).
The results of PND-ReScU® I (2004-2007)
The Perinatal Depression·Research & Screening Unit (PND-ReScU®) (Borri C et al, 2008), between February 2004 and March 2007 has conducted research on the assessment of risk factors for perinatal depression, promoted by the Ministry of Health and created through the collaboration between the Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology (DPNFB) of the University of Pisa and the Department of Obstetrics and Gynaecology "Piero Fioretti of the Azienda Ospedaliero-Universitaria Pisana (AOUP). The study, with a longitudinal naturalistic drawing, had the primary aim to assess the prevalence and incidence of PND and to detect the possible presence of additional risk factors for the PND, in addition to those already known, in an attempt to point strategies and tools for an effective screening of the disease (Borri C et al, 2008; Banti S et al, 2011).
The study protocol therefore provided an initial assessment at baseline (third month of pregnancy, T0), followed by seven follow-up visits: at the sixth (T1) and eighth month of pregnancy (T2), and first (T3), third (T4), sixth (T5), ninth (T6) and twelve months post-partum (T7). In total, 1066 women were included in the study and 500 women who completed all assessments up to the 12th month postpartum.
The results of PND-ReScU® I reported period prevalence rates of mMD during pregnancy higher than in the postpartum period (12.4% vs. 9.6%), consistent with previous studies (Evans J et al, 2001; Gaynes BN et al, 2005).
The 1-year period prevalence was instead significantly lower than that reported by Gaynes (39.6% -67.4%) (Gaynes BN et al, 2005). Ninety-two women (8.6%) met criteria for mMD at study entry, of whom 55 (5.1%) had a diagnosis of recurrent depression, while 37 (3.5%) had their first episode of mMD. The diagnostic instrument used (SCID-I), however, did not allow to ascertain if the mMD episode started immediately before or after the onset of pregnancy, so it was not possible to establish accurately the mMD incidence rates at study entry. However, in line with a meta-analysis of Gavin NI et al (2005), was found a significant decrease in the point prevalence of mMD across three trimesters of pregnancy, at variance with a meta-analysis of Bennet HA et al (2004), in which was suggested that point prevalencis quite stable during pregnancy.
At the first month postpartum point prevalence estimate of mMD in the PND RESCU I study weas significantly lower than reported by O'Hara and Swain (13%) (O'Hara M and Swain A, 1996) and by Gonidakis et al (12.5%) (2008), but still within the confidence interval reported by Gaynes et al (95% CI, 2.2-6.4) (2005). Furthermore, point prevalence estimate of mMD in remaining postpartum period was significantly lower than that reported by Gaynes et al (2005).
Incidence
Of the 974 women without a diagnosis of depression at baseline, 2.2% (95% CI, 1.1-3.2) had a new episode of mMD during pregnancy while in the postpartum period was 3-fold as much (6,8%). Therefore, the high prevalence of depression during pregnancy in PND-ReScU® I study depends on the fact that 92 women (8.6%) were
already depressed at baseline and not on the incidence of new episodes. Overall, the incidence of postpartum depression in this study was 6.8% (95% CI, 4.6-9.2), in line with Kitamura T et al (2006). Gaynes BN et al (2005) reported postnatal incidence estimates from delivery to third month postpartum of 14.5% (95% CI, 10.9-19.2), whereas Chaudron LH et al (2001) reported that 5.8% of women became clinically depressed between delivery and the fourth month postpartum. Could not be excluded that the incidence of depression reflect the incidence of this disorder in a female population during the childbearing age. However, although no study has examined the incidence of mMD in a female population during the childbearing age with a similar frame and using a structured clinical interview based on DSM-IV criteria, differences in incidence rates across these intervals cannot be estimated stably because of the sample size.
Considering that the estimates of prevalence and incidence study PND-RESCU ® I turn out to be lower than in literature, we therefore assume that assess pregnant women may be useful in reducing the effects of psychopathology on mothers and infants, providing psycho-educational counseling to the mothers themselves and, where necessary, psychological and/or pharmacological treatment.
Role of early perinatal screening The negative effects of untreated depression and anxiety disorders in pregnancy have long been known (O'Connor TG et al, 2002) and the midwives and psychiatric consequences in the short and long term affect not only women, but also children and more general family. For this reason, NICE clinical guidelines (2007) emphasize the importance of early detection of perinatal psychopathology and the American College of Obstetricians and Gynecologists (ACOG, 2006) recommends screening for depression in every trimester of
pregnancy. Despite this, to date have not been systematically evaluated neither the role of screening of all pregnant women, neither the usefulness of organizing preventive intervention around women showing scores at high risk of perinatal psychopathology (Gaynes B et al, 2003). Effective postpartum care in the community can prevent short, medium and long-term consequences of unrecognised and poorly managed problems. Recently Haran et al, 2014, compared the scope and content and assess the quality of clinical guidelines about routine postpartum in primary care. They considered a total of 626 references, identified by the search, but only six guidelines met the inclusion criteria and were reviewed. These were: 2 from Australia, 3 from the UK and 1 from USA (Haran et Al, 2014). Only one guideline provided supporting recommendations for the care of postpartum women and their infants (NICE 2006).The other guidelines only focused on the infant, specific postpartum issues in the mother, or preventive activities. The scarcity of comprehensive guidelines is a concern and further research is needed to strengthen the evidence supporting recommendations made within guidelines. The prenatal period may instead be a favorable time, as well as appropriate for screening and intervention, because women come in contact with more professionals in the health field. However, it is estimated that only 5% of pregnant women with a mental disorder receive any treatment, including psychological support (Robertson E et al, 2005). These data were confirmed by Flynn HA et al (2006) who reported that, among all pregnant women at risk of PND, only a minority of women with prenatal diagnosis of MDD was treated and an episode in place was not predictive of the use of a treatment, suggesting the need to improve the screening and recognition of depression. In this context play a fundamental role various professionals, especially midwives, which should be formed so as to be able to recognize the possible risk factors and symptoms suggestive of depression (Alder et al, 2010).
One of the benefits of screening for perinatal depressive symptoms is the consequent early therapeutic intervention, which could lead to better results in terms of prognostic. Even though for now the evidence is limited, it is a main problem in the perspective of the investments of public health.
In an attempt to clarify some of these issues, Gaynes et al (2005) identified 15 studies to evaluate the results of the impact of screening and early intervention, but none of these studies was actually designed for this purpose. Gaynes et al had taken into account the studies that assessed the presence of depression or risk factors for perinatal depression; in relation to women with positive screening, the researchers had compared the outcomes of women who received treatment to a control group. This study allowed to assess whether early intervention on women identified at risk of depression could improve outcomes, compared to the control group.
Several studies have investigated the utility to perform psychosocial interventions during pregnancy in order to prevent postpartum depression, producing mixed results, however: there are eight randomized controlled trials (Buist A et al, 1999; Brugha T et al, 2000; Elliott S et al, 2000; Zlotnick C et al, 2001 e 2006; Zayas L et al, 2004; Zlotnick C et al, 2006; Muñoz R et al, 2007), only three of which demonstrate the effectiveness of psychosocial interventions in significantly reducing depressive symptoms compared to a control group (Elliott et al, 2000; Zlotnick et al, 2001, 2006).
Two other small studies performed in the prenatal period found no protective effect of psychosocial interventions (Brugha TS et al, 2000; Stamp GE et al, 1995) compared to a control group.
Psychosocial interventions include psychoeducation about perinatal depression and how to manage it, strategies to develop or strengthen social support, identification of the role transitions, provide information on the development and on the 'care of the child, develop
more realistic expectations about pregnancy, on the birth and becoming a new mother. In particular, research is increasingly moving in the direction of the development of a psychoeducational intervention quote (Rowe HJ & Fisher JR, 2010).
A recent randomized trial conducted on 377 women in Mexico (Lara MA et al, 2010) provides encouraging data on the possibility that the incidence of depression can be reduced by a educational intervention in pregnancy. These data seem also confirmed by a psycho-educational group program conducted in Australia on 399 women (Fisher JR et al, 2010). As for the screening carried out in the postpartum period were considered by Gaynes et al (2005) 11 studies, but only on ethnic populations with certain characteristics; Furthermore screening tools and interventions varied considerably so it was difficult to compare (Armstrong K et al, 1999; Chabrol H et al, 2002; Chen CH et al, 2000; 49(6):395-9. Dennis CL, 2003; Fleming AS et al, 1992; Hiscock H et al, 2002; Honey KL et al, 2002; Horowitz JA et al, 2001; Wisner KL e Wheeler SB; Onozawa K et al, 2001; Wisner KL et al, 2001). The results were heterogeneous: of the nine trials that employed psychosocial interventions, six (K Armstrong et al, 1999; Dennis CL, 2003; Hiscock H et al, 2002; Honey KL et al, 2002) reported a significant benefit of the patients treated compared to untreated. These results, though limited, suggests that provide any form of psychosocial support to pregnant women, especially those at risk of having a depressive disorder, may reduce depressive symptoms. Also in relation to the postpartum period, in 2010 a randomized controlled trial has provided evidence to support the effectiveness of a screening program for the DPP (Leung SS et al, 2010). This study involved 462 Chinese mothers, recruited at two months postpartum, and has shown the effectiveness of EPDS as a screening tool and the importance of a follow-up intervention to improve the mental health of women at six months postpartum. In the United States, Yawn et al, have recently conducted the first large randomized trial on the efficacy of screening and follow-up for postpartum depression: The Translating Research into Practice for Postpartum Depression (TRIPPD) Study is the first large US based effectiveness study of
