CHAPTER 6 PREVENTION OF POSTNATAL DEPRESSION

CHAPTER 6 PREVENTION OF POSTNATAL DEPRESSION 6.1 The purpose of prevention approaches The purpose of preventive interventions is to decrease the distress and disruption of postnatal depression, reduce the associated personal, social and economic costs, and utilise the opportunity for mental health promotion. The first postnatal year is recognised as a critical period because of the possible long-term consequences of postnatal depression for the women, their partners, the infant and other children (Cox, 1989; Murray, 1992; Holden, 1996). Preventive approaches potentially offer significant gains in both the present and future. However, very limited research of interventions designed to prevent the onset or decrease the severity of postnatal depression has been published. Nevertheless, postnatal depression is suited to prevention strategies (Wisner & Wheeler, 1994), because: the onset is preceded by a clear marker (birth); there is a defined period of highest risk for onset (the first three months after delivery); a high-risk sample can be identified by screening for previous affective history and current social factors; and pregnant women and recent mothers have frequent antenatal and postnatal contact, which would enable health professionals to detect risk factors and implement prevention programs. Several researchers have encountered problems recruiting women and their partners to participate in postnatal depression research (Appleby & Whitton, 1993), and the attrition rate from prevention studies is particularly high (Elliott et al., 1988; Stamp et al., 1995; Whitton et al., 1996a). These problems may be related to the women s beliefs that the aetiology of postnatal depression is associated with parenting rather than mental illness and they may interpret depressive symptoms as fatigue or frustration. Hesitation in seeking professional assistance, unless there is a personal or family history of affective disorder, is also evident in the reluctance to join prevention studies (McIntosh, 1993; Whitton et al., 1996b). 6.2 Issues and definitions in prevention It has been suggested that prevention in the mental health field has been delayed unnecessarily because current research regarding the aetiology of depression is not definitive (NHMRC, 1993). Preventive interventions are determined by theoretical models (Elliott, 1989a; Ussher, 1992; Walsh & McPhee, 1992; Sharp, 1996), and biopsychosocial models are based on multiple and interactive components that may be amenable to preventive investigation. Models must take account of complex theories of postnatal depression that include both biological factors, such as genetic endowment or predisposition to depression (possibly indicated by a family history of mood disorder) and psychosocial factors such as recent major life events, current stressors, lack of support, physical exhaustion, personality characteristics, and negative cognitive style (Elliott, 1989a; Morse, 1993). Prevention of postnatal depression 129

Specific knowledge about potentially modifiable risk factors and protective factors that affect the development of postnatal depression is essential to decide the nature and targets of prevention strategies. However, some factors cannot be directly modified by the individual (e.g. age, ethnicity, gender, and family history; Mrazek & Haggerty, 1994). While there is some consensus about the risk factors most likely to influence the development of postnatal depression, translating known risk factors into predictive screening protocols and devising appropriate prevention programs is not as clear (Appleby & Whitton, 1993; Cooper et al., 1996). Complex interactions of biopsychosocial risk factors with individual variations must be considered when planning intervention programs and this means that one single approach will not suit all women. Other requirements in developing preventive approaches include (Lorion, 1991): establishing the base rate occurrence of a disorder from clinical trials or epidemiological data, and acknowledging that everyone with risk factors will not necessarily develop the disorder; determining the predictive accuracy of risk factor screening procedures used in selecting intervention participants or research subjects so that vulnerable populations are specifically identified; awareness that screening for vulnerability might exclude people who do not have certain risk factors and might still develop problems or benefit from the intervention; devising preventive intervention programs that are brief enough to be acceptable, long enough to achieve lasting benefits, intensive enough to have an effect, and are user friendly and not too expensive; ensuring large long-term prospective samples are organised to trial preventive interventions and assess outcomes with regular monitoring and follow-up, having a wide range of intended outcomes including decreasing the influence of risk factors, reducing specific situational stresses, and promoting mental health, not just preventing the onset of postnatal depression; and recognising that non-compliance with intervention strategies and attrition of participants are major problems, however those who decline enrolment or withdraw from involvement may be those at the greatest risk. 130 Postnatal depresssion A systematic review of published scientific literature to 1999

Table 6.1 Biopsychosocial factors in depression Predisposing Precipitating Maintaining Biological family history of depression hormonal changes following neurotransmitter imbalance personal history of depression delivery hormonal changes low IQ caesarean section (breastfeeding, (these factors also have psychological breastfeeding menstruation) relevance) extreme fatigue Psychological poor relationship with own parents limited coping strategies poor sense of self low self-esteem feelings of failure and dependent personality negative cognitive style disappointment cognitive vulnerability anxious, worrier perfectionist personality traits Social feeling trapped or out of control negative perception of labour and delivery depressed parents during childhood stressful life events chronic stressors loss or prolonged separation from unemployment or excessive housing parents or spouse work demands finances chronic work or marital difficulties financial constraints employment poor social support or living social and geographical relationships in poverty isolation no confidante single parenthood marital separation recent bereavement Prevention can be divided into primary, secondary and tertiary levels and preventive interventions can be classified as universal, selective or indicated depending on the target population (Mrazek & Haggerty, 1994; Patton, 1997): universal measures must be cost beneficial for everyone in the eligible population and targeted to the whole population (e.g. all childbearing women); selective strategies are cost beneficial to a subgroup of the population who are considered to be at higher risk (e.g. women with a history of depression); and indicated approaches can be applied to asymptomatic groups who have risk factors that could justify more costly and extensive interventions (e.g. women who had a very preterm delivery by emergency caesarean section). Primary prevention reduces the incidence of disordersby preventing their development, using measures either directed at all childbearing women or at specific subgroups. The measures include a more realistic portrayal of parenting in the media, educating school children regarding the practicalities of childrearing, providing training for health professionals about the nature and effects of childbirth-related mental health problems, educating women and Prevention of postnatal depression 131

their partners about the practical and emotional support necessary for parenting, and providing perinatal care sensitive to psychosocial issues and vulnerability factors. Pre-conceptual counselling for couples and antenatal booking visits provide an opportunity to elicit risk factors for postnatal depression and monitor women s emotional well-being (Sharp, 1996). Health professionals are ideally placed to assess marital difficulties and the availability of support, provide information concerning postnatal depression in an acceptable way during preparation for parenting classes, and advise women and men about which symptoms to observe and act upon promptly. Secondary prevention reduces the prevalence of disorders by early identification and interventions that minimise frequency, duration and severity. This area involves the detection of women who are more vulnerable to mental health problems through screening for antenatal and postnatal risk factors, and the provision of appropriate interventions, such as preventive counselling to modify the negative and harmful effects of postnatal depression. For example, pregnant women could be allocated to a midwifery group practice within an existing obstetric service or a community-based general practice providing continuity of care during the antenatal, perinatal and postnatal periods. Midwives or maternal and child health nurses could then utilise a screening measure such as the EPDS for early identification of depressive symptoms and refer to general practitioners for further assessment, treatment and case management. General practitioners will need to incorporate multidisciplinary counselling or psychotherapy services if they have neither the time nor the specialised training to provide such services themselves (Cox, 1989; Kumar et al., 1995a). Another postnatal strategy would be to increase general practice and community nursing interventions in the first three to six months after delivery to provide monitoring, support, information and referral to specialised treatment services as necessary (Holden, 1996). Tertiary prevention involves early identification and treatment to limit the disabilitycaused by an established disorder, even though the condition has not been prevented. This includes regular antenatal and postnatal follow-up contact with women at high-risk of postnatal depression to provide support, information and effective treatment as soon as possible (Holden, 1996). Strategies may include prophylactic medication and individual or couple psychotherapy for women with a prior history of affective disorder and their partners immediately after birth or at the first sign of symptoms. Other tertiary strategies include admission to specialist day programs or inpatient facilities, involvement in group programs (e.g. treatment, support or self-help groups), parent-infant interaction programs, and linking mothers with supportive trained volunteers who make regular home visits (Pope & Watts, 1996). 6.3 Prevention of postnatal depression As mentioned, there are few publications that report preventing the onset of postnatal depression as the main outcome measure of the preventive intervention. However, there are several studies that offer useful evidence to ascertain whether limiting the influence of risk factors can decrease postnatal problems and whether strengthening protective factors reduces the prevalence of postnatal distress, anxiety or depression. 132 Postnatal depresssion A systematic review of published scientific literature to 1999

6.3.1 Biological interventions Biological preventive intervention studies primarily focus on postnatal depression as a physical illness with a biological aetiology (e.g. changes in hormone or neurotransmitter levels) related to the specific physiological events that accompany childbirth. There have been many claims that physical causes should be able to be identified, especially in regard to hormones (Harris, 1993; Harris et al., 1994; Harris, 1996), however, this has not been substantiated. It was concluded that the results of endocrine research in puerperal mental illness are not encouraging (George & Sandler, 1988) and the aetiology of symptoms in the postnatal period is still unclear (Ussher, 1992; Gregoire, 1995; Wisner & Stowe, 1997). There have been very few prevention studies conducted that assess biological factors such as prophylactic hormone contributions and psychotropic medications. Some biological factors are not modifiable at present (e.g. genetic) and studies in this area have used mainly tertiary prevention approaches, which should be regarded as treatment and not as prevention. Hormone concentrations There is a particularly steep rise in progesterone levels during pregnancy followed by a sharp drop in progesterone immediately post-delivery (Dalton, 1980). It is hypothesised that postnatal depression may be due to women having difficulty adequately adjusting to the marked differences between hormone levels in late pregnancy compared to the early puerperium (Dalton, 1971). Despite such assertions about the role of hormonal change in the aetiology of postnatal depression or in prophylaxis and treatment, research results have not established such links. Proponents of the hormonal approach recommend increasing and stabilising progesterone levels for both treatment and prevention of postnatal depression and puerperal psychosis (Dalton, 1980) without adequate evidence to do so (Wisner & Stowe, 1997). Furthermore, there is some evidence that progesterone may exacerbate depressive symptoms in certain women with mood disorders (Hammarback et al., 1985). The effectiveness of hormonal preventive strategies for postnatal depression has yet to be properly examined in wellcontrolled clinical trials. Further research is required in this area and to date no systematically derived data support the use of progesterone (Wisner & Stowe, 1997). Further, depot progestogen is associated with an increased risk of postnatal depression and causes suppression of endogenous 17 beta-oestradiol and progesterone secretion (Lawrie et al., 1998b). Therefore, progesterone contraceptives should be used with caution in the postnatal period, especially with women who have a history of depression. Psychotropic medication Further research is needed to determine the role of such medications in preventing postnatal depression. More studies are also required to determine the likelihood of biological preventive approaches being acceptable to subject groups (e.g. the use of medication during pregnancy and lactation or frequent invasive procedures being necessary for physiological data collection). Future studies must have well-controlled research designs including large numbers of randomly assigned subjects, comparison of their progress with matched control groups, use Prevention of postnatal depression 133

of standardised assessment measures, allocation of assessors who are blind to the participants group status, and analysis of the data by the original intention to treat regardless of attrition from the research groups. See Appendix 5.1 for details regarding biological prevention. 6.3.2 Psychosocial interventions Most of the psychosocial research published to date has not been specifically directed to the prevention of postnatal depression. Instead psychosocial prevention programs have targeted factors that are amenable to change such as reducing postnatal distress, enhancing parentinfant attachment and providing education about child development, improving couple communication and interactions, and increasing the availability of support. Reducing postnatal distress The most quoted psychosocial prevention study assessed the effectiveness of antenatal groups in reducing postnatal emotional upsets (Gordon & Gordon, 1960). The results suggest that such groups can help reduce emotional upset. However, the study methods were unreliable, and no diagnostic measure of postnatal depression was included. Therefore the results demonstrate that providing realistic and solution-focused antenatal care can positively influence postnatal emotional outcomes, not that postnatal depression could be prevented in this manner. In another study, the effectiveness of relaxation training in reducing postpartum distress was examined (Halonen & Passman, 1985). The women who undertook relaxation interventions reported lower postnatal distress compared to the two non-relaxation groups. However, this difference may reflect coping better with the psychological concomitants of the maternity blues, rather than a true preventive strategy for postnatal depression. The study also found that simply describing potential postpartum stressors to pregnant women does not reduce depressed mood in the maternity blues period. Exposure by discussing the realities of parenthood is not sufficient on its own and may even reduce the feelings of elation commonly occurring during the initial postnatal days. Discussion of postnatal stressors needs to be accompanied by suggested ways to diminish or manage stressful situations. Enhancing parent-infant interaction Current research in Australia is investigating the effects on infants when mothers have postnatal depression. However, there are no peer-reviewed publications yet available to outline preventive interventions specific to parent-infant interactions when mothers are depressed following childbirth. A review of postnatal nursing interventions claimed there is evidence that primiparous women benefit from structured teaching and supportive counselling programs which address their concerns, attitudes, perceptions, and role-related knowledge (Donaldson, 1991). Infant growth, development, and health may directly and indirectly benefit from interventions designed to enhance the mother s knowledge, skills and ability to foster mother-infant attachment. Although short-term interventions may demonstrate a significant positive impact 134 Postnatal depresssion A systematic review of published scientific literature to 1999

on maternal psychological and behavioural measures, it is more difficult to achieve measurable infant effects. There may be a time lag between the intervention directed to the mother and improved infant developmental outcomes, and the first stage of active intervention needs to continue throughout the initial six to eight weeks post-delivery (Donaldson, 1991). In this review of maternal adaptation following childbirth, it was noted that mothers involved in postnatal interventions tended to ask more questions, express more concerns, and engage more community helping resources than control mothers. This suggests that postnatal psycho-educational interventions actively stimulate maternal coping and problem solving behaviours. Seeking information, expressing concerns, and accessing resources may be positive indicators that mothers are attempting to cope with the demands and challenges of parenting, rather than indicators that mothers are not coping well (Donaldson, 1991). Improving couple communication Marital dissatisfaction is the most common presenting problem in adults seeking psychological services and approximately 50% of American and 40% of Australian marriages now end in divorce (Behrens & Sanders, 1994). The birth of an infant is a transitional period in a marital relationship and it is a high-risk time for decline in relationship adjustment. Couple satisfaction frequently decreases during early parenthood (Behrens & Sanders, 1994). Preventive programs to assist coping with parenting and relationship changes could include addressing expectations about becoming both parent and partner, beliefs about gender roles, the division of household labour, conflict resolution styles, communication patterns and maintaining intimacy. There is some evidence of benefit from such programs. Increasing availability of support There is also some evidence that providing support, such as listening visits, can lead to better obstetric outcomes and better psychosocial adjustment in mothers. A review of listening visits research has recommended that future studies need to evaluate antenatal assessment and preventive strategies for postnatal depression (Clement, 1995). For instance, research is required to measure whether increased specific community or maternal and child health nurse contacts conducted antenatally could assist in decreasing postnatal depression and improving perinatal psychological outcomes (Clement, 1995). See Appendix 5.2 for details of psychosocial prevention studies. 6.3.3 Prevention research directly targeting postnatal depression Treatment study results suggest that increased community nurse intervention in the early postnatal months could decrease the likelihood that high risk women would develop postnatal depression (Holden et al., 1989), so similar interventions might be used for prevention. In addition, previous research has used participants from the general childbearing population so the majority of these women would not be expected to develop postnatal depression. Therefore subsequent studies have sought to screen antenatal women to identify a high risk population and to apply selective prevention studies within this subgroup. Prevention of postnatal depression 135

A key study was published in two separate book chapters but not in a peer-reviewed journal (Elliott et al., 1998; Elliott, 1989b). It is included as the results are crucial for comparison with later research. The Leverton Scale (Leverton & Elliott, 1988) was used to identify primiparous and multiparous women who were more vulnerable to postnatal depression according to the presence of risk factors. As part of the study, 188 women were assessed antenatally and 99 were identified as being more vulnerable to postnatal depression, while 89 women were identified as being less vulnerable. Women in the more vulnerable category were then randomly assigned to the intervention group (N=48) or the control group (N=51). Each group contained matched women of similar parity and expected delivery date. The intervention consisted of 11 group sessions using a psycho-educational approach including social support strategies, promoting positive mental health, and preparation for parenthood. Five group sessions were scheduled during the pregnancy as an adjunct to antenatal classes. There were also monthly meetings held up to six months post-delivery. In addition, health visitors had been asked to make an antenatal visit in mid-pregnancy in order to establish contact and provide continuity of care and support as early as possible. Participation in the intervention program revealed important differences in attendance, with 86% of primiparous women attending an average of seven group sessions, and only 56% of multiparous women attending an average of four meetings. The researchers suggested that poor participation was influenced by the timing of meetings and the inconvenience and lack of comfort in the setting, even though creche facilities were provided. There was a trend but not significant difference in the outcome data between multiparous women who did and did not attend the intervention sessions. Therefore, their results were not analysed separately. Women were assessed using a standardised psychiatric interview (PSE) at three months postpartum, to which fixed criteria for the diagnosis of major depression could be applied in the presence of depressed mood plus at least four other specific symptoms. Women who did not meet the criteria for major depression because they had between one and three specific symptoms were deemed to have borderline depression, although this was not a formal diagnostic category. A problem with this research is that the two chapters reporting these results contain different and incomplete data and the results are difficult to follow. Another publication relating to the same sample and the same design, has reported slightly different outcomes and subject numbers (Elliott, 1989b). This version states that the prevalence of both major and borderline depression at any time in the first three postnatal months demonstrated that the more vulnerable women in the intervention group had a significantly lower rate (19%; N = 48, three major and six borderline) than the more vulnerable women in the control group (40%; N = 50, five major and 15 borderline). The prevalence of depression was also lower in the original less vulnerable group (16%, N = 90, four major and 10 borderline), which suggests that the Leverton Scale was able to detect a higher risk group of women. The researchers concluded this would appear to confirm the belief that psychosocial interventions can prevent postnatal depression. However, the analysis included both major depression and borderline depression categories, and it is not certain whether the latter group would actually meet recognised diagnostic criteria for either minor depression or adjustment disorder with depressed mood (e.g. DSM or ICD). This is a problem because the 136 Postnatal depresssion A systematic review of published scientific literature to 1999

significant difference between the two more vulnerable groups may actually depend on the differing rate of borderline depression, as there appears to be no significant difference in the prevalence of major depression between the groups. These results should be treated cautiously since they have not been peer-reviewed and the Leverton Scale has never been published. Differences in the data and interpretation of results between the separate publications make the results difficult to interpret. See Appendix 5.2 for details concerning prevention research. 6.3.4 Training health professionals in detection and prevention It is clear that sound scientific evidence about prevention is still lacking and such information is a vital precursor to planning comprehensive programs of preventive and early intervention in postnatal depression. However, there is some evidence that the influence of certain risk factors can be modified and that universal, selected and indicated preventive strategies could be developed and trialed on the basis of these findings. Providing adequate information and training to health professionals concerning mental health issues is essential for good patient care as many nurses and medical staff have been shown to be wary and uncomfortable about dealing with psychiatric and psychological problems (Whitehead & Mayou, 1989; Lepper et al., 1994; Oermann, 1994). There is evidence from Britain and Australia concerning the effectiveness of skills training to improve detection of and treatment for postnatal depression among health practitioners, and to assist planning and service delivery in this area (McClarey & Stokoe, 1995; Watts & Pope, 1998). Community-based consultation sessions have been held in most Australian states to ascertain consumer experiences and expectations regarding postnatal depression (e.g. Health Department of Victoria, 1990; New South Wales Health Department, 1994; Pope, 1995). These reports have all indicated that a greater emphasis needs to be placed on perinatal mental health issues, especially in training health professionals in the overall physical, psychological and social care of pregnant women and recent parents. More research is needed to identify specific interventions that reduce the occurrence of depression associated with childbirth and to recommend practical and adaptable cost-effective approaches. Primary care teams and mental health services also require specific training and skills to better recognise psychological morbidity during the first postnatal year and accurate prediction measures to assess risk amongst their client populations. When evidence is available concerning useful preventive approaches, such programs need to be endorsed and funded by government and private health and family agencies as potentially responsible and cost-effective actions. Preventive programs will require support from comprehensive mental health specialist services comprised of fully resourced multidisciplinary teams with links to primary care and community based services (Cox, 1994b). Prior service planning and liaison with community agencies to create, implement, and evaluate suitable intervention programs will be essential. See Appendix 5.2 for details of studies regarding health professional training. Prevention of postnatal depression 137

6.4 Summary of evidence for prevention There can be long-term consequences of postnatal depression for women, their partners, the infant and other children, therefore preventive approaches are warranted. Despite limited preventive research being currently available, postnatal depression is suitable for prevention programs because the onset is preceded by a clear marker, there is a defined period of highest risk during which a sample of women may be identified, and there is substantial antenatal and postnatal contact with health services. Problems have been encountered in recruiting and retaining participants in postnatal depression prevention research, which may be related to women s beliefs about the aetiology of postnatal depressive symptoms. Translating risk factor research results into predictive screening protocols and primary prevention programs has not been successful, as complex interactions of biopsychosocial risk factors with individual variations must be considered, and this requires further research. The effectiveness of biological methods (e.g. progesterone, oestrogen or antidepressant medication) to prevent postnatal depression needs to be properly examined in wellcontrolled clinical trials. To date, no systematically derived data is available to support the use of these approaches. Much of the psychosocial research concerning prevention of postnatal depression has targeted contributing factors such as reducing postnatal distress, enhancing parent-infant attachment, improving couple communication and interactions, and increasing the availability of support. The effectiveness of psychosocial approaches in preventing postnatal depression has not been satisfactorily demonstrated, and larger samples with well-designed studies are required. Providing training in childbirth-related mental health issues for health professionals has been shown to increase detection rates, improve patient care and may aid development of primary and secondary prevention strategies. 138 Postnatal depresssion A systematic review of published scientific literature to 1999

CHAPTER 7 SYSTEMATIC REVIEW OF PEER-REVIEWED TREATMENT AND PREVENTION STUDIES Comparison: Support companion in labour (prevention) Outcome: Self-esteem Study: Wolman W Outcome Expt Expt Control Control Absolute effect Time point n mean (sd) n mean (sd) size (95% CI) Day 1 91 65.30 (1.80) 96 65.90 (2.00) -0.60 [-1.145, 0.055] 6 weeks 77 74.50 (2.00) 75 58.80 (2.80) 15.70 [14.925, 16.475] Comparison: Support companion in labour Outcome: Anxiety between time points Day 1 and 6 weeks Study: Wolman W Outcome Expt Expt Control Control Absolute effect Time point n mean (sd) n mean (sd) size (95% CI) Anxiety traits Day 1 74 40.20 (0.94) 75 39.80 (0.90) 0.40 [0.10,0.70] State anxiety Day 1 74 28.29 (0.85) 75 37.80 (1.09) -9.51 [-9.82, 9.20] State anxiety 6 weeks 74 28.00 (0.92) 75 40.40 (1.47) -12.40 [-12.79,-12.01] Systematic review of peer-reviewed treatment and prevention studies 139

Comparison: Antenatal Intervention (prevention) Outcome: Postnatal depression as measured by EPDS Study: Stamp G Outcome Expt Expt Control Control Absolute effect Time point n mean (sd) n mean (sd) size (95% CI) Depression 6 weeks P/N 8 64 11 64 0.69 [0.26,1.83] Depression 12 weeks 7 63 11 65 0.62 [0.23, 1.67] P/N Depression 6 months 9 60 6 61 1.60 [0.55,4.70] P/N Comparison: Prenatal parenting education Intervention (prevention) Outcome Mean anxiety state as measured by State-Trait Anxiety Inventory (STAI) at three time points Study: Midmer D Outcome Expt Expt Control Control Absolute effect Time point n mean (sd) n mean (sd) size (95% CI) 2 nd trimester 81 32.82 55 33.24-0.42 [-4.53,3.69] (12.00) (12.00) 6 weeks 58 31.43 45 37.38) -5.95 [-10.62,-1.28] P/N (12.00) (12.00) 6 months 62 31.95 42 36.67-4.72 [-9.42,-0.02] P/N (12.00) (12.00) 140 Postnatal depresssion A systematic review of published scientific literature to 1999

Comparison: Prenatal parenting education Intervention (prevention) Outcome: Dyadic Adjustment Scale at three time points Study: Midmer D Outcome Expt Expt Control Control Absolute effect Time point n mean (sd) n mean (sd) size (95% CI) 2 nd trimester 81 117.63 55 116.98 0.65 [-3.46,4.76] (12.00) (12.00) 6 weeks 58 117.59 45 110.29 7.30 [2.63,11.97] P/N (12.00) (12.00) 6 months 62 114.16 42 108.64 5.52 [0.82,10.22] P/N (12.00) (12.00) Comparison: Prenatal parenting education Intervention (prevention) Outcome: Postpartum Adjustment Questionnaire Study: Midmer D Outcome Expt Expt Control Control Absolute effect Time point n mean (sd) n mean (sd) size (95% CI) 6 weeks 58 64.74 45 70.60-5.86 [-10.53,-1.19] P/N (12.00) (12.00) 6 months 62 64.58 42 70.12-5.54 [-10.24,-0.84] P/N (12.00) (12.00) Systematic review of peer-reviewed treatment and prevention studies 141

Comparison: Fluoxetine plus counselling vs placebo plus counselling (treatment) Outcome: Postnatal depression as measured by administration of fluoxetine plus 1 counselling session Study: Appleby L Outcome Expt Expt Control Control Absolute effect Time point n mean (sd) n mean (sd) size (95% CI) 22 11.10 23 19.10-8.00 [-15.60,-0.40] (15.00) (10.50) Comparison: Fluoxetine plus counselling vs placebo plus counselling (treatment) Outcome: Postnatal depression as measured by administration of fluoxetine plus 6 counselling sessions Study: Appleby L Outcome Expt Expt Control Control Absolute effect Time point n mean (sd) n mean (sd) size (95% CI) 21 10.50 21 13.00-2.50 [-9.01,-4.01] (11.40) (10.10) Comparison: Fluoxetine plus counselling vs placebo plus counselling (treatment) Outcome: Postnatal depression as measured by administration of placebo plus 1 counselling session vs 6 sessions Study: Appleby L Outcome Expt Expt Control Control Absolute effect Time point n mean (sd) n mean (sd) size (95% CI) 22 11.10 21 10.50 0.60 [-7.34,8.54] (15.00) (11.40) 142 Postnatal depresssion A systematic review of published scientific literature to 1999

Figure 7.1 Summary of systematic review Systematic review of peer-reviewed treatment and prevention studies 143

Table 7.1 Characteristics of included studies Method Participants Interventions Appleby, 1997 Randomised controlled trial. Allocation by way of computergenerated random numbers. All women received some form of treatment as it was considered unethical to have a no treatment group. Participants blinded to drug allocation as were the counselling session psychologist and the supervising psychiatrist. Analysis was not performed on intention to treat basis. Women found by screening in an urban health district to be depressed at 6 8 weeks postpartum. Women who scored 10 on the EPDS were interviewed using the revised CIS. Those scoring 12 on the EPDS (the threshold for significant psychiatric morbidity and who satisfied RDC for major or minor depressive disorder) were invited to participate in the treatment trial. Women were excluded if there was a history of chronic (> 2yrs) or resistant depression, current drug or alcohol misuse, severe illness requiring hospital admission. Women who were breastfeeding were also excluded. 2,978 women were eligible for screening, 2,395 (80%) agreed to complete EPDS, 503 (21%) scored 10 on EPDS of whom 406 (81%) agreed to further assessment. 188(9.7% of initial sample) Confirmed cases of depression were identified of whom 87 (3.6% of initial sample) agreed to participate in the drug treatment trial. Eligible women were allocated to 1 of 4 treatment groups: 1. fluoxetine plus 1 counselling session. 2. fluoxetine plus 6 counselling sessions. 3. Placebo plus 1 counselling session 4. Placebo plus 6 counselling sessions. Fluoxetine is a serotonin specific reuptake inhibitor, a class of drugs that is anxiolytic and non-sedating. The counselling sessions were based on CBT and designed to be delivered by non-specialists in mental health, e.g. health visitors. Sessions were structured to offer reassurance. 144 Postnatal depresssion A systematic review of published scientific literature to 1999

Outcomes Notes Psychiatric morbidity after 1, 4, and 12 weeks, measured as mean scores and 95% confidence limits on the revised CIS, the EPDS and HRSD. The aim of the study was to determine the optimal treatment for non-psychotic depression in childbearing women. The hypotheses were: 6 counselling sessions would be more effective than 1 fluoxetine would be more effective than placebo, and after 1 counselling session the combination of fluoxetine and additional counselling would be equally effective. The authors found that in this group of women studied there was a benefit to women who received fluoxetine and a benefit to women who received CBT but, beyond an initial counselling session the benefit for women receiving both fluoxetine and counselling is less clear. It may be an individual woman s choice as to which mode of treatment she feels is most helpful. The study lacked the power to show any clear benefit that may have been detected. To show a difference of 4 in the mean scores between the 4 groups with a {sd} of 8.4, there was only a 24.7% power for 1 endpoint and 16% power for 2 endpoints. continued Systematic review of peer-reviewed treatment and prevention studies 145

Method Participants Interventions Midmer, Wilson & Cummings, 1995 The aim of the study was to Women assessed as being at measure the influence of a low risk for pregnancy prenatal intervention on the complications, who had already outcomes of postpartum paid to attend antenatal anxiety. Randomised controlled parenting classes at the study trial. Women randomly hospital and who were allocated to either routine available, with their partner, for antenatal parenting classes or to a 2 nd trimester intervention. routine antenatal classes plus 2 Data was available for 81 out of extra information sessions. 130 82 participants in the couples who fitted the study intervention group who criteria were contacted either by completed the 1 st questionnaire. phone or mail-out. 70 couples 55 of 58 control group agreed to participate. Analysis participants completed the was performed on an intention initial questionnaire. to treat basis. Control group Attendance at routine antenatal parenting classes. Intervention group Attendance at routine antenatal parenting classes plus attendance at 2 extra sessions, the contents of which were based on previous assessment of the educational needs of postnatal couples and included role-play and valuesclarification exercises. More couples were randomised to the intervention group to allow group sizes that would facilitate better group dynamics. Stamp, Williams & Crowther, 1995 Randomised controlled trial. After consenting, women were randomly allocated to 1 of 2 groups by a telephone call from the antenatal clinic to a researcher who opened the next in a series of sequentially numbered envelopes prepared in advance by a researcher independent of study involvement. The woman was informed of her allocation prior to leaving the clinic. It was calculated that a sample size of 140 would have an 80% chance of detecting a reduction of postnatal depression from 37% to 15 % at the 5% level of statistical significance. Assessors were not blind to study allocation. Women attending a public antenatal clinic. No privately insured patients attended the clinic and were therefore excluded. 249 women consented to complete a modified screening questionnaire (Leverton scale) to identify women vulnerable to postnatal depression. 144 screened as vulnerable. 73 were randomised to the intervention group and 71 to the control group. Following unavoidable exclusions, 71 women in the intervention group and 68 in the control group completed the trial. All women received the usual antenatal care offered by the hospital. In addition the intervention group were asked to attend, at 32 weeks and 36 weeks, 2 special antenatal classes designed to provide non-directive, practical and supportive sessions with an emphasis on the emotional and practical expectation of life changes precipitated by the arrival of a baby. Focus was on access to information, preparation and support, the development and extension of women s existing networks and goal setting abilities. Partners were encouraged to attend. 146 Postnatal depresssion A systematic review of published scientific literature to 1999

Outcomes Notes Marital adjustment and postnatal adjustment were measured by 3 scales, the Spielberger STAI and Spanier Dyadic Adjustment Scale. These were repeated in the postnatal period at 6 weeks and 6 months. In addition a postnatal evaluation using a modified version of O Hara s Postpartum Adjustment Questionnaire (PPAQ) was given at 6 weeks and 6 months. The STAI is a standardised 40-item self-report instrument consisting of a set of statements about anxiety and self-evaluation. Score range 20 80, the higher the score the higher the rate of anxiety. The DAS is a 32-item self-report scale including a dyadic consensus, satisfaction and affectational expression. Range 1 151, the higher the score the greater the marital adjustment. The PPAQ is a 61-item self-report measure developed to assess social role adjustment in childbearing women. Range 34 170, a low score indicating a better overall postnatal adjustment. The trial hypothesis was that women who attended 2 specific antenatal groups and 1 postnatal group would have a reduced frequency of postnatal depression by 59% from 37% to 15% at 6 weeks, 12 weeks and 6 months postpartum compared to a control group of women also vulnerable for postnatal depression. Outcome was measured by the use of the EPDS at 6 weeks, 12 weeks and 6 months postpartum. continued Systematic review of peer-reviewed treatment and prevention studies 147

Method Participants Interventions Oakley et al., 1990 Randomised controlled trial. Central coordinating centre contacted by telephone for randomisation schedule, stratified by centre. Ethics committee approval obtained from each hospital. Sample size calculation present describing 420 women being required for an 80% chance of detecting a difference of 150g in mean birthweight between groups. A total of 509 women recruited, 255 to the intervention group and 254 to the control group. Recruitment drawn from 4 hospital populations. Women were eligible to enter the trial if they had at least one normally formed infant weighing < 2,500g following spontaneous onset of labour, were less than 24 weeks gestation with a singleton pregnancy, were fluent in English and had been assessed as socially disadvantaged. Midwifery home visiting social support programme designed to improve birth outcomes for women who have previously had a low birth weight baby. The social support group received a minimum package of 3 home visits at 14, 20 and 24 weeks plus 2 phone calls and brief home visits between these times. There was 24-hour access to contacting a midwife. Semistructured interview schedules were used to maintain consistency of information. Any other information was kept to a minimum. No clinical care was provided. Wickberg & Hwang, 1996 Randomised controlled trial. A consecutive sample of Swedishspeaking women attending one of 17 child health clinics in the area surrounding Goteborg, Sweden were asked to complete an EPDS questionnaire at 2 and 3 months postpartum. Those who scored 12 were asked to participate in a further interview at which time they were assessed with the MADRS and diagnosed according to DSM-III-R for major depression. Those scoring a MADRS of 10 were invited to participate in the trial. The study nurses were given counselling training and supervised on a regular basis. A psychologist blinded to the women s study allocation performed the MADRS. The mean scores for depression were similar for each group (19.6 in the intervention group and 17.1 in the control group). 57 women eligible. 41 women agreed to participate and were randomly allocated to the intervention or control group. Characteristics of the two study groups were similar with respect to age, education level, marital status, type of delivery, previous episodes of depression and major depression at the time of the 1 st interview. Control group received usual routine care, not consisting of any check-ups, but with the possibility of attending the clinic whenever needed. Intervention group received usual routine care plus 6 weekly, 1-hour counselling sessions with a nurse at a predetermined time either in the woman s home or at the child health clinic. One week after the completion of the study period all participating women were assessed with the MADRS. 148 Postnatal depresssion A systematic review of published scientific literature to 1999

Outcomes Notes Baseline information was obtained on 507 women (2 lost to followup). At 6 weeks, 94% return rate for postal questionnaires 243(96%) in the intervention group and 234(92%) in control group. Pregnancy outcomes were obtained from the woman s case notes. The 6-week postnatal self-report questionnaire was not a standardised or replicable measure. Women in the intervention group had fewer admissions, were more likely to have a spontaneous vaginal delivery, lower rate of epidural use and were less likely to have an infant that was admitted to the neonatal intensive care unit. Intervention mothers had better subjective ratings of psychological adjustment in that they felt they were in control, had more help from their partners and did not report feelings of being low or depressed as often as the mothers in the control group. Although these findings were not based on standardised measures, they do provide some guidance. 12 (80%) of the women allocated to the intervention group diagnosed with major depression at the commencement of the trial, showed no evidence of having a major depression at the end of the 6 counselling sessions. In the control group, 4 (25%) of the 16 women showed no evidence of a major depression at the corresponding time point. Authors concluded that counselling by child health nurses, who have received training and regular supervision, is helpful in managing postnatal depression. continued Systematic review of peer-reviewed treatment and prevention studies 149

Method Wolman et al., 1993 Randomised controlled trial. Randomly ordered cards in sealed, opaque envelopes. Women were recruited only in the mornings to accommodate labour supporters who were unable to stay after dark. Participants Total of 189 nulliparous women with no significant obstetric problems who had < 6cm cervical dilatation and who did not have a supportive companion. 92 were randomised to the intervention group and 97 to the control group. 150 Postnatal depresssion A systematic review of published scientific literature to 1999

Interventions Outcomes Notes Intervention group women were assigned a lay supporter who stayed for the whole labour and birth (64) or labour only (24). Within 24 hours of delivery a structured questionnaire was administered by a clinical psychologist relating to perception of labour and pain experienced in labour and on day 1. Coopersmith Self-esteem Inventory, STAI, and a non-standard measure of depression, Pitt Depression inventory. Significant differences were found at 6 weeks between intervention and control groups for feeling competent during labour, self-esteem, anxiety and depression scores. However, as there was no follow-up of postnatal progress and as the depression measure used has no norms, recommended thresholds or indications of severity, the results are difficult to interpret in terms of how it may assist the prevention of postnatal depression. Systematic review of peer-reviewed treatment and prevention studies 151

Excluded studies Beck et al., 1985 Cullinan, 1991 Dalton, 1971 Fleming et al., 1992 Kissane & Ball, 1988 Leverton & Elliott, 1988 Marks et al., 1996 Meager & Milgrom, 1996 Reason for exclusion Not analysed on intention to treat i.e. those who did not complete the treatment were omitted. Study had only a 22% power to detect a difference of 6 with an (sd) of 11 at l2 months follow-up. Only 7% power to detect improvement from 70% improved (0 9) in CBT group to 85% in cognitive therapy plus amitriptyline group. Poor methodology. No data supplied to substantiate reported outcomes. No demographic information, no control group or standardised measure of depression used other than EPDS. The aim of this study was to determine whether postnatal depression was caused by a woman s difficulty in adjusting to the marked difference between hormone levels in late pregnancy and the early puerperium. No formal assessment of women s hormone levels appear to have been undertaken to form a baseline for whether change has occurred. No standardised measures were used. Reliability between ratings was not assessed and no differentiation was made between the 3 postpartum mood disorders that may occur during the study data collection phase. No randomisation. The way in which the groups were formed/initiated makes comparison difficult and the data needed to be viewed as three separate samples. Review of l4 patients attending a mother-baby unit in a general psychiatric hospital over two-year period. Insufficient data. Lack of description of follow-up. Readmission was the only outcome measure mentioned. Conference paper. Little informative data presented. Study methodology has never been published in peer reviewed medical or psychological literature, so difficult to assess quality and reproducibility of information. Non-concurrent controls. Some recruits were already in a trial of postpartum psychosis, having had a previous episode of severe mental illness. Preliminary results only given as trial was still in progress. Use of chi-square for analysis was not appropriate. Not analysed on intention to treat Confounders such as concurrent medication, time since onset of depression and small group sizes made it very difficult to find validation of assumptions. Insufficient power to detect the desired difference rates. Should be treated and discussed as pilot study only. 152 Postnatal depresssion A systematic review of published scientific literature to 1999

Excluded studies Morgan et al., 1997 Morris, 1987 Pop et al., 1995 Sichel et al., 1995 Stuart & O Hara, 1995 Wisner & Wheeler, 1994 Reason for exclusion No control group so unable to test effectiveness of group program. Recruitment process not specified. Highly motivated sample, which may have biased results. Poor methodological description of method of recruitment. No power to detect true effect of treatment, no control group, poorly defined group program. Process of randomisation unclear. Women appeared to have chosen their preferred place for delivery, i.e. either home or hospital. Not surprisingly the majority of women gave birth in their chosen setting and the study revealed no major difference in the occurrence of blues or depression in the early postnatal period based on obstetric factors. No control group. Very small numbers. No observer blinding. 12 Women eligible, of whom only 6 participated in study. No control group. Insufficient power to determine effectiveness of treatment. Very small sample size. Poor allocation process. Women could choose group leading to disparity in allocation (8 choosing monitoring and I5 choosing antidepressant treatment plus monitoring). The study participants were assessed, treated and reviewed by the same person which leaves study result interpretation open to severe bias. Systematic review of peer-reviewed treatment and prevention studies 153

APPENDIX 1 THE LITERATURE REVIEW 1.1 Focus of the literature review According to the contract specifications from the NHMRC, the literature review involved systematically searching for and critically analysing only published peer-reviewed scientific literature related to postnatal depression available in English up to 1999. Attempts were also made to identify key papers published in languages other than English. However, no significant publications were located which contained unique information not already available in English journals or which necessitated translation into English. There is considerable research work in progress in Australia at present. This includes funded and follow-up projects, postgraduate research theses, and recently completed randomised controlled trials that have yet to be published. We are unable to include conference presentations or reports of such data at this stage and look forward to future publications to extend knowledge in these areas (e.g. prevention trials, large-scale intervention programs, fathers clinical depression, and infant attachment issues). 1.2 Literature search and systematic review methods In the initial stage of the search process, more than 75,000 peer-reviewed publications were identified using the keywords described below. About 10,000 potentially relevant abstracts, which met predetermined eligibility criteria for the systematic review, were subsequently extracted for further scrutiny. More than 1,300 research articles were eventually selected and ordered so they could be assessed in a more rigorous manner to determine suitability for inclusion in the review document. Full copies of papers were obtained through Interlibrary Loan services from local, national and international holdings. All research literature was reviewed independently by two investigators to decrease opportunities for bias in both selection of papers included for review of evidence and in the reporting of conclusions. The team met regularly to discuss outcomes of the literature search and systematic review. The review process consisted of assessing: definition of disorder (diagnostic criteria utilised) population sampled (enrolment process, inclusion or exclusion criteria, sample size, comparability of age, socioeconomic status, ethnicity and reproductive experiences) research design (control for potential bias, method and timing of assessment, statistical analysis, outcome measures) level and quality of evidence (as proposed in the draft NHMRC guidelines, 1999) strength of evidence and strength of support for the conclusions reported mechanisms for assessment of treatment complications and length of patient follow-up critical analysis of variations between findings of the relevant studies. Appendix 1 The literature review 155

Data management was achieved using the following software programs: Endnote 3.0 - to compile an extensive bibliography Microsoft Word 7.0 - for ease of electronic transfer of the review report Revman 3.1 - to classify studies and produce explicit and concise reports. 1.3 Search strategy Databases searched included Medline, CINAHL, PsycINFO, Best Evidence, and the Cochrane database of Systematic Reviews. International and National Government and other health agency publications relating to women s, maternal-infant and mental health policies were also searched for background and resource information, to complete the detail and quality of information required for this review. Searches of databases were conducted by specialist author, title, and subject in medical and psychology related journals, as well as general peer-reviewed journals. The reference lists of recent, specific articles and reviews were hand searched as part of the quality assessment process and to measure our capture rate of relevant references. The initial search was based on the identification of titles containing appropriate keywords and combinations of keywords. Many keywords were utilised during the search phase and keywords searched are listed below. Maternal depression Puerperal depression Depression in the puerperium Depression, postnatal Antenatal depression Depression, antenatal Depression in pregnancy Adolescent pregnancy Adolescent pregnancy and depression Hormones and depression Thyroid function and postnatal depression Cognitive vulnerability Infant temperament, behaviour, cognitive development Maternal-infant attachment Low birthweight infants and postnatal depression Edinburgh Postnatal Depression Scale validation 156 Postnatal depresssion A systematic review of published scientific literature to 1999

Antidepressants and breastfeeding Antidepressants and postnatal depression Efficacy of treatment of postnatal depression Tricyclics in postnatal depression Selective Serotonin Re-uptake Inhibitors (SSRIs) Electroconvulsive Therapy Cost effectiveness in treating postnatal depression Psychotherapy or counselling for postnatal depression Self help groups for depression or depression, postnatal Prevention of postnatal depression Protective factors in postnatal depression As noted, approximately 1,300 published papers were selected to be reviewed in a rigorous manner to assess suitability for inclusion in the literature review. These papers were then either included or excluded and further subgrouped for inclusion or exclusion in the systematic review phase of the review process. 1.4 Selection criteria Selection criteria for inclusion of eligible papers were agreed upon so reviewers could determine whether the article met the criteria or whether it should be excluded. The following selection criteria were used: Articles must have been published in peer-reviewed journals, unless key results were contained only in book chapters and were unavailable elsewhere. The main focus of each publication was required to involve some aspect of functioning in relation to the diagnosis of postnatal depression (e.g. prevalence, risk factors, and treatment outcomes). Research results were published primarily in English during the period from 1980 to 1999 and full copies needed to be available to properly assess study details. Other childbirth-related mental health disorders (e.g. antenatal or postnatal anxiety disorders, maternity blues, puerperal psychosis) were not the main subjects of the current search and systematic review and such data was not selected or reviewed. Limited literature describing these conditions is presented in Section 2 to distinguish them from postnatal depression. If the title and/or abstract left room for doubt, then it was not excluded unless the reviewer read the article in full. We erred on the side of caution in the first stages of the search, so unsuitable papers were only excluded once complete information was available. Appendix 1 The literature review 157

In the systematic review phase, research papers were selected, assessed and recorded by utilising the format acceptable for a Cochrane Collaboration review, which includes: title and abstract using a structured format text of the review including introduction of background and objectives, selection criteria and search strategy, methods, results (descriptions of studies, methodological quality, study results), discussion and conclusions standard tables and figures showing characteristics of studies included, specifications of interventions compared, results of included studies, and record of studies excluded. 1.5 Levels of evidence Both the level and quality of evidence were considered during the review phase. This was necessary to assess study design and methods used by research investigators to minimise opportunities for bias that might affect the study outcomes. The six point rating system outlined in the recent draft of A Guide to the Development, Implementation and Evaluation of Clinical Practice Guidelines (NHMRC, 1999 Draft) was utilised for ranking the level and quality of the research evidence obtained in the review process. The hierarchy of evidence was assessed as follows (NHMRC 1999 Draft). Level I: Level II: Level III-1: Level III-2: Level III-3: Level IV-4: evidence obtained from a systematic review of all relevant randomised controlled trials evidence obtained from at least one properly designed randomised controlled trial evidence obtained from well-designed pseudo-randomised controlled trials (alternate allocation or some other method) evidence obtained from comparative studies with concurrent controls and allocation not randomised (cohort studies), case control studies, or interrupted time-series with a control group evidence obtained from comparative studies with historical control, two or more singlearm studies, or interrupted time series without a parallel control group evidence obtained from case studies, either post-test or pre-test and post-test In order to further classify evidence relating to risk factors and treatment, methods outlined in the Clinical Practice Guidelines for Depression in Young People (NHMRC 1997) were employed. For instance, evidence was categorised in terms of confirmed, probably and possible risk factors as well as possible protective factors. Treatment effectiveness outcomes were also rigorously assessed using NHMRC guidelines. 158 Postnatal depresssion A systematic review of published scientific literature to 1999

APPENDIX 2 PREVALENCE 2.1 Summary of prevalence studies (listed chronologically by assessment method) Diagnostic criteria Cox et al., 1982: A prospective study with 105 women used assessments with the SPI at the antenatal booking visit, 35 weeks gestation, 10 days postpartum and three to five months postpartum. Only 4% of women were depressed during pregnancy, compared with 30 per cent incidence of depression (13% major, 16% minor) by the five month postnatal assessment. Nott & Cutts, 1982: 212 women were recruited from five general practices in Britain. 200 of these women were interviewed with the SPI between 8 and 14 weeks postpartum, demonstrating 18 % incidence of depression. Cutrona, 1983: 85 nulliparous women recruited from an American university population were assessed from approximately 38 weeks gestation until eight weeks postpartum using the BDI and HRSD with DSM-III criteria for major depression. The point prevalence for diagnosis of major depression was 3.5% antentally, 4.7% at two weeks and 3.5% at eight weeks postpartum, with total postpartum incidence of 8.2%. Prevalence of minor depression was not reported. In contrast, depressive symptoms measured by the BDI were considerably higher with 25% during pregnancy, 33% at two weeks and 12% at eight weeks postpartum. Kumar & Robson, 1984: 119 primiparous women were interviewed using the SPI with RDC diagnoses during pregnancy and at three months and 12 months postpartum. Data from114 of these women showed the incidence of depression rose significantly in early pregnancy (10%) and at three months postpartum (14%), with the majority of subjects reporting depression at either time, rather than both. Watson et al., 1984: 128 women were interviewed using the SPI and ICD-9 (World Health Organization, 1978) diagnoses at 16 weeks gestation and at six weeks and 12 months postpartum. Psychiatric disorders were identified in eight women (6%) in early pregnancy, and in 20 women (16%) at six weeks postpartum. Postnatal depression accounted for only 15 (12%) of these cases. The annual incidence of affective disorders was 22%, with onset most likely in the first three months post-delivery. O Hara, 1986; O Hara et al., 1984: A series of results have been reported for 99 nulliparous and multiparous public and private patients assessed during the second trimester of pregnancy and at nine weeks postpartum, and six months postpartum. Diagnosis of depression was confirmed with the SADS and RDC, and depressive symptoms were assessed with the BDI. 12 women (12%) were depressed (eight major, four minor) in the postnatal period. The comparison of depression diagnosis and depressive symptomatology showed that mean BDI scores for women actually diagnosed as depressed in the postpartum period were below the recommended BDI cut-off level for even mild depression. Contrary to the usual inflated sores for self-report measures of depression, these results suggest that studies using only BDI scores as the measure of depression may underestimate the prevalence of depression. Alternatively, Appendix 2 Prevalence 159

these results could indicate that diagnostic methods and self-report scales detect different subgroups of depressed women. Hopkins et al., 1987: A prospective study recruited 49 married, white, middle-class women in the United States at six weeks postpartum. Subjects were initially screened at routine postnatal visits with the BDI and 44 women with higher scores (above 10) were interviewed prior to 12 weeks postpartum using the SADS to confirm diagnostic status. Of those interviewed, 25 (51%) women met RDC for major (N=17) or minor (N=8) depression at approximately two to three months postpartum. Gotlib et al., 1989: 295 women were assessed with the BDI and SADS using RDC diagnoses during pregnancy and until four weeks postpartum. The prevalence of postnatal depression was estimated at 6.8%. But 50 women who had the highest prevalence of depression during pregnancy had dropped out of the study prior to the postnatal assessment. The researchers estimated that the true prevalence would have been closer to 13% if not for the attrition of depressed women. There were problems using screening with the BDI to determine which subjects should have SADS interviews, resulting in an inflated number of false negatives. The critical issue reported in these results was that only half of the postnatal subjects had an onset of depression postnatally, and the others were already depressed during pregnancy. Harris et al., 1989a; Harris et al., 1989b: A British study examined major depressive disorder in 147 women and reported a series of results. Women were followed from 16 weeks gestation until six to eight weeks postpartum. Assessments were carried out with clinical interviews using DSM-III-R criteria, the MADRS, and the Raskin Three Area Scale for Depression (Raskin, Schulterbrandt, Reating & Rice, 1967), and self-report including the EPDS and the BDI. 22 women (15%) met DSM-III-R criteria for major depression, and the MADRS (2), EPDS (21), and Raskin scale (22) correctly identified more depressed women than the BDI (13). The false positive scores for self-report measures ranged from lowest with the EPDS (7) to highest with the MADRS (26). Samples were also taken for plasma cortisol, progesterone, oestradiol and prolactin concentrations, and salivary progesterone and cortisol assays (Harris, Johns, Fung, Thomas et al., 1989a). The results did not show any relationship between plasma or salivary cortisol levels, plasma oestradiol concentrations or salivary progesterone data and postnatal depression. Affonso et al., 1991: A prospective American study assessed depression in the first three months postpartum with 202 women who were recruited during pregnancy at 10 to 14 weeks gestation. These women had low-risk pregnancies, were predominantly Caucasian, married and had not been depressed in the year prior to the current planned pregnancy. Major and minor depression was measured using the SADS with RDC criteria, and the reported prevalence was 5%. Campbell & Cohn, 1991: An American study with 1,033 low obstetric risk primiparous married, middle-class women who delivered full-term healthy infants found a 9.3% (N=96) prevalence of major and minor depression at eight weeks postpartum measured by the SADS and RDC. Current depressive symptoms were also measured by the CES-D using a cut-off level of 16, and 13% of the sample were considered depressed. But there was only 60% concordance between the RDC and CES-D outcomes, suggesting that while the latter is useful as a screening instrument, it does not adequately identify clinical depression. 160 Postnatal depresssion A systematic review of published scientific literature to 1999

Boyce et al., 1993: 103 primiparous and multiparous Australian women were assessed at around 12 weeks postpartum using DSM-III-R criteria. 8.7% were diagnosed with major depression. There were significantly different mean EPDS scores for depressed (mean=18) and non-depressed (mean=5) women, although there were no differences in age, marital status, or parity. The onset of depression was evenly distributed over the six-month assessment period. Cooper et al., 1993: 483 women from Oxford were assessed antenatally and followed up for 12 months postpartum. At three months, 243 women were assessed, and postpartum high scorers on the GHQ (N=89, 18.4% of the sample) and a random sample of low scorers (N=48) were interviewed with the PSE to determine diagnostic status. The PSE identified 25 (5.2%) cases of depression. Carothers & Murray, 1990: 702 women from Cambridge were included, of whom 674 returned EPDS questionnaires. But only 646 were willing to continue with the study. All women who had high EPDS scores plus a sample of women with low EPDS scores were assessed with the SPI and the prevalence of major or minor depression was estimated to be 8.6%. Pop et al., 1993: A prospective longitudinal study in the Netherlands with 133 primiparous women and 160 multiparous women who were followed up with RDC assessments at four weeks, ten weeks and eight months postpartum. The incidence of depression was 21 per cent (N=61, 6.8%major, 13.9% minor depression) with the peak prevalence of postantal depression at ten weeks post-delivery. In this study, women did not seem to be especially prone to developing depression in the first ten weeks postpartum, in contrast to other studies. Mallett et al., 1995: 242 women were assessed at eight weeks postpartum and followed up at 12,20 and 28 weeks postpartum, with the RDC, HRSD, and the EPDS. Depression levels were classified as definite major (N=31, 13%), probable major (N=14, 6%), definite minor (N=19, 8%) and probable minor (N=19, 8%). It is unusual to report so many probable depressions as probable cases normally refer to the number or type of required symptoms not being present, or symptom duration and severity criteria not having been met. It would seem that definite cases (21% of the sample) are more reliable estimates, rather than adding in all the probable cases (total of 35%). Areias et al., 1996a; Areias et al., 1996b: Women were recruited from the antenatal clinic and assessed with the EPDS and SADS during pregnancy and at 12 months postpartum. A subsample of the women and their partners (24 women and 12 men) were interviewed at three months postpartum. A significant difference in the incidence of major, minor and intermittent depression was noted for women between antenatal measures (16.7%) and postnatal measures at three months (31.5%). The 12-month incidence of depression for women was 53.7%. The prevalence of depression among their partners remained stable throughout pregnancy and the early postpartum period (4.8% at both times), however the 12-month point prevalence for partners was 28.6%, which was a considerable increase. These results demonstrate a significant difference in depression diagnoses for women compared to men in the first three months postpartum, but not in the following four to twelve postpartum months. However, there were very small subject numbers available for statistical comparisons. Hall et al., 1996: A study of 738 low income, unemployed, predominantly young and single African-American mothers used the CES-D as an estimate of depressive symptoms. It was Appendix 2 Prevalence 161

reported that 42% of the sample had high depression scores, but these results are not generalisable for culture-specific reasons. In addition, the CES-D overestimates dysphoria and may be unsuitable for pregnant and postpartum samples because of the emphasis on somatic complaints. Brugha et al., 1998: Of 507 nulliparous antenatal women recruited in a British study, 163 had complete postnatal GHQ and Schedules for Clinical Assessment in Neuropsychiatry (Wing, Babor, Brugha, Burke et al., 1990) data available which revealed 25 cases (15.3%) of ICD-10 Depression at three months postpartum. However, there were problems with nonresponders which bias the study data. Participants who did not return the three month postnatal GHQ (N=71) were significantly different from the remaining sample of responders (N=427), and they were more likely to have antenatal predictor factors for postnatal depression. They were younger, unemployed or off work sick, came from an ethnic minority, their partner was from a low socioeconomic group, and there was a briefer or more intermittent relationship with the partner. Further, they were more likely to have a past history of at least one suicide attempt and a history of severe psychiatric illness in their relatives, the current pregnancy was unplanned or unwanted, and they reported less support from their partner and mother. Clinician-rated Paykel et al., 1980: 120 women given a semi-structured clinical interview at six weeks postpartum. 20 per cent had mild depressive symptoms. Of the women who became depressed, the depressive symptoms had developed since delivery in 88% of the women. Stein et al., 1989: 483 women were recruited from a British antenatal clinic and interviewed at home about six to eight weeks prior to the expected date of delivery, and of those 460 women were followed up at three months postpartum. Depressive symptoms were assessed with the GHQ (Goldberg, 1972) and the MADRS. 29 (6.3%) women were described as psychiatrically disturbed during pregnancy, while 31 (6.7%) women had unipolar postnatal problems identified. Self-report Pitt, 1968: 305 women recruited in pregnancy. Prevalence assessed at follow-up between six and eight weeks postpartum using a screening questionnaire devised for the study. 33 women (10.8%) were diagnosed as having significant depressive symptoms at 8 weeks postpartum. By 12 months postpartum, 12 women (3.9%) had not improved and 19 (6.2%) had new or exacerbated symptoms. Hayworth et al., 1980: 181 women between 30 and 36 weeks gestation were recruited from a British antenatal clinic and given self-report measures of depression (SRDS), hostility, and locus of control to complete at six weeks postpartum (N=127). Seven women (5.5%) had moderate to severe depressive symptoms and 21 (16.5%) had mild depressive symptoms at six weeks postpartum. Bridge et al., 1985: From a cohort of 161 women, a subgroup of 93 women were assessed in the first trimester of pregnancy in an attempt to predict later self-ratings of depressed postnatal mood (SRDS) up to 12 months postpartum. At six weeks postpartum, 8% had depressive symptoms, with a total of 20 per cent having mild symptoms. There was an overall 162 Postnatal depresssion A systematic review of published scientific literature to 1999

12-month incidence of depressive symptoms in 16.5% of the women, with 40% having mild symptoms. Dennerstein et al., 1989: An international prospective study, in which 329 women were approached during antenatal classes or at public hospital outpatient clinics and 293 women agreed to participate. The final sample comprised 293 primiparous women including 100 women from the Netherlands, 97 from Australia and 96 from Italy. They were aged between 18 and 40, and data was complete for 283 women. They were assessed with the BDI at 28 weeks gestation, four days and four months postpartum. Overall, 43% of women reported a range of postnatal emotional problems, and 14% of the sample had high BDI scores (greater than 17) at four months postpartum. Boyce et al., 1991: 258 Australian primiparous women were approached through a public obstetric hospital to participate in a study. The final sample of 125 women completed postnatal assessments with the EPDS and BDI at three and six months postpartum. There were high EPDS scores (using the recommended cut-off above 12.5) in 8.9% of women at three months and 6.4% at six months. The BDI estimates of depression (using scores above 10.5) were higher, with 13.5% of women being identified as depressed at three months and 11.4% at six months. Hannah et al., 1992: The EPDS was used to screen 217 women in Britain at five days and six weeks postpartum. 17 women (8%) who had mild depressive symptoms at five days postpartum were among the 25 women (11.6%) who had self-reported depressive symptoms at six weeks postpartum, suggesting a link between the maternity blues and postnatal depression for some women. Appleby et al., 1994: A prospective cohort attending a British antenatal clinic at 36 weeks gestation. 178 women were approached, of whom 165 completed antenatal questionnaires, and 126 (77%) women returned the EPDS at eight weeks postpartum. The overall rate of depression was 13%. But this may be an underestimate because there was a trend for women with high antenatal EPDS scores to fail to return their postpartum EPDS. Women who were currently being treated for depression or had received treatment in the past (30.8%) were three times more likely to be depressed than women who had not received any previous treatment (10.6%). Astbury et al., 1994: A population-based study in Victoria, Australia, involved a postal survey of all women who gave birth during one week in 1989. Questionnaires were mailed to 1,193 primiparous and multiparous women at eight months postpartum, and 799 questionnaires were returned with full responses available for 771 women (71.4% of the sample). Younger women, single parents and women born overseas of non-english speaking background were under-represented. Postnatal depression was assessed using the recommended EPDS cut-off level and the point prevalence was 15.4% at eight to nine months postpartum. Stamp & Crowther, 1994: The EPDS was used to screen 235 primiparous and multiparous Australian women in the first few postnatal days, at six weeks (N=222) and six months (N=192). High EPDS scores were recorded for 22 (9%) women while still in hospital (most likely measuring the maternity blues), 21 women (9%) at six weeks and 19 women (10%) at six months postpartum. Appendix 2 Prevalence 163

Webster et al., 1994: The EPDS was used to screen 206 New Zealand women for depression at four weeks postpartum. A prevalence of 7.8% (N=16) was found for significant depressive symptoms using the normal cut-off score. The prevalence increased to 21.5% (N=44) when a lower cut-off level (scores above 9) was used, as sometimes reported for screening purposes. McGill et al., 1995: A study assessing the incidence of postnatal depression in New Zealand recruited postnatal women on alternate days over a six month period. 2,000 women agreed to participate and postal questionnaires including the EPDS were sent at six months postpartum. 20% of women had high EPDS scores. Fergusson et al., 1996: The Avon longitudinal study of pregnancy and childhood enrolled antenatal women in representative health districts over almost two years and about 85%-90% of eligible women (14,893) pregnancies were involved. Data was available for 9,316 women who completed the EPDS at 18 weeks and 32 weeks gestation, and at 8 weeks and 32 weeks postpartum. 10.6% of women were depressed during both antenatal and postnatal periods and 5.8% of women reported only postnatal depression. The observed rates of depression following childbirth were 9.2% of women (N=859) at eight weeks postpartum, and 8.4% of women (N=765) at 32 weeks postpartum. Using latent Markov modelling to examine transitions over repeated measures, 57% of the sample were classified as not vulnerable to depression, and 43% were considered vulnerable to depression. During the postnatal period, 83 % of women depressed at eight weeks remained depressed at 32 weeks postpartum. Warner et al., 1996: A study of British women recruited on alternate days from the postnatal wards of two maternity units over a 20 month period. of the 2,978 eligible subjects, 2,375 (80%) women completed screening interviews with the EPDS at six to eight weeks postdelivery. The sample included primiparous (46%) and multiparous (54%) women, 62% ha planned their pregnancy, and 37% were still breastfeeding at the postnatal screening interview. High EPDS scores were recorded for 280 (11.8%) women. Lane et al., 1997: A prospective Irish study assessed predictors of mood disturbance in postnatal women and their partners. Over a six week period, women who delivered on alternate days at a Dublin hospital were invited to participate (N=385, 15 women were excluded because of language difficulties or poor infant outcomes). 370 women and their partners were informed about the study, and 308 (83%) women and 181 (49%) men agreed to participate. Full data was available for 289 (78%) women and 175 (47%) men. Outcome was assessed with the EPDS and the Highs Scale measuring postnatal elation (Glover, Liddle, Taylor, Adams et al., 1994) at three days and six weeks postpartum. The prevalence of high EPDS scores for women was 11.4% at three days and 11% at six weeks postpartum, while the Highs Scale scores (above seven) were 18.3% at three days and 9% at six weeks postpartum. Outcomes from both measures and both assessment times were correlated, possibly due the significant risk factors remaining unchanged in the sample population. Stuart et al., 1998a American birth records were used to select a sample of primiparous and multiparous mothers of full-term infants. The women were predominantly married, Caucasian, and had delivered their infants in the previous two to three months. 123 women were recruited (60%) of those contacted, and results from 107 women were available for the BDI and EPDS at 14 and 30 weeks postpartum. The joint prevalence of depression (BDI score above 10) was 23.3% at 14 weeks, and 18.7% at 30 weeks postpartum. The incidence of significant depressive symptoms in the assessment time between 14 and 30 weeks postpartum 164 Postnatal depresssion A systematic review of published scientific literature to 1999

was 7.48%. The correlation between anxiety measures (BAI and STAI) and depression measures (BDI and EPDS) was high, and provided strong support for the comorbidity of anxiety and depression up to at least seven months postpartum. 2.2 Summary of studies comparing prevalence between childbearing and nonchildbearing women Rees & Lutkins, 1971: A British study compared 99 women and 77 of their partners with a control group of 27 nulliparous women who worked in a local factor or hospital. The BDI was completed in pregnancy and during the first 12 months postpartum. Using cut-off scores above ten, the incidence of antenatal depressive symptoms was 34% (9% moderate, 3% severe), compared to the postnatal incidence of 30% (10% moderate) for mothers. This was also compared to the incidence of 11% for control women, and the incidence of antenatal depressive symptoms for fathers of 10% (3%) moderate, and postnatal depressive symptoms in fathers of 13% (2% moderate). Childbearing women experienced increases in irritability, fatigue, work inhibition, and lower libido in both antental and postnatal periods, compared to their partners and control subjects. However, there was a poor description of the research methodology in this publication, and the control group was not well matched (differed in age and parity from mothers). Troutman & Cutrona, 1990: Prevalence of depression was compared in adolescents aged 14 to 18, who comprised 128 childbearing and 114 nonchildbearing populations. The acquaintance control method of recruitment was used, where subjects nominated a nulliparous acquaintance within two years of their own age. Pregnant adolescents were recruited from child health clinics or a hospital and from education programs, and assessed with the SADS and RDC during the second or third trimester, and again at six weeks and 12 months postpartum. The same method and timing of assessment was used with the nonchildbearing group. There were no significant differences in major and minor depressive episodes between the childbearing and non-childbearing comparison subjects at six weeks (total prevalence 26% childbearing and 15% non-childbearing) or 12 months (total prevalence 20% childbearing and 19% non-childbearing) postpartum. However, the difference between groups for six-week prevalence of minor depression (20% childbearing group, 10% controls) approached significance. O Hara et al., 1991a: Hormonal data was available for 18 of 19 childbearing women who were depressed, and overall there were few differences between childbearing and nonchildbearing groups, except that childbearing women had significantly lower levels of oestradiol at 36 weeks gestation and on day two postpartum. There were no significant differences between depressed and non-depressed women for free or total oestradiol, progesterone, prolactin, total plasma cortisol, urinary free cortisol, or for ratios of prolactin to oestradiol or progesterone at any assessment point. However, there was very strong support for the vulnerability-life stress hypothesis in predicting postnatal depression for the childbearing group and slightly less support, although significant results, for the prediction of depression in the non-childbearing women. A number of problems with the study design - including that it failed to provide a well-matched comparison sample, and that 56% of the childbearing women approached for the study refused to participate - raise questions about the reliability of the findings. Nevertheless, there were no significant differences in reports of prior personal history of depression between childbearing (36.8%) and non-childbearing (40.2%) women or Appendix 2 Prevalence 165

in family psychopathology (both groups 38%). However, the lifetime risk of major depression has been reported as between 10% and 20% for women (Kessler, McGonagle, Zhao, Nelson et al., 1994; Szewczyk & Chennault, 1997; Wisner & Stowe, 1997). The depression history reported by the two groups in this study is well above the expected range for a relatively young population (mean age 27). Cox et al., 1993a: A Scottish study recruited women at antenatal clinics and through the Edinburgh birth register. Women were sent the EPDS at five months postpartum and 243 (97%) returned their questionnaires. This childbearing group was marched with control group women recruited from general practice registers and aged between 16 and 45 years, who were neither pregnant nor had given birth in the previous 12 months. The final sample included 232 matched pairs. From 147 postnatal women selected for interview with the SPI (96 with EPDS scores above nine and 51 with EPDS scores below eight), there were 137 interviews completed. In comparison, 156 control women were selected for SPI assessment (106 high and 50 low EPDS scores) and 140 interviews were completed. With attrition, this eventually left 129 postnatal women and 136 control women in the final sample. The two groups were satisfactorily matched for marital status, number of children and social class. Postnatal women were slightly younger than controls and predominantly working class. There were no significant differences between groups for six month point prevalence of RDC diagnosis of depression, with 9.1% childbearing women (N=21, major 3.5%, minor 5.6%), and 8.2% non-childbearing control women (N=19, major 3.5%, minor 4.7%) meeting diagnostic criteria. This was similar to the six-month incidence of 13.8% (6.5% major, 7.3% minor) for postnatal women and 13.4% (5.6% major, 7.8% minor) for control women. However, the depression for three postnatal women began during pregnancy, and in three of the control women with prolonged depression, it had begun after an earlier childbearing experience. Therefore, the three depressed women from the control group actually had chronic child-birth related depression following a previous delivery, and should not have been included in the non-childbearing comparison group. For 16 (76%) postnatal women, the depression began less than five weeks after delivery, compared with only five (26%) control women in the same time span. This indicates there is an increased risk of depression within the first month after delivery, suggesting that childbirth and its immediate sequelae are important causal factors for unipolar postnatal depression. Gair, 1994: In a qualitative study using the EPDS as a screening tool, high scores were found in five of 18 Australian women (27%) who had adopted an infant. The scale was administered verbally by the researcher, which may have affected the results. Nor is it known when the scale was administered. Nevertheless, these results suggest the stresses of motherhood do not occur exclusively for women who have given birth, and supports the hypothesis that childrearing can act as a specific stressor. Augusto et al., 1996: This study examined point prevalence of depression between two and five months postpartum in Portuguese women compared with a matched group of nonchildbearing women. From 410 childbearing women identified in one year, 352 (85.9%) agreed to participate, and the last 118 women recruited were asked to nominate potential controls - close friends who were within two years of their own age and not childbearing in the past two years. There was no difference between the groups in terms of parity or social class, although the controls were on average two years older and had fewer children. Assessments with the EPDS and SRDS were completed between nine and 20 weeks 166 Postnatal depresssion A systematic review of published scientific literature to 1999

postpartum, with a mean of 15 weeks postpartum. The point prevalence of depression with the EPDS was 13.1% in the full childbearing sample, 16.1% in the postpartum comparison group and 7.6% in non-childbearing controls. Therefore the risk of depression was more than double in postpartum women compared to matched non-childbearing women. As well, more postpartum women (6.8%) had significantly high depression scores compared with no women having high scores in the control group. In contrast to earlier studies, postnatal women were found to be more severely depressed than non-childbearing controls. However, the women may have nominated friends who were well, which would introduce a significant bias. 2.3 Summary of studies of prevalence of postnatal depression in different cultures Cox, 1983a: A comparison of the prevalence of postnatal depression in 183 Ugandan women and 89 Scottish women at six to 15 weeks postpartum found incidence of 10% and 13% respectively. The researchers concluded that a traditional way of life and having a home delivery did not reduce the likelihood of developing postnatal depression. Williams & Carmichael, 1985: From a total birth cohort of 272 urban multi-ethnic families in Australia, 99 families were followed up during the first postnatal year to assess maternal depression through child health nurse and paediatrician observations and information from same-culture interpreters. The assessors were not mental health specialists and no standardised methods for diagnosing depression or depressive symptoms were available at that time for use with immigrant women from varying cultures. 10 mothers (10%) were considered to be severely depressed, 16 (16%) moderately, and 9 (9%) were mildly affected, with no significant differences between the 35 Australian women and 64 immigrant women (mainly middle and southern European). Watson & Evans, 1986: A British study measured psychiatric morbidity with the GHQ in 101 women at eight weeks, eight months and 14 months postpartum with women from three cultures (45 indigenous English, 19 Bengali, 16 English speaking immigrants complete ted the GHQ at these times). 19 per cent of the overall sample had high GHQ scores at eight weeks, 13% at eight months and 19% at 14 months. There were no significant differences between the cultural groups in GHQ scores. Jadresic et al., 1995: 108 women in Chile recruited in an antenatal clinic used RDC diagnoses at two to three months postpartum and identified 10.2% of the cohort with postnatal depression. Moon Park & Dimigen, 1995: The hypothesis that traditional approaches in non-western cultures would protect against postnatal depression was investigated by comparing BDI scores for 157 women from two cultures to assess whether depression rates were different. 105 mothers recruited from hospitals in Korea who had definite cultural traditions associated with childbirth were compared with 52 mothers recruited from Scotland where the postpartum period was not clearly structured. There were no obvious differences between groups in age, education, marital status, or employment. Scottish BDI scores (mean 6.72) were significantly lower than Korean BDI scores (mean 11.22). There were no significant differences for affective-cognitive items, although Korean women scored significantly higher on somatic items. Appendix 2 Prevalence 167

Ghubash et al., 1997: 95 women in the United Arab Emirates were assessed with the EPDS at one week postpartum and the PSE at eight weeks postpartum. High EPDS scores occurred for 18% at one week postpartum possibly measuring the maternity blues, and 14% met PSE criteria for depression at eight weeks postpartum. Kit et al., 1997: In 154 Malaysian women (Indian, Malay and Chinese) recruited from the postnatal clinic, only 3.9% reported depressive symptoms with the EPDS at six weeks postpartum. Matthey et al., 1997: An Australian study with 128 Anglo-Celtic, 126 Vietnamese and 125 Arabic women who were recruited from public hospital antenatal clinics during pregnancy used assessments at six weeks and six months postpartum with the GHQ-30, the EPDS and the DIS. Vietnamese and Arabic women reported fewer depressive symptoms during the diagnostic interview. Some Vietnamese women commented that items in the interview were culturally inappropriate and to admit to such problems would bring shame on them. Women were more likely to reveal symptoms with the self-report scales. There were no significant differences amount the the groups on EPDS scores at six to eight weeks postpartum. Although there were significant differences in GHQ mean scores, both the Vietnamese and Arabic groups had higher scores than the Anglo-Celtic group of women. Tamaki et al., 1997: A cross-sectional study assessed different groups of Japanese women using the EPDS at one month (N=1,096), three months (N=822), and four months (n=913) postpartum. Questionnaires were filled in by 627 women at all time points. At one month, 18 per cent of women had high EPDS scores, 12% at three months and 6.7% at four months postpartum. Women who practised Satogaeri (going home to stay with their mother for the first postnatal month) were not protected from postnatal depression. Yoshida et al., 1997a: To assess whether Japanese women who gave birth in Britain might have higher levels of postnatal depression than women giving birthing Japan, 98 women were assessed from 36 weeks gestation until three months postpartum. The measures used were the EPDS and SADS interviews with RDC to obtain depression diagnosis. 12 mothers (12%) met the criteria for depression with onset during the first three months postpartum (six major, six minor), and peak onset occurring at one month. These results were comparable to estimates of postnatal depression in Japan. It has been asserted that the admission rate for postpartum psychiatric illness is considerably lower in Japan than in other countries (Okano, Nomura, Kumar, Kaneko et al., 1998). However, this study included only 32 (out of 37) women admitted to psychiatric hospitals within three months of childbirth between 1986 and 1990, from a total of 93,739 live births. An unknown number of women with less severe illness may have been managed in community or non-psychiatric clinics and hospitals. The point prevalence of unipolar affective disorders in Japanese mothers was estimated as 3.3% by interview with DSM-III-R criteria and 8.2% using RDC diagnoses (Okano & Nomura, 1992). The authors claimed that the Japanese custom of Satogaeri might reduce stress and prevent or delay the onset of postnatal illness, but no evidence was found to support this conclusion. As well, the stigma of mental illness in Japan may result in lower rates of the presentation and diagnosis of psychiatric disorders (Okano, Nomura, Kumar, Kaneko et al., 1998). 168 Postnatal depresssion A systematic review of published scientific literature to 1999

Glasser et al., 1998: A comparison was made between a community-based sample of 288 Israeli-born women and Russian immigrant women assessed at 26 weeks gestation with the BDI and at six weeks postpartum with the EPDS. The study group was unrepresentative of national demographics in Israel because it contained a higher proportion of adolescent mothers and more immigrant women with less education. 34% of women had high BDI scores during pregnancy (19.4% mild, 14% moderate-severe) and 22.6% had high EPDS scores (cut-off score above nine) at six weeks postpartum, with 44% of women being depressed at both assessment points. Immigrant status was the only significant risk factor in predicting postnatal depression. It is difficult to accurately compare the antenatal and postnatal depression scores in this study because of the use of different depression measures at each interval. Hearn et al., 1998: A British study with 185 Caucasian and Asian women who delivered in a seven month period and were recruited at the six to eight week postpartum check up. 176 women were assessed with the EPDS and 30 (17%) had depressive symptoms. There were significant differences in the number of high EPDS scores between Caucasian (13%) and Asian (54.5%) women. The authors suggested that women from ethnic minorities might be at higher risk of postnatal depression. But there was a potential bias in the sample, as only women who attended the postnatal check were recruited, and depressed women may be less frequent attendees of follow-up appointments. Piyasil, 1998: Using DSM-IV criteria, a paediatrician assessed anxiety and depression symptoms during the first postnatal week in Thai adolescent mothers (less than 18) and older mothers (20 to 35). No cases of major depression were reported. There were significant differences in depression scores (23% adolescents compared to 12% adults had high scores), but no differences in anxiety scores. The timing of assessment may mean the study actually reports maternity blues in Thai women. 2.4 Summary of studies on course of postnatal depression Onset Kumar & Robson, 1984: Three times as many cases have been detected at three months compared to six months and 12 months postpartum. Cooper et al., 1988: 40 per cent of new cases occurred within the first three months postpartum. About 25% of new cases have their onset between six and 12 months. Watson et al., 1984; O Hara et al., 1990: 66-69% of new cases occurred within the first three months postpartum. Ballard et al., 1993a : Seasonal variation was investigated amongst couples recruited from a British postnatal ward and assessed with the EPDS at six weeks (N=178) and six months postpartum (N=148) (). All high scorers and a sample of low scorers were assessed by interview to give RDC diagnoses at six months postpartum with 28 (19%) women and 13 (9%) men considered cases. The season variation was significant, with depression occurring more often in autumn and slightly less so in spring, confirming similar findings for nonpuerperal depression (Ballard, Mohan & Davis, 1993a). Appendix 2 Prevalence 169

Duration Pitt, 1968: Of 305 women studied, 12 (43%) of the 28 women diagnosed with postnatal depression were still depressed at their infant s first birthday. Kumar & Robson, 1984: In a study conducting diagnostic interviews with women at six and 12 months postpartum, half of the women who had been depressed at three months were still depressed at six months postpartum, but none were considered cases at the end of the first postnatal year. Watson et al., 1984: 25 per cent of women with postnatal depression had episodes lasting three or more months and a further 25% had episodes that lasted over six months following childbirth. O Hara, 1986: In a study of 99 women, 12% were depressed by nine weeks postpartum according to RDC diagnosis, and half of these cases recorded symptoms in the first week postdelivery. But episodes began as late as six weeks postpartum and the mean duration of an episode was 3.3 weeks (range from one to six weeks). Cooper et al., 1988: About two-thirds of cases had episodes of three months or less. Cooper & Murray, 1995: The course of postnatal depression was studied in three groups of primiparous women: 34 without a prior history of depression, 21 with prior depressive episodes, and a control group of 40 of psychiatrically well women. The groups were originally screened with the EPDS at six weeks postpartum and interviewed with the PSE at two to three months postpartum to determine diagnostic status. The mothers were reassessed with the SADS and RDC when their children were 18 months and five years old. Women who had no previous episode of depression had a significantly shorter episode of postnatal mood disturbance compared with women who had previously had non-puerperal depression, and 73% of first episodes of depression which started within six weeks of delivery lasted less than three months. One woman from each of the depressed groups remained depressed for the entire 18-month period, and four (9.5%) women from the control group experienced episodes of major or minor depression. Recurrence Williams & Carmichael, 1991; Williams & Carmichael, 1985: In a follow-up study of 224 families from an original birth cohort of 272 multi-ethnic families from a poor socioeconomic suburb in Australia, 27% of mothers still had significant depressive symptoms four years later. In an earlier study with a subgroup of 99 from the same cohort, 35% of women were depressed during the first postnatal year. At four-year follow-up, the most important association with depression was the quality of the marital relationship particularly in relation to support offered. 50 mothers (22%) had significant depressive symptoms for two or more years duration. Campbell et al., 1992: This examined the course and recurrence of postnatal depression in primiparous women expecting full-term healthy singletons, by screening 1,400 women. Those who met the RDC criteria for depression between six and eight weeks postpartum (8.8%) were included with a sample of well-matched, non-depressed women from the same population. The study compared 70 depressed (56% major, 33% probable major, 11% minor) and 59 non-depressed women who were followed up for two years. At four months 170 Postnatal depresssion A systematic review of published scientific literature to 1999

postpartum, 50% of the depressed women still met criteria for depression and by six months, only 25% of the sample were still depressed, although more than 40% continued to report subclinical levels of depressive symptoms. The average duration of depressive episodes was four months, and women who were depressed for longer periods reported lower levels of partner support and infants who were more fussy or difficult to manage. Bell et al., 1993: Relapse based on subsequent referral to mental health services was assessed for women who had been initially admitted to a mother-infant unit in a psychiatric hospital within six months of childbirth. 40 % of women had a diagnosis of major depression. Follow up was conducted on average 8.8 years after admission, and of 53 (80%) women assessed, a total of 58% had relapsed. But 71% of women with a previous history of non-puerperal illness relapsed compared to only 39% of women who had only experienced a puerperal illness. This study pointed out the problems encountered in defining what actually constitutes a relapse. England et al., 1994: A retrospective case-note review of 100 outpatient referrals for postnatal depression found that nearly 19% of major depression cases and 10% of minor depression cases became chronic, ie the illness lasted longer than two years. This suggests that chronicity in postpartum depression is similar t non-puerperal depression, and an increased length of delay before seeking adequate treatment adversely affected the depressive conditions. Small et al., 1994a; Small et al., 1994b: An Australian case-control study. Women who had participated in a population-based survey at eight to nine months postpartum and who had high EPDS scores were followed up 12 to 18 months later when their children were around two years old. 45 women were interviewed and, as measured by the EPDS, women who had been depressed at eight to nine months postpartum were significantly more likely to remain depressed at follow up (N=15, 33.3%) compared with the control group (N=2, 4.4%). Cooper & Murray, 1995: Recurrence was also studied by following for five years three groups of primiparous women, including 34 with no history of depression, 21 with prior depressive episodes, and a control group of 40. 35% of the control group had depression, compared with 60% of the women who had experienced postnatal depression, although there was a nonsignificant difference between groups for postnatal depression as first onset (56%) or recurrent depression (67%). But when the recurrence of depression was categorised as puerperal (subsequent to another delivery) or non-puerperal, there were significant differences between all groups. Women with the first episode of depression in the puerperium were significantly less likely to experience a non-puerperal depression and more likely to develop a subsequent postpartum episode than were women with a previous history of depressive episodes. 2.5 Summary of studies on depression in fathers Zaslow et al., 1984: An observational case study with 37 middle-class American families with firstborn infants. 62% of fathers and 89% of mothers retrospectively reported having experienced a depressed mood between birth and up to four months postpartum. No father was assessed as being clinically depressed or needing professional assistance. The behaviour in the 11 families where the father s mood had been low for more than eight days was assessed during home visits and compared to the 14 families whose fathers who had not reported any depressed mood. The home observers were blind to the fathers mood reports. The depressed group of fathers had fewer vocalisations with the infant, less caregiving and touching, and Appendix 2 Prevalence 171

diminished proximity to the infant and their partner, often going away to a separate room in the house. These fathers were less likely to focus on their infant as a topic of conversation. In these families, the mothers spent significantly more time with their infants and engaged in more vigorous tactile contact, in comparison to families where the fathers did not have depressed moods. Vigorous tactile and kinaesthetic stimulatory behaviours are usually exhibited during fathers play with infants are not commonly observed amongst mothers. Quadagno et al., 1986: 21 couples were recruited during the third trimester of pregnancy and followed up during the first postnatal week and at six months after delivery. Adjective checklists assessing 20 different emotions in both mothers and fathers were completed daily for 10 days at each assessment period. Men and women checked similar adjectives during the immediate postpartum period, including nervous, worried, helpless, anxious, enthusiastic and happy. Harvey & McGrath, 1988: 40 men whose wives were admitted to a mother-infant unit with puerperal psychosis were compared with 25 men whose wives had no postpartum psychopathology. Anxiety and depressive disorders were present in 42% of men in the index group compared to 4% of men with non-depressed partners. 7 (17.5%) of the index men met DSM-III criteria for major depression or dysthymia. Marital and social function was poorer in the index group than in the comparison group. Raskin et al., 1990: 86 couples were assessed during pregnancy and at eight weeks postdelivery with the CES-D, finding a prevalence of 22% of depressive symptoms in both mothers and fathers. Carro et al., 1993: In a prospective, longitudinal study, 70 couples initially assessed at one month postpartum were followed up when their child was between two and three years old to assess the likelihood that parental factors can be sources of risk or protection for subsequent childhood development. Parental depressive symptoms were measured with the BDI and mothers completed the Child Behaviour Checklist (Achenbach, Edelbrock & Howell, 1987). Maternal and paternal depressive symptoms were clearly implicated as risk factors for later child maladjustment, both alone and in combination with each other. There were no indications that low paternal depressive served as a protective factor for children. Lovestone & Kumar, 1993: Of 24 partners of women who had been admitted to a motherinfant unit, 12 (50%) of the men assessed with the SADS met RDC or DSM-III criteria for psychiatric disturbance. This included 10 (41.7%) men who had major or minor depression. Ballard et al., 1994: In a community sample of 200 couples assessed at six weeks and six months postpartum with the EPDS, 10% of fathers were depressed at six weeks postpartum and 5% were depressed at six months postpartum. Fathers were significantly more likely to be diagnosed with depression if their partner was also depressed. Areias et al., 1996a; Areias et al., 1996b: In a study with 54 primiparous Portuguese women and 42 of their partners, assessments were made with the EPDS and SADS during pregnancy and at three, six and 12 months postpartum. The prevalence of depression in men, measured by SADS interviews, remained stable throughout pregnancy and the early postpartum period (4.8% at both times), but reached 28.6% at 12 months. 21.4% of men in this sample reported a history of depression and another five (11.6%) had other diagnoses (two anxiety disorders, two alcoholism and one drug dependence). 172 Postnatal depresssion A systematic review of published scientific literature to 1999

Lane et al., 1997: A prospective Irish study assessed predictors of mood disturbances in women and their partners in the postpartum period. Full data was available for 289 women and 175 of their partners. Six men (3%) had high EPDS scores at three days postpartum and two men (1.2%) with high scores at six weeks postpartum. In only one couple were both partners depressed concurrently. Deater-Deckard et al., 1998: 7,018 men, whose partners were involved in the Avon longitudinal study of pregnancy and childbirth in Britain, completed postal questionnaires including the EPDS at about 18 weeks gestation and eight weeks postpartum. Using a cut-off score above 12 at each assessment, 3.5% (N=232) of men reported expressive symptoms at 18 weeks gestation as did 3.35% (N=219) of men at eight weeks postpartum. The stability of these results over time suggests that the events surrounding childbirth did not constitute a specific risk factor for men, in contrast to the reported effects of childbirth on women. Men whose partners were depressed before or after the birth and men who lived in stepfamilies were significantly more likely to be depressed themselves. A high EPDS score in men was related to being an older age, having less education, experiencing more stressful life events, receiving less social support, having a smaller social network, and having more aggressive and less affectionate partner relationships. 2.6 Summary of studies on effects of postnatal depression on the infant Robson & Kumar, 1980: In Britain, a cohort of 193 primiparous (N=153) and multiparous (N=40) women were recruited, resulting in 112 women being interviewed on day seven postpartum regarding perceptions and feelings about their newborn infant. 40% of primiparous women and 25% of multiparous women recalled that the strongest emotional reaction when holding their newborn infants for the first time was indifference. At three months postpartum, mothers who were clinically depressed were more likely to express feelings of indifference or dislike towards their infant than mothers who were not depressed. Cutrona & Troutman, 1986: In a study with 55 women recruited from antenatal classes, infant temperament and perceived difficulty to manage was strongly related to the mother s level of depression as assessed with the BDI at three months postpartum. Mothers completed reports on their infants crying behaviour, which was also confirmed by direct independent observations. Hopkins et al., 1987: A prospective study in the US recruited 49 women who were married, Caucasian, middle-class primiparous at six weeks postpartum. It found that infant-related stressors (both neonatal health complications and infant temperament) were significantly associated with postnatal depression. The infants of depressed mothers were rated as more difficult, fussy and unadaptable than were the infants of non-depressed mothers. This was not just a function of maternal perception as there was some independent assessment. The researchers concluded that negative maternal perceptions of infant temperament might lead to reciprocal negative patterns of mother-infant interactions, regardless of the original causes. Zekoski et al., 1987: 30 non-depressed mothers were randomly assigned to participate in a mood-induction procedure followed by a 10-minute video-recorded interaction with their infant several months after delivery. Infants appeared more distressed when their mothers adopted a depressed mood than either neutral or elated mood states. The infants were less responsive to their depressed mother and this Appendix 2 Prevalence 173

offered less opportunity for reciprocal interaction. Mothers in the depressed mood state were less successful than the other groups at eliciting positive responses from their infants. Field et al., 1988: In an American study with 74 African-American and Cuban mothers and their three to six month old infants, 40 depressed and 34 non-depressed mothers were compared regarding interactions with their infant. The infant s behaviour with a nondepressed stranger was also assessed. Physiological measures and three minute videotaped interactions were used to assess infants responses. Depressed mothers received lower ratings than did non-depressed mothers on all interaction behaviours. The infants of depressed mothers also received lower interaction ratings with their own mothers, and also had elevated heart rate and cortisol levels during the interactions with their own mothers, suggesting they were generally stressed during the interactions. They also received lower ratings of interaction with the non-depressed stranger than did infants of non-depressed mothers. The nondepressed strangers were also rated as less appropriately interactive with these infants. It was hypothesised that the avoidance and unresponsiveness displayed by these infants caused the non-depressed stranger to behave in a depressed-like manner when interacting with them. Whiffen & Gotlib, 1989: A Canadian study selected 50 women from a larger investigation of depression during pregnancy and the postpartum period to assess the association between depression and specific infant characteristics. At two months postpartum, depressed mothers experienced significantly more difficulties with infant care and were more bothered by their infants behaviour than non-depressed mothers. Independent assessments confirmed that infants of depressed mothers expressed more negative emotions and their behaviour deteriorated quicker during testing, suggesting they responded negatively to stress quicker than did infants of non-depressed mothers. But there was no significant difference in mothers ratings of their infants temperaments, suggesting that depressed mothers blamed themselves, rather than their infants, for their perception that infant care was difficult. These infants were more temperamentally difficult at two months postpartum than infants of non-depressed mothers, but it is still not clear whether such infant characteristics precede or follow maternal depression. Stein et al., 1991: The ongoing effects of maternal depression on maternal-infant interaction were reported for mothers who had participated in an earlier study of postnatal depression. They were followed up when their infants were 19 months. The interaction between 49 depressed mothers and their infants was found to be less mutually responsive and harmonious than for 49 non-depressed mothers and their infants. Depressed mothers were rated as having less rapport with their infants, who were rated as showing less concentration and more negative responses. They were also more likely to exhibit marked distress at their mother s departure and tended to be less sociable with a stranger. They were considered to be less securely bonded with their mothers. These adverse infant outcomes were still obvious even when the mother s depression had remitted. Murray, 1992a; Carothers & Murray, 1990: A study comparing the children of 56 depressed and 42 non-depressed women up to the age of 18 months assessed cognitive, social and behavioural development. The results showed some adverse outcomes for children of postnatally depressed mothers, including being more likely to have behaviour problems at 18 months of age, including tantrums, disruptive sleeping and feeding, and separation problems. 174 Postnatal depresssion A systematic review of published scientific literature to 1999

Miller et al., 1993: A Canadian study recruited 113 women during the third trimester of pregnancy and assessed a final sample of 88 women with the GHQ, STAI and the Pitt Depression questionnaire at 33 to 36 weeks gestation and at five weeks postpartum. Mothers were also asked to keep a diary for one week regarding infant behaviour at five weeks postpartum. There was no relationship between maternal antenatal mood and infant crying at five to six weeks of age. But lower maternal postnatal mood and higher maternal anxiety were significantly related to increased infant behaviours, including fussiness, less time spent sleeping, longer and more frequent crying, and colic. Milgrom et al., 1995: An Australian study compared maternal ratings of infant crying at three and six months postpartum in 29 depressed and 44 non-depressed mothers. The three-month assessment found infants of depressed mothers cried significantly more than did infants of non-depressed mothers. But by six months, there was little difference between the groups regarding reported amounts of infants crying. There were no significant differences in rating of infant temperament between the two groups. Murray et al., 1996a; Murray et al., 1996b: A British longitudinal study has produced multiple publications from a low-risk, middle-class sample. 702 primiparous women with healthy infants were recruited from a maternity hospital and assessed at six weeks postpartum with the EPDS and the SPI to identify probable cases of depression. 56 depressed and 42 non-depressed mother-infant pairs participated in the study. There was little difference observed in the behaviour of the two groups of infants. Levels of positive engagement with the mother were comparable, as were infant expressions of avoidance or distress. Depressed mothers were less sensitively attuned to their infants, less affirming of their infant and more negating of their infant s experience. Disturbances in early mother-infant interactions were also predictive of poor infant cognitive outcome at 18 months of age. Another report from the same study investigated the role of infant factors and mother-infant interactions in women at high and low risk of postnatal depression in an attempt to determine whether the effect of neonatal behaviour differed between the two groups. 238 high risk women were identified, of whom 188 mothers of healthy, full-term singletons agreed to be involved. A random sample of 43 women at low risk for depression was identified. 32% of high risk women and 19% of low risk women were diagnosed with major depression by two months postpartum. Video recordings of made of a subgroup of 32 mothers with irritable infants and a random sample of 45 mothers with non-irritable infants. They were filmed during play at two months postpartum. Mothers perceptions of their infants unsettled or irregular behaviour in the first postpartum week were also predictive of postnatal depression, such that 54% (20 out of 37 mothers) who perceived their infant as highly unsettled became depressed. Of the mothers with more settled infants, 22% (27 out of 121 mothers) became depressed. The findings suggest that maternal mood is closely related to the course of infant development, and for vulnerable women having an irritable infant with poor motor control significantly increases the likelihood of postnatal depression. Appendix 2 Prevalence 175

2.7 Summary of studies of effects of postnatal depression on older children Richman, 1978: Three-quarters of eight-year-old children with reading difficulties had mothers who were depressed when the children were three years old. Wrate et al., 1985: This study focused on the three year old pre-school children of mothers who had been diagnosed with postnatal depression in an earlier study (Cox, 1983b). The depressed mothers described their preschool children more negatively and more often reported behavioural problems compared with non-depressed mothers. Philipps & O Hara, 1991: In a follow-up study when children were 4.5 years old, postnatal depression exerted an indirect effect on children s behaviour problems. Murray, 1992a; Murray et al., 1996b: A study of children with depressed mothers found that boys performed significantly poorly on cognitive tasks at 18 months, compared with children of non-depressed mothers. Sinclair & Murray, 1998: Five year old children whose mothers had postnatal depression were more likely than control children to be rated by their teachers as behaviourally disturbed. This disturbance was most prominent in boys, while girls of depressed mothers showed a trend to be rated as more prosocial than control women. Sharp et al., 1995: 60 children of mothers who had been depressed in the postpartum period were compared with 75 children of non-depressed mothers. There was a specific gender effect of maternal depression on the cognitive development of four year old boys, but the daughters of depressed mothers performed as well as the control group. 176 Postnatal depresssion A systematic review of published scientific literature to 1999

APPENDIX 3 RISK FACTORS 3.1 Further details of studies of risk factors for postnatal depression 3.1.1 Confirmed risk factors History of antenatal depression O Hara et al., 1982; O Hara et al., 1984; O Hara, 1986; Gotlib et al., 1991; Bernazzani et al., 1997: Propsective studies in America and Canada with large samples of nulliparous and multiparous women from public and private practices assessed during pregnancy and at nine weeks, three months or six months postpartum, demonstrated that elevated antenatal BDI scores were signficant predictors of postnatal depression. This lead the researchers to conclude that depression during pregnancy is a significant risk factor for postnatal depression. Marital relationship Dimitrovsky et al., 1987: An Israeli study found that poor attitudes towards partners were significantly associated with both antenatal and postnatal depression. Paykel et al., 1980; O Hara et al., 1983: Depressed women reported less likelihood of discussing problems with their partner, and being less able to rely on each other for practical or emotional support than non-depressed postnatal women. Schweitzer et al., 1988: Women with postnatal depression are more likely to perceive their marriage as troubled and less intimate, and their partners as less empathic and supportive. Relationships characterised by high levels of control and low levels of care and marital intimacy have also been associated with postnatal depression. Stemp et al., 1986: Lack of partner support and low marital intimacy are key factors in postnatal distress. Lack of support Logsdon, McBride & Birkimer, 1994: Discrepancies between antenatal expectations of support and perceptions of postnatal support actually received were investigated with a convenience sample of 105 women surveyed onemonth before and six weeks after delivery. The only significant difference between expectations and reality was that women expected to feel closer to their husbands than they did, and women with closer marital relationships were less depressed than women who were dissatisfied with their relationship. Small et al., 1994a; Small et al., 1994b: An Australian case-control study followed up two years after childbirth 45 women who had reported high EPDS scores in an earlier population based study. The factors women believed contributed to feeling depressed were lack of support, isolation, fatigue and physical health problems, and factors they believed contributed to their recovery were more partner support, less fatigue, their child getting older and resuming outside work. Depressed women were significantly more likely to have a Appendix 3 Risk factors 177

temperamentally difficult infant, less partner support with household tasks and more negative events occurring since the birth than non-depressed women in the control group. Stressful life events Brown & Harris, 1978: A community survey in London examined the relationship between psychosocial stressors and subsequent affective disorders in women. Stressful life events or chronic difficulties, family bereavement, unsuitable housing, financial problems, caring for three or more children, lack of social and emotional support and no outside employment were all associated with depression in working class married women with young children. Hall et al., 1996: A study wtih low income, unemployed, predominantly young and single African-American mothers reported that depression was related to higher levels of everyday stressors and number of negative life events, low self-esteem, and poor quality primary relationships. Orr et al., 1989: In an American study, exposure to both acute and chronic environmental stressors was significantly associated with a three times greater risk of depression in mothers of young children than in women without stressful events. Powell & Drotar, 1992: An American study with 287 low obstetric risk private patients examined the relationship between social support, daily hassles and depressed mood measured by the BDI at 36 weeks gestation, and at two months and six months postpartum. Daily hassles had a more negative impact than either childcare or life event stressors in this sample and were more predictive of increased depressive symptomatology. 3.1.2 Probable risk factors Single parenthood Lipman et al., 1997: A large, cross-sectional community survey conducted in Canada examined the sociodemographic, physical and mental health characteristics of mothers. Of the 9,953 eligible participants, 1,540 were mothers with at least one dependent child (under 16 years) of whom 288 (18.7%) were single mothers. Single mothers were significantly more likely to be poor, younger (under 25 years) and have current mental health problems or a history of affective disorder. Single mother status was the strongest predictor of mental health morbidity (major depression in the past year), and single mothers were significantly more likely to have used mental health services than mothes with partners. These results do not relate specifically to the first postnatal year. Severe maternity blues Hapgood et al., 1988: A prospective New Zealand study with 66 women found that maternity blues ratings were not associated with previous obstetric history, current pregnancy, labour or delivery experiences, parity or breastfeeding variables. However, mood lability in the first two weeks postpartum was associated with postnatal depression within six months postpartum, and it was suggested that the maternity blues may identify women at risk of postnatal depression, especially in the context of a personal and family history of affective disorder. 178 Postnatal depresssion A systematic review of published scientific literature to 1999

Hannah et al., 1992: In a British study of 217 women given the EPDS at five days and six weeks postpartum, 8% of women had mild depressive symptoms at five days and were amont the 11.6% reporting depressive symptoms at six weeks postpartum. Nevertheless, 42% of women who had depressive sumptoms in the first postpartum week were not depressed later in the postnatal period, which means that hormonal changes are probably only significant for a small proportion of postnatal women. Pop et al., 1993: A prospective study of 293 women in the Netherlands demonstrated that having severe maternity blues was signficantl related only with postnatal minor depressiong assessed using RDC at four and ten weeks postpartum. However, the association of the maternity blues with maternal depression weakened later in the postnatal year. Birth experiences and obstetric complications Astbury et al., 1994; Brown & Lumley, 1994: A population-based Australian survey of 771 women demonstrated that high EPDS scores at eight to nine months postpartum were significantly associated with having an assisted delivery (caesarean section, forceps, vacuum extraction) and having unwanted people present at the birth (including family, staff and students). Additional results were reported in relation to women s satisfaction with care received during labour and delivery. However, these results do not include those women who had an elective caesarean section delivery (final sample N = 690). Factors associated with dissatisfaction of care were having an emergency caesarean section, increased obstetric interventions for primiparous women (induction, epidural anaesthesia, forceps, and episiotomy) and not being able to hold the infant soon after birth. These factors were among those selected for a logistic regression model. Other significant factors were lack of involvement in decision making, being given insufficient information, a perception that staff were unhelpful, finding the pain worse than expected, and having lower education levels. Boyce & Todd, 1992: An Australian study investigated whether delivery by emergency caesarean section increases the risk of postnatal depression. 192 primiparous women were recruited in the first trimester of pregnancy through a hospital antenatal clinic and assessed with the EPDS at one, three and six months postpartum. Four women who had elective caesarean section were excluded (N = 188) and 21 (11%) women had an emergency caesarean section, 49 (26%) had a forceps delivery, and 118 (61%) had a spontaneous vaginal delivery. These groups were significantly different in age with the oldest women more likely to have had emergency caesarean sections. However, analysis showed that maternal age was not significantly associated with an increased risk of postnatal depression. There were no personality differences between groups. There were significant differences in EPDS scores at three months postpartum between women having emergency caesarean sections, 46% scoring above the cutoff level, compared with women having forceps and spontaneous vaginal delivery (6.8%). The researchers concluded that women having emergency caesarean sections were six times more likely to develop postnatal depression at three months postpartum. It was suggested that women recover more rapidly from the physical complications of operative delivery than the psychological complications and they were also less likely to receive psychosocial assessments, treatment or prevention within current health care systems. Appendix 3 Risk factors 179

Burger et al., 1993: A retrospective survey investigated whether complicated pregnancies increased the risk of postpartum depression or perceiving a child as vulnerable, even up to the age of four to eight years old. Mothers of 1,095 children from community-based primary care paediatric practices were interviewed about their pregnancy, labour and delivery complications and whether they had felt depressed in the first three months postnatally. After controlling for prematurity, neonatal hospitalisation, and demographic factors, women with severe pregnancy complications were significantly more likely to perceive their children as vulnerable (17% compared to 9% without pregnancy complications) and to report postpartum depression. There are major problems with potential recall bias when assessments are made retrospectively. However, these results suggest that long-term problems may be associated with perinatal events. Campbell & Cohn, 1991: A prospective American study with more than 1,000 primiparous married women who delivered full-term healthy infants found that postpartum depression was significantly linked to pregnancy and delivery complications. Edwards et al., 1994: Another study used a retrospective self-report of depressed mood following delivery (BPDS; Stein & Van den Akker, 1992) to compare the effect of caesarean section and vaginal deliveries. A total of 300 women were selected and 150 were allocated to each mode of delivery group. Women were assessed between 21 and 32 months after the birth (103 respondents in the caesarean section group and 93 in the control group). There were no significant differences between groups for depressive symptoms, but there was a significant within group difference for women with caesarean sections, such that 24.3% who had general anaesthesia were depressed compared with 3.4% who had epidural or spinal anaesthesia. These results indicated that emergency caesarean sections with general anaesthesia were more likely than elective caesarean sections to be associated with increased rates of postnatal depression. Fisher et al., 1995; Fisher et al., 1997: A prospective Australian study examined psychosocial variables and operative interventions with 272 nulliparous women (152 privately insured and 120 from public hospital antenatal clinic). The final sample of 242 (89%) women (146 private and 96 public patients) completed standardised psychometric questionnaires regarding locus of control, self-esteem, partner relationship and current mood state, and semi-structured interviews in the latter half of pregnancy and again at four to six weeks postpartum. Rates of operative delivery interventions were influenced by non-obstetric factors, and privately insured women (57%) were significantly more likely to have operative deliveries than women receiving public health care (38%). The increased likelihood of operative procedures was associated with having high self-esteem, a secure relationship with a highly educated partner, and good strategies for coping with anxiety. This indicates that obstetric decision-making was significantly influenced by patient personality and socioeconomic circumstances. Further results were reported concerning changes in self-esteem and mood for women in this cohort, showing that significant adverse psychological effects were associated with operative methods of delivery. In particular, women who had caesarean section deliveries were more likely to experience a deterioration in mood and self-esteem, than women with operative vaginal deliveries or women with spontaneous vaginal deliveries respectively. Garel et al., 1988: As part of a French follow-up study regarding psychosocial consequences of caesarean section delivery, two groups of primiparous women (103 caesarean section and 180 Postnatal depresssion A systematic review of published scientific literature to 1999

103 vaginal delivery) were compared at two months (92 and 84 responses) and twelve months (79 and 71 responses) postpartum concerning subjective outcomes. Women who had caesarean section deliveries were significantly more likely at two months postpartum to report the negative impact of delivery and to feel tired and less confident in their childcare. They were also more likely to report psychosomatic complaints (depressed mood, insomnia, headaches), and were less likely to be planning another pregnancy. Unfortunately this study did not employ standardised measures, nor did the analysis differentiate between emergency and elective caesarean section. Green, 1990; Green et al., 1990: A prospective study conducted in four different health districts in Britain sent postal enrolment questionnaires at 28 to 30 weeks gestation to all antenatal women who were expected to deliver in a particular two month period. A total of 825 (73.5%) valid questionnaires were returned and subsequently 751 women responded again at 36 weeks gestation and 710 responded at six weeks postnatally. The study used only six items from the usual ten items in the EPDS scale to assess antenatal mood and postnatal emotional well being rather than postnatal depression. It was reported that postnatal emotional well-being was significantly related to antenatal mood particularly for women who were unhappy to be pregnant, and the woman s subjective experiences in labour, especially the feeling of not being in control and having interventions perceived as unnecessary (e.g. episiotomies, enemas). Obstetric interventions were not related to postnatal well being, except for a significant association between caesarean section delivery (N = 61) and very low emotional well-being in a disproportionately large number of women. Murray & Cartwright, 1993: A British primiparous sample (N = 694) involved 13 women with a past history of non-puerperal depression and 58 women who developed postnatal depression following the current pregnancy who were compared to 42 control subjects. Obstetric risk appeared to be unrelated to the prevalence of postnatal depression. However, postnatally depressed women had significantly more complicated labours and delivery by forceps or caesarean section than control women, and were more likely to have experienced past stressful obstetric events (e.g. previous adverse reproductive events or losses, including termination of pregnancy for genetic reasons). Otamiri et al., 1992: A Swedish study investigated perceived differences in maternal-infant relationships and maternal attitudes between women who had elective caesarean sections (N = 53), vaginal breech deliveries (N = 28), or normal vaginal deliveries (N = 45) as controls. Using Visual Analogue Scales, a midwife rated maternal-infant interactions in the obstetric ward and mothers made similar ratings at one month follow-up. There were no significant differences between delivery groups for maternal or infant well being. However, no direct measure of postnatal depression was included. Pop et al.,1995: A prospective study in the Netherlands with 293 Caucasian women recruited antenatally to assess whether homebirths or hospital births were associated with increased incidence of the maternity blues or postnatal depression. Homebirths constituted 52% of this sample, significantly more nulliparous women had hospital births, and 77% of women delivered in the setting they had planned. Mode of delivery and the presence of the maternity blues or postnatal depression were assessed at four weeks postpartum demonstrating no differences in the incidence of maternity blues or depression between homebirths and hospital births. Appendix 3 Risk factors 181

3.1.3 Possible risk factors Early discharge Astbury et al., 1994: In this retrospective Australian study, women who reported that their postnatal hospital stay was too short were significantly more likely to report higher EPDS scores at eight to nine months postpartum than women who were happy with time of discharge and length of hospital stay. Beck et al., 1992: An American descriptive study assessed 49 women for the effect of early discharge in relation to BDI scores at six weeks and twelve weeks postpartum using a correlational design. No significant differences were found between early (one to two days postpartum) and standard (three days postpartum) discharge groups, however there was very limited difference between the actual lengths of stay. This study involved only privately insured, primiparous women with uncomplicated pregnancies and labours and therefore has limited generalisability, as most women normally choosing early discharge are multiparous, older, less educated and from lower socioeconomic groups (Mitchell, Counsell & Gedis, 1993; Scott, 1994). Carty, 1990: A Canadian study recruited 189 antenatal women, 45 of whom did not meet selection criteria (had caesarean section or forceps delivery), leaving 131 women to be randomly assigned to postpartum hospital discharge times including 12 to 24 hours (N = 44), 25 to 48 hours (N = 49), or four days (N = 38). Psychological outcome was assessed using the STAI and the BDI at 37 weeks gestation, and at one week and one month postpartum. Women experiencing the longest hospital stay (four days) had significantly higher depression scores on the BDI than did women who were discharged between 12 and 24 hours postdelivery. There were no significant differences between groups at any assessment point for either trait or state anxiety scores. Dowswell et al., 1997: A British descriptive study recruited 720 women, with 120 women randomly selected from each of six different districts, to examine the relationship between length of postnatal hospital stay and maternal psychological well-being measured by the EPDS at four to eight weeks postpartum. Mothers with healthy full-term infants were contacted and there was a 72% response rate to the postal questionnaires. There were significant differences between the six districts in terms of length of stay, however the mean length of stay was 2.58 days for unassisted vaginal deliveries. There were no significant differences between districts for EPDS scores, and women who had caesarean section deliveries had significantly higher mean depression scores than did women with uncomplicated or assisted vaginal deliveries. Women who perceived their hospital stay as too short were significantly more likely to have the highest EPDS scores. Hickey et al., 1997: An Australian prospective cohort study with 425 primiparous and multiparous women assessed whether early discharge from hospital (within 72 hours) after childbirth increased the risk for postnatal depression. 153 (36%) women in the early discharge group, and 272 (64%) women discharged after 72 hours were assessed with the EPDS on the second or third day postpartum, and then at six weeks, twelve weeks, eighteen weeks and twenty-four weeks postpartum. Women in the early discharge group were more likely to be multiparous, had less formal education, had bottle-fed their infants in first week postpartum, reported a poor relationship with their parents, and had a non-significant trend 182 Postnatal depresssion A systematic review of published scientific literature to 1999

for history of depression. The groups were matched on age, marital status, socioeconomic level, and baseline EPDS scores. 42 women (9.9%) were diagnosed with major depression, based on EPDS scores and meeting DSM-II-R criteria (interviewed with the SCID) for major depression. 22 (14.4%) women in the early discharge group developed postnatal depression compared to 20 (7.4%) women from the standard discharge group. It was concluded that early discharge increased the risk of postnatal depression threefold after controlling for other sociodemographic, obstetric and psychosocial risk factors. Breastfeeding Cooper et al., 1993: The relationship between early termination of breastfeeding by eight weeks post-delivery and postnatal depression was examined in two large independent studies carried out in Oxford and Cambridge in Britain. The Oxford sample included 483 women assessed antenatally and followed up for 12 months postpartum. There were 25 cases of depression identified with the PSE and 14 of these women (56%) had given up breastfeeding by eight weeks. This was significantly different from non-depressed women where only 40 out of 175 women (23%) had stopped breastfeeding. In the majority of cases, women gave up breastfeeding once they were already depressed. The Cambridge study initially included 702 women, 674 of whom returned EPDS questionnaires and all high scorers plus a sample of low scorers were assessed regarding RDC criteria for major or minor depression (N= 58) and compared with non-depressed women (N= 55). Only 102 of these women attempted to breastfeed and in the depressed group 30 (55.5%) had given up by eight weeks and 10 out of 48 (21%) had done so in the non-depressed group. In all cases the onset of depression preceded stopping breastfeeding. Cox et al., 1982; Alder & Cox, 1983: 62 women who attempted to breastfeed their infants and had participated in an earlier postnatal depression study were followed up with retrospective postal questionnaires at one to two years postpartum to assess the relationship between breastfeeding and postnatal depressed mood. There was no significant difference between depressive symptoms (previously measured at three to five months postpartum) for women who continued to totally breastfeed (N = 29, 12 with depressed mood) or partially breastfeed (N = 33, seven with depressed mood) for at least 12 weeks. The authors reported that 45% of women who were breastfeeding their infants and taking oral contraceptives, had depressive symptoms. However, this number actually referred to only four depressed women. It was concluded that women who were not using oral contraceptives and who were partially breastfeeding (N = 13) were least likely to have depressive symptoms. Based on this incomplete data it was suggested that hormonal changes associated with breastfeeding are implicated in the onset of postnatal depression. This claim has not been supported by any subsequent prospective research with well-controlled designs, much larger subject samples and standardised assessment of depression diagnosis (e.g. Cooper, Murray & Stein, 1993; Misri, Sinclair & Kuan, 1997). Misri et al., 1997: A Canadian study retrospectively assessed an outpatient sample of 51 women who met DSM-IV criteria for major depression with postpartum onset and who had ceased breastfeeding. The majority (83%) reported that their depression had commenced while they were still breastfeeding and these results support earlier contentions that hormonal factors are unlikely to precipitate postnatal depression. Appendix 3 Risk factors 183

Tamminen, 1989: A study with 90 primiparous Finnish women used the BDI to assess postnatal mood (8% mild-moderate scores) in relation to breastfeeding attitudes. Depressed women (N = 10) expressed more difficulties with breastfeeding than non-depressed women (N = 80), even though they had been more positive in their antenatal expectations. Again this sample is too small and non-representative to draw any meaningful conclusions. Thyroid dysfunction Harris et al., 1989c: A British study examined the relationship between thyroid dysfunction and depression during pregnancy and the first two postnatal months with 147 women (65 antibody-positive and 82 antibody-negative) who were assessed using DSM-III criteria as well as the EPDS, MADRS, and Raskin Scale. 22 women (15%) met DSM-III criteria for major depression and there was a non-significant trend for higher depression scores in women with thyroid dysfunction on all the outcome measures except the Raskin Scale. Three women out of eight with thyroid dysfunction met criteria for major depression and were depressed according to all three self-report scales, however these numbers are small and these findings clearly need to be replicated. Mallett et al., 1995: In order to examine the relationship between cognitive function, thyroid status and postnatal depression, a total of 242 women (110 thyroid antibody positive and 132 antibody negative) were assessed at 8, 12, 20 and 28 weeks postpartum. It was hypothesised that since impaired cognitive function can occur both with thyroid disorder and with depression, and since a small proportion of postnatal depression occurs in cases of autoimmune thyroiditis, postnatal cognitive impairment would be related to thyroid dysfunction or to depressed mood. Outcome measures included RDC for depression, HRDS, EPDS, reaction time and digit span, thyroid antibody levels, plasma T3 and T4 and thyroid stimulating hormone. Of the antibody positive group, 62 women (56%) developed thyroid dysfunction (hypothyroidism and/or hyperthyroidism), however the analysis of results showed that neither thyroid status nor antibody status bore any relationship to cognitive performance tests. Cognitive impairment was significantly associated with depression diagnosis in this study, while thyroid status was not related. Re, 1993: A single case was reported of postpartum hypothyroidism which was initially diagnosed as postnatal depression because of tearfulness, fatigue, and difficulty managing the infant between six and fourteen weeks postpartum. Correct diagnosis was made following thyroid function tests. Hormonal changes Brinsmead et al., 1985: An Australian study with 19 women assessed the possible relationship between depressed mood and plasma concentrations of beta-endorphins and cortisol at 36 to 38 weeks gestation, during labour, on days one to four postpartum and at eight weeks postpartum. The POMS was used to measure depressive and anxiety symptoms, as well as self-rated visual analogue scales concerning maternal mood. There were no significant differences between any of the psychological measures at any time and the results failed to show any significant association between changes in beta-endorphin concentrations and the maternity blues. The only correlation approaching significance was between changes in hormonal concentrations associated with mood elevations at day two (the highs) and 184 Postnatal depresssion A systematic review of published scientific literature to 1999

postpartum depressed mood at eight weeks. The authors concluded that post-delivery elation may predict later depression, but much larger samples assessed using standardised diagnostic measures are needed for confirmation. Harris et al., 1989a: Results from a smaller subgroup (N = 96 out of 147) in a longitudinal study reported significant differences in hormone levels between depressed and non-depressed breastfeeding women. Of the 18 breastfeeding women, three out of the six depressed women were taking oral contraceptives, in contrast to seven out of 26 depressed women who were bottle-feeding their infants (N = 78). These results therefore relate to very small groups and are probably not generalisable. Three depressed breastfeeding mothers not taking oral contraceptives had lower progesterone levels and for the seven depressed women who were bottle-feeding their infants and who were taking oral contraceptives, there were higher progesterone levels. In each group this related to more likelihood of being depressed. Therefore, administering progesterone supplements to the latter group is likely to increase their rate of depression. There was also a significant difference in prolactin levels between women who were breastfeeding who were depressed (N = 3) and were not depressed (N = 3). However, sampling for prolactin levels was not controlled with respect to the timing of the last breastfeed and therefore these levels may not be accurate. Harris et al., 1989a: As part of a larger British study of hormonal involvement in postnatal depression, 147 primiparous and multiparous women were followed from sixteen weeks gestation until six to eight weeks postpartum. Depression outcome measures included the EPDS, MADRS, and Raskin Scale. Samples were also taken for plasma cortisol, progesterone, oestradiol, and prolactin concentrations and salivary progesterone and cortisol assays. 14.9% of the sample had significant depressive symptoms at six to eight weeks, but there was no relationship between plasma or salivary cortisol levels, plasma oestradiol concentrations or salivary progesterone data and depression. Harris et al., 1994; Harris et al., 1996: The Cardiff puerperal mood and hormone studies were designed to assess the relationship between mood and concentrations of progesterone and cortisol during the perinatal period to test the hypothesis that rapid physiological withdrawal of steroid hormones after delivery is associated with depression. These studies involved the same prospective cohort: 164 primiparous antenatal women were initially approached for enrolment over a two year period, representing only 5% of those expected to deliver at the hospital during that time. Eight women refused to participate and 36 women were excluded because they rated their marital relationship as fair or poor, they had financial problems, or had a caesarean section delivery. This left a cohort of 120 primiparous women who were apparently assessed antenatally with various depression measures (e.g. EPDS, BDI, and DSM-III-R criteria for major depression, all of the results were not reported) and saliva and plasma concentrations of progesterone and cortisol. They were asked to collect saliva samples twice daily until delivery, three times daily for the first five postnatal days, and then twice daily until six weeks postpartum. Blood samples were collected at the antenatal screening interview, and at one and five days post-delivery and at six weeks postpartum. Plasma concentrations of progesterone, oestradiol and cortisol were measured as well as saliva concentrations of progesterone and cortisol. There was a 75% compliance for saliva samples and all were processed for progesterone, but saliva cortisol levels were only processed for the 20 highest scoring women on the EPDS, the 20 middle scorers and the 20 lowest scoring women. 80 (67%) women scored above the threshold indicating the presence of maternity Appendix 3 Risk factors 185

blues between days one and ten, and 78 (65%) women experienced peak maternity blues on day five postpartum, as measured by the Stein scale (Stein, 1980). Peak Stein maternity blues scores were significantly associated with antenatal EPDS scores, suggesting that those women were depressed during pregnancy, but inadequate information is presented in this paper regarding this issue. The results also demonstrated a weak but significant association between peak maternity blues scores on day five postpartum and salivary progesterone concentrations. There were no links between plasma progesterone concentrations and the maternity blues or for either plasma or salivary cortisol. Harris et al., 1996: Another study in the Cardiff series assessed associations of mood at five to six weeks postpartum with perinatal saliva cortisol and progesterone levels. Of the 120 primiparous women in the study cohort, only seven women (5.8%) developed major depression according to DSM-III-R criteria. Extensive analyses failed to reveal any evidence that progesterone profiles were associated with postnatal depression mood at five to six weeks postpartum. Comparison of depressed and non-depressed women provided no support for the theory that the fall in progesterone or cortisol from antenatal levels to the day of peak maternity blues was related to later postnatal depressed mood. However, there was a significant negative association between evening levels of salivary cortisol and postnatal depression. The authors concluded this study provides no support for the treatment strategy of progesterone augmentation, as a prophylactic against postnatal depression. Pop et al., 1993: A prospective study in the Netherlands assessed 293 women for RDC diagnoses of depression, and found the prevalence of postnatal depression was between 7% and 14%, with the peak prevalence at ten weeks post-delivery. In this study, women were not especially prone to depression prior to this time. Therefore, it is unlikely that there is a direct relationship between the abrupt changes in hormones which occur shortly after parturition, because by ten weeks postpartum most of the main hormonal changes have stabilised. Bereavement Frommer & O Shea, 1973: A British study with 220 married primigravid women recruited in a two month period at three antenatal clinics, included 58 women who reported that prior to eleven years of age they had been separated from either or both parent or that either parent had died. These women were compared to a control group matched by age, social class and expected delivery date for women who did not report childhood separations. Following attrition, the separated group comprised 40 women and the control group 30 women. Outcome measures were the mother s subjective descriptions of how she felt about herself, parenthood and her relationship, and a social worker s assessment of mother and infant progress at two to three months, six to seven months, nine to ten months and around thirteen months postpartum. Mothers self-report of depressed mood (feel depressed) and difficulty managing the infant (sleeping, feeding, later temper tantrums) were significantly higher in the group separated from a parent in childhood. The social worker assessment was significant only when the mother did not report depression (i.e. mother appears depressed to observer). The possible link between childhood losses and later parenting ability is an important issue given the current rate of marital break-up in our society, and it should be feasible to detect these women and offer extra services and support, if necessary. These early results await verification with much more stringent methodology in future research. 186 Postnatal depresssion A systematic review of published scientific literature to 1999

Premature delivery Brooten et al., 1988: A study in America with 47 socially disadvantaged mothers of low birthweight (less than 1500gms) infants completed an Affect Adjective Checklist describing anxiety and depression at discharge from neonatal intensive care (around six to eight weeks) and at nine months corrected age. Mothers were significantly more anxious and depressed prior to discharge than at nine months postpartum. Interestingly, mothers with infants who stayed in hospital longer had lower negative affect at discharge, possibly because they had adjusted to the reality of having a preterm infant. However, multiparous women had significantly higher negative affect at discharge, probably due to having a special needs infant and other children to care for at home. Gennaro, 1988: Self-ratings of anxiety and depression at week one postpartum and up to week seven were compared for sixteen mothers of preterm and ten mothers of full-term infants. The results revealed that mothers of preterm infants had significantly higher ratings in the first postnatal week, yet this difference did not persist in subsequent measurements. Logsdon et al., 1997: A descriptive study of 37 mothers of preterm infants assessed self-esteem and self-reported depressive symptoms prior to the infant s discharge from the neonatal intensive care unit and again at the four week post-discharge check. Mothers who reported low self-esteem before discharge were more likely to have a depressed mood at the four-week check, even if their self-esteem score had improved. Singer et al., 1999: A longitudinal prospective study in America compared mothers of lowbirthweight infants at high-risk (with bronchopulmonary dysplasia, N = 122) and low-risk (N = 84), with mothers of full-term infants (N = 123) in regard to psychological distress as measured by the BSI (Derogatis, 1988; 1992) at one, eight and twelve months, and two and three years (age corrected for prematurity). Mothers of high-risk low-birthweight infants reported significantly more psychological distress (especially anxiety and depression), at every assessment up to two years post-delivery, than either mothers of low-risk low-birthweight infants or mothers of full-term infants. Severity of maternal depression was related to lower child development outcomes in both low-birthweight groups. Steer et al., 1991; Steer et al., 1992: An American study with inner city predominantly African-American younger (13 to 15 years) and older (16 to 18 years) pregnant teenagers assessed BDI levels and found an overall prevalence of 8.2% depressive symptoms with no significant differences between the two age groups. Another related study assessed the effect of depressed mood during pregnancy on pregnancy outcomes, using the BDI at 28 weeks gestation with primiparous and multiparous adolescents (12 to 17 years) and adults (18 to 28 years), the majority (62%) of whom were African-American. The BDI scores did not predict pregnancy outcomes for the adolescent group, however in the older age group the risk of poor outcome (i.e. low birth weight, preterm delivery, small for gestational age infants) rose significantly for each additional point scored on the BDI. Interestingly, none of the women in the study were diagnosed or treated for clinical depression. These results suggest that maternal depression could be implicated in the increase of preterm deliveries amongst lower socioeconomic groups. Appendix 3 Risk factors 187

Physical illness Barnet et al., 1995: This study included mainly African-American teenagers (125 of 129 eligible, mean age 16 years) who were enrolled in the third trimester of pregnancy and followed up until four months postpartum. Anonymous urine drug screening was used to measure substance use, and 42% screened positive for postnatal illicit drug use (mainly marijuana followed by opiates and cocaine). More substance users (44%) reported depressed mood than non-users (24%). But it was not clear whether drug use precipitated the depression or vice versa. 188 Postnatal depresssion A systematic review of published scientific literature to 1999

APPENDIX 4 TREATMENT 4.1 Summary of studies of effects of medication during pregnancy and lactation (Studies are listed chronologically and alphabetically) Bader & Newman, 1980: A single case study of a woman who had been taking amitriptyline for ten years reported that none of the drug was detected in the serum of her breastfed infant at six weeks postpartum. Isenberg, 1990; Burch & Wells, 1992; Sovner & Orsulak, 1979: Single case studies report the use of fluoxetine and imipramine during lactation, and suggest that concentrations of these medications in breastmilk are similar to maternal plasma levels. Misri & Sivertz, 1991: In a study with 18 pregnant women who had major depression and were taking tricyclics, no fetal malformations were reported. It was claimed that the proportion of complications during labour and delivery was similar to estimates in the general childbearing population. The only problems noted were short-term withdrawal symptoms in breastfed neonates, reported by mothers or paediatricians. However, larger samples and formal evaluation of the effects of the medication for infants are required. Wisner & Perel, 1991; Wisner & Perel, 1996: A study of seven breastfeeding women with major depression found no detectable level of nortriptyline in their infants blood samples. Maternal concentrations ranged from 47 164 ng/ml, and two infants (aged three and eight weeks) had low concentrations of the metabolite 10-hydroxynortriptyline. There were no maternal or paediatrician reports of the adverse effects of medication on these infants. In a subsequent letter to the editor, further data was reported for five mother-infant pairs, with no detectable levels of nortriptyline or metabolite found in infants blood levels, when maternal concentrations ranged from 90-193 ng/ml. Buist et al., 1993; Buist & Janson, 1995: An Australian study of 20 women with major depression admitted to a mother-baby unit found the level of dothiepin excreted into breastmilk was similar to maternal plasma levels. There was considerable variation between plasma and breastmilk concentrations achieved by women receiving the same dose and levels should be measured on an individual basis. There were no maternal reports of sedation or failure to thrive in the infants. The authors concluded that infant accumulation of antidepressants by breastmilk exposure occurs at a relatively low overall dose. But the longterm sequelae of such exposure are not known. Most women who ceased breastfeeding in this study did so because of concern regarding the impact of medication on their infant. Fifteen of these women and their children were followed up three to five years later and there were no differences in the children s temperament and cognitive performance, compared with children of depressed non-medicated mothers and children of non-depressed control mothers. There was a trend for higher levels of dothiepin to be associated with higher cognitive scores in children, which was not related to higher maternal education. It was also concluded that the effects of dothiepin by breastmilk exposure are undetectable in children at three to five years of age. 60% of the depressed medicated group were still taking antidepressants three to five years after their admission to the mother-infant unit. Appendix 4 Treatment 189

Pastuszak et al., 1993: In a prospective study comparing 74 women taking tricyclic antidepressants, 74 women taking fluoxetine and 74 women not taking any psychotropic medication, women treated with antidepressants reported higher rates of miscarriage. However, there were no differences between groups in the rate of fetal malformations. Altshuler et al., 1995: Eight serial breastmilk sertraline and nortriptyline levels were measured in a 28-year-old breastfeeding woman with a history of recurrent major depression. There was substantial variation in the levels of antidepressant in the breastmilk over a 24 hour period, with the lowest levels occurring two hours before and one hour after ingestion and the peak level between one and nine hours after ingestion. No detectable infant levels of either drug were found at either three weeks or seven weeks postpartum. Goldstein, 1995 reported in Baum & Misri, 1996: A prospective case report evaluation of 112 infants exposed in utero to fluoxetine during the third trimester was conducted using the worldwide fluoxetine pregnancy registry. There were increased rates of premature delivery and neonatal complications included hyperbilirubinaemia, jitteriness, irritability, sleep disturbance, and palpitations. Chambers & Johnson, 1996: An American study compared 228 pregnant women taking fluoxetine and 254 pregnant women not taking psychotropic medication. Infants of women taking fluoxetine in the first trimester of pregnancy were at greater risk (15.5%) of having three or more minor malformations compared to infants (6.5%) of mothers not taking antidepressants. There was no increase in the risk of major congenital malformations or spontaneous pregnancy loss. Infants exposed to fluoxetine in the third trimester had an increased risk of premature delivery, admission to special care nurseries, lower birth weight, shorter birth length and poor neonatal adaptation (including respiratory difficulty, cyanosis on feeding and jitteriness) compared with infants who were exposed to fluoxetine only in the first or second trimester. Taddio et al., 1996: Another study with breastfeeding women who were taking fluoxetine found that concentrations of fluoxetine and norfluoxetine in the plasma of 11 infants was below the detectable limit (1 ng/ml) and low but detectable in infant urine samples (1.7 ñ 17.4 ng/ml). The authors estimated that the average daily dose received was 10.8% of the maternal dose and mothers reported no adverse effects of the medication on their infants. Mammen et al., 1997: Sertraline and norsertraline levels were measured in the plasma of three mothers, with significant histories of depression and other psychiatric disorders, and in their breastfed infants. All infant plasma levels were low (< 2 ng/ml) and the authors concluded that none of the infants showed adverse effects according to maternal and paediatrician reports. Nulman et al., 1997: A study of 214 women who had major depression during pregnancy, compared 80 women taking tricyclic antidepressants, 55 women taking fluoxetine and 84 control women who did not take medication. No differences were found between infants exposed to drugs only in the first trimester or throughout the entire pregnancy. There was no evidence that fluoxetine or tricyclic exposure during pregnancy affected either global IQ, language development or behavioural development in pre-school children. However, tapering tricyclic use before delivery was recommended to minimise the possibility of withdrawal symptoms in neonates. 190 Postnatal depresssion A systematic review of published scientific literature to 1999

Stowe et al., 1997: Levels of sertraline were examined in 12 depressed mothers and their breastfed infants attending a pregnancy and postpartum mood disorders program. Detectable concentrations of both sertraline and desmethylsertraline were present in all breastmilk samples. Only three of the twelve infants had detectable plasma concentrations of the drug (< 1 ng/ml), while six infants had detectable concentrations of the metabolite desmethylsertraline, with higher maternal doses increasing both compounds in infants. Mothers reported no adverse effects for their infants. The authors concluded that sertraline, its metabolite and all other antidepressants studied thus far, are present in breastmilk at concentrations greater than in maternal serum, although there is considerable individual variability. Infants concentrations were higher than expected (although below limits of detection (> 5.0 ng/ml) in commercial laboratories). It was suggested that delayed elimination of medication by an immature metabolic system may be a problem and emphasises the need for metabolite monitoring to determine infant exposure. Wisner et al., 1997a: A literature review of 15 studies concluded that serum levels from breastfed infants did not contain quantifiable amounts of amitriptyline, nortriptyline, desipramine, clomipramine, doxepin, and sertraline. Adverse effects were reported for two infants whose mothers were taking either doxepin or fluoxetine (Matheson, Panele & Alertsen, 1985). In these cases high serum levels were found and infant symptoms included increased crying, decreased sleep, increased vomiting and watery stools, which decreased when the mothers ceased breastfeeding (Lester, Cucca, Andreozzi, Flanagan et al., 1993). The authors suggest this effect could also be explained by antigens in the breastmilk (which was not tested for antigens) or by the mothers knowledge of her treatment biasing her observations. Variability in metabolic processing amongst infants may result in unexpectedly high serum levels. Preterm infants or neonates with hyperbilirubinaemia are more at risk of adverse effects from maternal antidepressant treatment because of impaired drug metabolism and drug accumulation. Wisner et al., 1997b: Levels of nortriptyline were examined in seven women and their infants. Six of the women had been assigned to receive nortriptyline as part of a larger randomised controlled trial and one mother of a premature infant had been treated in a postnatal disorders clinic. Detectable levels of nortriptyline (10 ng/ml) were found in one infant, but plasma levels of the metabolites were negligible (< 4 ng/ml). Neither the paediatrician nor the mother reported any concerns about the infant. In another infant higher levels of metabolites were found. No ill effects were reported and when the serum level was repeated two weeks later no hydroxymetabolites were identified at the 10 ng/ml level. For the premature infant born at 35 weeks gestation (weight 5lbs), no quantifiable metabolites were detected but a low level of hydroxymetabolite was found (16 ng/ml). No neonatal complications were reported and the infant s mother had the highest hydroxynortriptyline levels in the study. Yoshida et al., 1997b: One study compared 10 breastfed infants of mothers taking tricyclic antidepressants to 15 infants who were bottle fed. The daily dose of medication ingested by breastfed infants was about 1% of the maternal dose and very small amounts were detected in the infants plasma and urine. No acute toxic effects were found in the breastfed infants, and there was no evidence of developmental delay as measured by the Bayley Scales of Infant Development up to 30 months and compared with the bottle fed infants. Appendix 4 Treatment 191

Yoshida et al., 1998: A further study assessed four postpartum mothers who were taking fluoxetine (20-40 mg/day) and their breastfed infants. Three of the women were diagnosed with major depression and one woman had obsessive-compulsive disorder. The concentrations of fluoxetine and norfluoxetine in maternal plasma ranged from 138-272 ng/ml and in breastmilk 99-177 ng/ml. The amount of fluoxetine and norfluoxetine in the infant s plasma and urine was undetectable. The estimated daily infant dose was between 3% and 10% of the maternal dose. Infants were assessed at the commencement of the study and again at 12 to 13 months of age. None of the infants showed neurological abnormality or developmental problems as measured by the Bayley Scales of Infant Development. 4.2 Summary of studies of psychosocial treatments Barnett & Parker, 1985: An Australian study found that a social worker intervention was more effective than either a non-professional intervention or no intervention, in decreasing state anxiety for 89 highly anxious primiparous postpartum women followed up for 12 months. Only pre-treatment self-report depression scores (BDI) were reported with no posttreatment scores, therefore conclusions cannot be drawn about the utility of the intervention for postnatal depression. Morris, 1987: One study reported results from unstructured group psychotherapy over an 11 month period for seven postnatal women who had been depressed for more than a year. It was stated that BDI scores decreased significantly after treatment, however, no data were presented. No control group was used and insufficient description of the group program was provided to enable replication. Holden et al., 1989: A British study examined the effectiveness of counselling in the treatment of postnatal depression. Health visitors received three weekly training sessions based on non-directive counselling skills and previous research demonstrating the importance of therapeutic listening and extra support in postnatal depression (Snaith, 1983; Kumar & Robson, 1984; Cox, 1986; Cutrona & Troutman, 1986). The aim of the intervention was to focus on the mother rather than the infant. Weekly appointment with empathic and nonjudgmental health visitors enabled women to share their feelings, evaluate problems, and decide on appropriate actions. The EPDS was used to screen 734 women at six weeks postpartum. Those with high scores were interviewed by a psychiatrist at 12 weeks and the EPDS repeated. 60 women had RDC depression diagnosis and 55 women were randomised to the treatment (N=26) or control (N=24) group. Prior to the intervention, 17 (65%) in the treatment group and 17 (71%) in the control group had a diagnosis of major depression. The treatment group received an average of eight to nine 90 minute counselling sessions, while the control group received routine health visitor care. The post-treatment interview revealed significant changes in depression status, with 18 (69%) in the treatment group having recovered compared to 9 (38%) in the control group. Recovery was not related to type of delivery or severity of depression at the first interview. These results demonstrate that health visitors with training in non-directive counselling techniques can help women to recover from postnatal depression. However, medication was a confounding issue and 12 women were taking antidepressants. The authors claimed that only three women in each group were taking a therapeutic dose of medication and all three treatment group women recovered, but only one control group woman recovered. Two-thirds of the treatment group women recovered following the intervention and the majority (88%) attributed their recovery to the health 192 Postnatal depresssion A systematic review of published scientific literature to 1999

visitor sessions and the additional support they provided. Health visitors reported that training gave them a structured approach to postnatal depression enabling more effective use of time and increasing the focus on women s psychological well-being. One third of women in the treatment group did not recover during the intervention, including five women with personal or family histories of depression. For these women time-limited supportive counselling may be insufficient and longer-term psychotherapy or couples therapy may be required. Health visitors are not trained to deal with psychiatric crises (i.e. suicidal ideation, physical harm), diagnostic complexities, or severe long-term cases, and moderate-severe depression should be treated by multidisciplinary mental health practitioners (Elliott, 1994). Jacobsen et al., 1990: 60 women diagnosed with major depression and high BDI and HDRS scores, were randomly assigned to either BMT, CBT or combined BMT and CBT treatments for 20 sessions. BMT was less effective than CBT for depression in maritally non-distressed couples, while the two treatments were equally effective for maritally distressed couples. BMT was the only treatment to significantly improve marital satisfaction in distressed couples, whereas combined BMT and CBT was the only treatment effective in enhancing marital satisfaction of non-distressed couples. O Leary & Beach, 1990: One study with 36 maritally discordant couples where the wives had minor or major depression (SCID), randomly assigned subjects to one of three treatment groups including marital therapy, cognitive therapy (15 to 16 weeks) or wait-list control (). Women who received marital or cognitive therapy showed a significant reduction in BDI scores. Women in the marital therapy group showed a significantly greater increase in marital satisfaction than women in the cognitive therapy or wait-list groups. It was suggested that marital therapy might be the most effective form of therapy for significant marital discord with coexisting clinical depression. However, further large studies are required to confirm these results. Cullinan, 1991: A similar approach was used in another area of Britain with 58 health visitors who received non-directive counselling training. The EPDS was used to screen 874 women between six and eight weeks postpartum. 126 (14%) women had high EPDS scores and these women were offered six to eight counselling visits by the health visitors. However, only 49% of high scorers received counselling, 15% declined the offer and the remaining women were referred to their general practitioner. Progress was measured by EPDS scores and women s selfreports. Overall, 87% of women receiving counselling improved, but there was considerable variation between geographical areas and 40% of women in one area showed no improvement. No actual data was provided about pre-treatment and post-treatment EPDS scores, no control group was used and standardised diagnostic methods were not used to validate changes in EPDS scores. Stuart & O Hara, 1994; Stuart & O Hara, 1995: A modified version of IPT was used to treat postnatal depression in 12 women who met DSM-III-R criteria for major depression between two months and six months postpartum. Modifications included an emphasis on resolving marital disputes and major role transitions that frequently accompany childbirth. Participants received twelve sessions of IPT and six (50%) women completed the therapy. Treatment resulted in significant reductions in depression scores on the EPDS, the BDI and the HRDS, and improvements on the Social Adjustment Scale. None of the women met criteria for major depression at the end of treatment and IPT may provide an alternative to Appendix 4 Treatment 193

antidepressants for women who wish to continue breastfeeding. This study included a very small sample, did not have control subjects and had a high attrition rate. Pitts, 1995: A British study reported in a non-peer reviewed journal, examined the effectiveness of an open-ended, unstructured postnatal support group for vulnerable and postnatally depressed women. In a six-month period, 17 women attended the group sessions (mean sessions 5.4, range 1 to 11). Twelve (71%) women had high EPDS scores prior to the commencement of group sessions. Only nine subjects completed both pre- and postgroup EPDS questionnaires, six of whom had high scores on the pre-group EPDS. Four women had post-group EPDS scores below threshold, three women still had high EPDS scores even though they were lower than their pre-group scores, and two women had increased EPDS scores. No data was provided regarding the timing of the post-group assessments. Seligman, 1995: A retrospective American survey was conducted with 7,000 of 180,100 readers of the Consumers Report, who answered questions about mental health. Respondents were typically middle-class and well educated, with a variety of symptoms and disorders, some of which may not meet DSM criteria. No difference was reported between psychotherapy alone and psychotherapy combined with medication. No specific method of psychotherapy was more effective than another, but longer treatment was better than brief contact. Several problems limited the conclusions that could be drawn, including the lack of a control group, using self-report data instead of standardised outcome measures, and not having pre-treatment measures of depression. Seeley et al., 1996: A British study conducted at a Cambridge maternity hospital screened consecutive women with the EPDS at six weeks postpartum. Women with high EPDS scores were interviewed with the SCID (DSM-III-R criteria) and 40 cases of major depression were identified. Forty non-depressed women were randomly selected from the same population to form a control group. Both groups of women completed structured interviews at eight weeks postpartum assessing practical aspects of infant care (e.g. sleeping and feeding) and the mother s relationship with her infant. Depressed mothers were more likely than non-depressed mothers to report a range of difficulties with their infants. In addition, health visitors trained in non-directive counselling and basic cognitive-behavioural skills offered 25 depressed mothers weekly supportive visits for an eight-week period. A further 25 mothers who had been seen before the health visitors received their training, comprised a control group. In total, data was available for 70 depressed mothers who received the health visitor intervention and EPDS scores decreased an average of 42% over the eight week period, compared to a 1% increase in the combined control group. Both groups reported significant reductions in infant care difficulties from six weeks to four months postpartum. The health visitor group reported a significantly lower rate of mother-infant relationship problems at four months, regardless of the severity of maternal depression. These results are difficult to assess as no pre- and postintervention data were provided, only global percentage reductions were reported, and the total sample size, sample characteristics and method of subject selection were not described. Wickberg & Hwang, 1996: Another study based on the same approach was conducted in Sweden and 1,874 women were screened with the EPDS at two and three months postpartum. Women with high scores on both occasions were assessed with the MADRS and DSM-III-R criteria and women with probable depression were randomised to the treatment 194 Postnatal depresssion A systematic review of published scientific literature to 1999

group (six one hour counselling sessions with nurses trained in non-directive counselling) or the control group (routine care). 41 women completed the trial. At the post-treatment assessment, 80% of treatment group women with major depression diagnoses had recovered compared to 25% of control group women. These results were tentative since four severely depressed women were excluded when they required specialist mental health treatment. The authors concluded that depression severity should be assessed by clinical psychologists or general practitioners and that counselling by nurses was useful for mild-moderate postnatal depression. Cooper & Murray, 1997: In a British treatment study, 194 postpartum depressed women assessed with the SCID were randomised to one of four conditions: 1) routine primary care; 2) non-directive counselling (based on Holden s approach); 3) modified CBT (based on problems managing infants and providing structured mother-infant interaction guidance (McDonnough, 1993); and 4) dynamic psychotherapy (based on the mother s experience of attachment, Cramer, 1997). Women in intervention conditions received weekly therapy between eight weeks and eighteen weeks postpartum. 171 women completed the study and all three treatments were effective in reducing depression as measured by the EPDS and SCID. There were no significant differences between intervention conditions at nine-month and eighteen-month follow-up nor between intervention and control groups by the nine-month assessment. Successful treatment and spontaneous remission from depression were not associated with significant improvement in the quality of mother-infant interactions (measured before and after treatment), cognitive development (assessed at nine and 18 months) or early infant behaviour problems (measured at nine months). However, treatment resulted in significant reductions in later infant problems (assessed at 18 months) and maternal reports of mother-infant relationship problems. There was no effect of treatment on infant attachment (measured at 18 months), however, early remission from depression was associated with less insecure infant attachment. This study was not analysed by intention to treat and it has not been published in a peer-reviewed journal. Morgan et al., 1997: The effectiveness of an eight week semi-structured group program was evaluated with 33 postnatal women who had high EPDS scores. The program was based on discussion and CBT exercises facilitated by an occupational therapist and nurse. A couples session was also attended by 21 spouses. Two-thirds of women had high pre-group EPDS scores and this decreased to 22% by the post-group assessment. In 14 couples data was also collected from the partner and 50% of distressed women also had a distressed partner. Significant decreases were found in women?s scores on the GHQ after intervention, and a significant increase on self-esteem scores. These gains continued at follow-up, which varied from six to twelve months. However, there was no control group. Stuart et al., 1998b: Additional data concerning IPT was presented as a conference paper: 120 postpartum depressed women were assigned to either 12 weekly sessions of IPT or a waitlist control group. The IPT group had significantly lower scores on the BDI and HRSD and significant improvements on measures of social adjustment. A total of 44% of women in the IPT group compared to 14% of women in the control group completely recovered from their depression as measured by the BDI. IPT treatment of postnatal depression needs to be examined in randomised controlled trials and compared to other treatment methods. Appendix 4 Treatment 195

DeRubeis et al., 1999: A recent meta-analysis of four major randomised trials (Rush, Beck, Kovacs & Hollon, 1977; Murphy, Simons, Wetzel & Lustman, 1984; Elkin, Shea, Watkins, Imber et al., 1989; Hollon, DeRubeis, Evans, Wiemer et al., 1992a) did not support the inference that antidepressant medication was superior to CBT for severely depressed outpatients. The reviewers concluded that the available results do not demonstrate a difference in acute efficacy between these two treatments. The effectiveness of group and individual therapy CBT was 46.6% for outpatients and 58.3% for inpatients. The overall effectiveness of individual CBT was 50.1% and group CBT was 39.2%, although these rates come from different trials. Thome & Alder, 1999: An Icelandic study used a national survey to recruit mothers around two to three months postpartum who reported having a difficult infant and who had high EPDS or Parenting Stress Index scores.76 participants were randomised to treatment or control conditions. The intervention was conducted between four and six months postpartum and consisted of a maximum of five telephone calls (mean 2.6 calls) made by a nurse to discuss with mother-infant problems, maternal distress, fatigue, health problems and role conflicts. Intervention group women reported significant reductions in fatigue and symptom distress (measured by an unpublished scale developed by Thome, 1996) and a time effect for reduction in distress in interaction with infant and feeding problems. The intervention effectiveness in reducing postnatal depression was unclear as post-treatment depression measures were not reported. 4.3 Summary of studies on admission Kissane & Ball, 1988: In a review of 14 patients admitted to a mother-infant unit in a general hospital psychiatry department, no re-admissions were reported in the follow-up period varying from several months to one year. These outcome measures might underestimate the relapse rate, as some women may not seek help following relapse and outcome criteria could include whether the mother is able to care for her infant on discharge (Stewart, 1989; Kumar et al., 1995b). Stewart, 1989: 32 mothers with joint admissions were more likely to be caring for their infants at two year follow-up than 26 mothers who had been admitted alone. There were substantial differences between the two groups with the joint admission mothers more likely to be older, socially stable, and have a longer hospital stay. The majority of joint admission mothers suffered from a psychotic illness or affective disorder, while the majority of mothers admitted alone had personality disorders or substance abuse problems. Bell et al., 1993: 53 patients were followed up for an average of 8.8 years after admission to a mother-infant unit within a psychiatric hospital and 58% had been re-referred to mental health services. Kumar et al., 1995b: Data is available from 100 consecutive admissions to a psychiatric mother-infant unit. There were 20 cases of schizophrenia, 56 affective psychosis, 24 unipolar disorders, 16 major depression, two minor depressions and one intermittent depression. The affective psychosis group was more likely to have an acute illness with admission occurring within two weeks of onset and a mean duration of admission of 8.9 weeks. Schizophrenic mothers had a particularly poor outcome in terms of caring for infants, with 50% of these 196 Postnatal depresssion A systematic review of published scientific literature to 1999

mothers still separated from their infants at discharge. The outcome for women with affective psychosis was good with 92.8% women being discharged with their infant. Milgrom et al., 1998: Consecutive admissions of 36 women admitted to a mother-baby unit over a six-month period were analysed. The mean duration of admission was 21.7 days compared with an average stay in the same unit of 40.2 days in 1990 (Buist, Dennerstein & Burrows, 1990b) and 91 days in 1986 (Sharp, Dennerstein, Hrasky, Lynch et al., 1986). The majority of women suffered from schizophrenia or other psychotic disorders, with major depression being the second largest group. For 20 women it was their first psychiatric hospital admission and for 13 mothers it was their first episode of psychiatric illness and seven cases were readmissions. Mothering skills were rated as incompetent or only passable in 57% of cases on admission to hospital, and there was only a small improvement by discharge. The majority of mothers (84%) were discharged with their infants. The authors suggested that there is an urgent need for specialised outpatient programs to address the ongoing and complex needs of women with postpartum psychiatric illness following inpatient admissions. Appendix 4 Treatment 197

APPENDIX 5 PREVENTION 5.1 Summary of studies of biological interventions in preventing postnatal depression Dalton, 1985; Dalton, 1989 as reported in O Brien & Pitt, 1994: 94 women who had a history of postnatal depression were given intramuscular progesterone (100 mg) beginning immediately after delivery and then daily for seven days postpartum. This was followed up by the use of progesterone suppositories for two months or until the resumption of menstruation. There was a 10% reported rate of relapse amongst this group, which is no different from the usual prevalence of postnatal depression. In addition, 242 women who requested progesterone prophylaxis because of previous postnatal depression were also followed up. Progesterone was administered by the general practitioner in exactly the same regime as described above. Of the 181 women who actually received progesterone, postnatal depression was reported to occur in 12 (7%) women compared to 14 out of 21 (67%) women in the control group. However, there are serious methodological flaws with these studies, including that the subjects were self-selected, there was no control group in the first study and follow-up assessment was conducted primarily by postal enquiry. Wisner & Wheeler, 1994: A non-randomised open clinical trial with 23 pregnant women tested the efficacy of antidepressant medication administered during the postpartum period to prevent a recurrence of postnatal depression. Participants were women with at least one previous diagnosis of postpartum unipolar major depression who sought advice at an American university-based outpatient clinic that treated perinatal mood disorders. The hypothesis was that three months administration of an antidepressant to postnatal asymptomatic women would block the onset of postpartum major depression. Women chose which treatment condition they would prefer, rather than being randomly assigned. The first group (N = 8) elected to have monitoring only with weekly telephone contact, and the second group (N = 15) elected to have monitoring plus antidepressant medication. The researcher who assessed the women s progress during clinical interviews was not blind to the treatment allocation. The intended study design was that postnatal antidepressant medication (nortriptyline or whatever had been useful in the previous episode) would commence within 24 hours of delivery. However, antenatal depression levels were also assessed and 10 of the 23 women were treated with antidepressants during the pregnancy. This included 47% of those in the medication group (seven out of 15), and 37% of those in the monitoring group (three out of eight). Antidepressant doses were tapered off in the two weeks preceding delivery, in order to recommence antidepressants again in the medication group immediately after delivery and to continue for at least three months postnatally. This means that a greater proportion of the medication group had already received antidepressant treatment until two weeks before delivery and may have received substantial benefit from that treatment. It must also be questioned how many women in that group were asymptomatic in the postnatal period and whether a significant relapse of depressive symptoms would actually be expected within the short postnatal follow-up period (i.e. three to six months).when both groups were assessed during the postpartum period, there was a significant difference between the numbers of Appendix 5 Prevention 199

women who had a recurrence of postnatal major depression in each group. Women who elected for only telephone monitoring had a 50% rate of depression diagnosis (four out of eight) as compared to women in the monitoring and medication group who had a 7% rate of diagnosis (one out of 15). The researchers concluded that prophylactic antidepressant medication reduced the recurrence of postpartum major depression. However, these results should be assessed conservatively, as there are major flaws in the research design and minimal attempts to deal with biases. Sichel et al., 1995: An open case series study reported outcomes for eleven women who sought advice regarding the risk of recurrence of postpartum disorders in a subsequent pregnancy. The women all attended a perinatal psychiatry research unit in an American hospital, which they specifically sought out because of their past history and the unit s reputation. Therefore these results cannot be generalised to all childbearing women. Seven of the women had histories of puerperal psychosis and four had histories of postnatal major depression. These women had experienced affective disorders only in connection with childbirth, and all remained well throughout the pregnancy and delivery. Women were monitored antenatally at 11 weeks, 25 weeks, and 39 weeks gestation. The subjects were consecutively treated with high-dose oral oestrogen immediately following delivery and this was administered daily in decreasing doses over the next four weeks (high doses were used in the first few postnatal days to approximate term pregnancy oestradiol levels before gradually tapering the dose). In order to prevent thromboembolic events, subcutaneous Heparin was administered twice daily for the first postnatal week. Women were evaluated daily for the first five postnatal days using a DSM-III-R symptom checklist and clinical interviews were performed at four weeks, three months, six months, and twelve months. The interviewer was not blind to the study allocation, there were no controls and no inter-rater reliability checks were reported. One woman who had a past history of puerperal psychosis (bipolar disorder requiring hospitalisation, ECT and medication) developed a relapse of postpartum affective disorder. All the other women remained well and required no treatment with psychotropic medication during the 12-month follow-up period. This low rate of relapse (9% compared to estimated relapse rates for major depression of 25% to 40%, and for bipolar disorders of 35% to 60%) suggests that prophylaxis with oral oestrogen in this small non-randomised case study possibly contributed to the prevention of postnatal affective disorders. However, these conclusions are tentative because of the methodology. The authors claim that a rapid change in oestradiol levels is responsible for puerperal affective disorder, even though previous studies (O Hara et al., 1991; O Hara et al., 1991) have failed to establish a link between postnatal affective symptoms and oestradiol levels. It has also been stated that the failure of research studies to demonstrate a relationship between postnatal depression and breastfeeding (which induces lower oestrogen levels) challenges any claims that oestrogen therapy will be a useful prevention approach (Wisner & Stowe, 1997). Lawrie et al., 1998b: A double-blind randomised placebo controlled trial was conducted in South Africa to investigate the use of progestogen in postpartum women. Women who had requested non-hormonal contraceptive methods were eligible for recruitment within 48 hours of delivery. Less than 25% of women approached agreed to participate, leaving a final sample of 180 women. Ninety participants were randomly allocated to one of two intervention conditions, to receive a single dose of either a synthetic progestogen (norethisterone enanthate 200 mg) or a saline placebo. Women also completed the EPDS and MADRS at enrolment, 200 Postnatal depresssion A systematic review of published scientific literature to 1999

one week, six weeks and three months postpartum. Serum concentrations of 17-oestradiol, progesterone, testosterone and the 17-oestradiol: progesterone ratio were obtained at six weeks. A total of 96.7% of women in the progestogen group and 90% of women in the placebo group completed the three-month follow-up. The groups were well matched for race, age, parity, psychiatric history, and maternity blues, however there was a higher caesarean section delivery rate in the progestogen group. At six weeks postpartum, women in the progestogen group had significantly higher depression scores on the MADRS and EPDS than the placebo group. There were no significant differences in depression scores between groups at three months postpartum. Moreover, there were no significant differences in serum concentrations of 17-oestradiol, progesterone, testosterone or the 17-oestradiol: progesterone ratio between women with higher MADRS scores (over 9) or lower MADRS scores. These results confirm previous conclusions from other studies that hormonal parameters do not correlate with depression scores in postnatal women. 5.2 Summary of studies of psychosocial interventions in preventing postnatal depression Gordon & Gordon, 1960: 161 women were recruited from antenatal classes and the investigators assigned whole class groups as either two experimental groups (N = 54 with partners and N = 31 without partners) or two control groups (N = 38 with partners and N = 31 without partners). The experimental groups participated in two 40-minute antenatal instruction sessions about psychosocial adjustments with a new infant. Outcome assessments were by participant self-report questionnaires and by 50 different obstetricians who judged subjects emotional reactions on a non-standardised subjective fourpoint scale at six to eight weeks postpartum. The results show that the experimental group reported significantly less emotional upset (15%) than the control group (37%), and the groups with partners attending had better results than for women alone. No power calculations were made to estimate the required sample size before the trial was conducted. The study had 74% power to identify a 50% reduction in emotional upset given the intervention, but only 20% power to identify a more likely 25% reduction. The authors stated that experimental group subjects who did not attend both sessions had more emotional difficulty than did those who attended both sessions. At the six month follow-up, only one experimental subject (2%) compared with 10 control subjects (28%) was having problems (). However, results for only half the sample was available at this follow-up, and there was only 24% power to identify even a 50% reduction at six months.no details were provided regarding the experimental and control groups, except they were matched by background history and were essentially the same makeup. No information was reported about the timing of recruitment or when the antenatal intervention groups were conducted. There was no assessment of antenatal mood or past history, no information about the cohort from which subjects were recruited, or whether women could decline to participate. The study was poorly designed with uncontrolled partner variables, non-standardised measurements (not replicable), too many obstetrician judges (possible variability), and non-random group assignment. It did not include diagnosis of postnatal depression as an outcome measure. Therefore the results demonstrate that providing realistic and solution-focused antenatal care can positively influence postnatal emotional outcomes, not that postnatal depression could be prevented in this manner. Appendix 5 Prevention 201

Halonen & Passman, 1985: This study involved 48 nulliparous women who had completed routine antenatal education classes, which concentrated on labour-specific relaxation training. Women were then randomly and equally assigned to one of four interventions including discussion only, exposure to postpartum stressors, relaxation training, or relaxation plus exposure. The interventions occurred individually in women s homes during a 90-minute visit. Women in the relaxation conditions had a 15-minute relaxation script read to them by the researcher, which they practised five times during the session. They were instructed to use relaxation as a coping strategy whenever they felt upset during the postpartum period. Women in the exposure conditions discussed 10 specific potential postnatal stressors which the authors claim might precipitate a postpartum depressive episode (e.g. pregnancy will prevent the return of your pre-pregnant figure; your husband comes home late and appears disinterested in you or the baby; Halonen & Passman, 1985). Those in the combined relaxation-exposure condition were instructed to use relaxation to combat these postnatal stressors. Women in the three intervention conditions (i.e. not the discussion group) were visited again one week later to encourage practice of their strategies and this was followed by contact on the second postpartum day and at 28 to 32 days post-delivery. The main outcome measure was the BDI (Beck, Ward, Mendelson, Mock et al., 1961) which was used one month prior to the birth, daily for nine days following the birth, and at one month follow-up after the birth. There were no significant differences between groups on antenatal BDI scores. The two relaxation interventions reported lower postnatal distress compared to the two non-relaxation conditions. Scores on the BDI were significantly lower from the seventh to tenth postnatal days in the relaxation groups. Oakley et al., 1990: In order to assess the effects of social support on pregnancy outcomes, 509 women with a history of low birthweight infants (less than 2500gm) were recruited from antenatal booking clinics in four British hospitals. The women were randomly assigned to the intervention group (N = 255) to receive additional antenatal social support or the control group (N = 254) to receive standard antenatal care. The study population was predominantly socially disadvantaged, 77% of the women were working class, 18% had unemployed partners and 41% smoked during pregnancy. The social support intervention consisted of a minimum of three home visits carried out from 14 to 28 weeks gestation, plus two telephone contacts and 24 hour on-call availability of the research midwife. The midwives provided listening visits when women could discuss any topic of concern and the midwives gave advice and practical information when it was requested. Pregnancy outcomes were assessed through the case notes (obtained for 507 women) and a six week postnatal self-report questionnaire sent by mail (94% response rate), which was not a standardised or replicable measure. The intervention group had better outcomes than the control group with regard to obstetric factors, including fewer antenatal hospital admissions, lower use of epidural anaesthesia, greater number of spontaneous vaginal deliveries, and less likelihood of having an infant in neonatal intensive care. Intervention group mothers also had better subjective ratings of psychosocial adjustment including feeling more in control, having more help from partners and not feeling as low or depressed as mothers in the control group. These findings are not based on standardised measures, however they provide some direction for future studies of psychosocial issues with high-risk pregnancies. 202 Postnatal depresssion A systematic review of published scientific literature to 1999

Wolman et al., 1993: A randomised controlled trial in South Africa assessed whether providing support during labour and altering the clinical orientation of care would decrease the rate of postnatal depression. It was hypothesised that volunteer support would increase maternal self-esteem, decrease anxiety and assist new mothers to feel competent, thereby preventing the onset of postnatal depression. 189 nulliparous women attending a community hospital were randomly assigned either to the intervention group which received additional volunteer companionship during labour (N = 92) or to the control group which received standard clinical care during labour (N = 97). There were no significant differences between groups on demographic measures, except that there were more black African women in the control group.outcome was assessed within 24 hours of delivery and at six weeks postpartum with the Coopersmith Self-Esteem Inventory (Coopersmith, 1967) the Spielberger STAI (Spielberger, 1983), and a non-standard measure of depression (Pitt Depression Inventory; Pitt, 1968). One woman left hospital before the first assessment and 21% of participants could not be traced for the six-week assessment. There were significant differences at six weeks post-delivery between intervention and control group ratings of feeling competent during labour, and self-esteem, anxiety and depression scores. It appeared women benefited from having additional support during labour, but there was no further follow-up of postnatal progress after the six week clinic check-up appointment and no attempt was made to actually diagnose cases of postnatal depression. Since the depression measure used in this study has no norms, recommended thresholds or indications of severity, these results contribute minimally to understanding whether or not postnatal depression can be prevented. Midmer et al., 1995: A randomised controlled trial of the influence of antenatal parent education on postnatal anxiety and marital adjustment. 130 couples in Canada were approached antenatally and 70 primiparous couples who agreed to participate were randomly assigned to experimental (41 couples) and control groups (29 couples). Participants in the experimental group were offered two extra antenatal sessions, each of three hours duration that was facilitated by social workers. The sessions included discussion of role changes, division of household chores, sexuality and intimacy, communication skills and problem solving approaches. Outcome measures included baseline data collected during the second trimester, followed by assessments at six weeks and six months postpartum using the Spielberger STAI (Spielberger, 1983), the Dyadic Adjustment Scale (Spanier, 1976), and a modified PPAQ (O Hara, Hoffman, Philipps & Wright, 1992). Both the groups had similar baseline data. However, the experimental group was functioning significantly better than the control group on anxiety, marital adjustment and overall postnatal adjustment outcomes at subsequent follow-up assessments. These gains may be attributable to the knowledge, understanding, and skills acquired in the intervention sessions. Of interest also was the finding that both groups showed a significant decline in marital functioning at both of the postnatal measurement points. It was suggested that this be linked to increased traditional sex role expectations occurring during the postpartum period (Midmer, Wilson & Cummings, 1995). Marks et al., 1996: In order to elicit whether marriage protects women from postpartum illness, a study in London involved 63 couples. This included 36 couples considered to be high-risk for psychiatric problems who were selected from participants in a study of postpartum psychosis, and 27 control couples who were selected from a local antenatal clinic. The high-risk group was comprised of multiparous and nulliparous women with histories of Appendix 5 Prevention 203

affective disorder (24 bipolar disorder and 12 major depression using RDC), while the women in the control group had no previous psychiatric history and were predominantly nulliparous.antenatal semi-structured interviews were carried out at 36 weeks gestation with women and their partners, and PSE (Wing, Cooper & Sartorius, 1974) interviews were carried out at four days, six weeks and six months following delivery, to determine which women relapsed. Partners psychiatric status was also rated using RDC at the antenatal assessment. Men s attitudes to their wives were assessed using expressed emotion methodology and rated for the presence and number of positive and critical comments. Other factors assessed were neuroticism, satisfaction with the marital relationship and attitudes to sex, pregnancy and parenthood in both the woman and her partner. 42% of the high-risk women (N = 15, including seven unipolar depression or panic disorders, eight psychotic illness) and one control woman (4%) had relapsed by the six month interview. High-risk women who relapsed were less satisfied with the pregnancy and the prospect of motherhood. Partners of women who remained well made significantly more positive comments about their wives, and the highest relapse rate occurred in those women whose partners were indifferent to them (i.e. they made neither positive nor critical comments). The most critical husbands rated their marriages as significantly less satisfactory as did their wives, and these men were more likely to have a psychiatric history themselves. None of the measured characteristics of women were associated with her partner s criticism.in contrast, the men s positive comments were associated with the woman s attitudes towards her sexuality, body image and parity (two or more children). Positive husbands had wives who were pleased to be pregnant, felt happy with their pregnant bodies and enjoyed their sexual relationship. In high-risk women, the time that had elapsed since the last admission also influenced her partner s rate of positive comments. This study concluded that having husbands who were positive, prevented the onset of postpartum disorders and that marital relationships which exhibited positive feelings between the couple, especially when the feelings were expressed in their sexual contact, protected against relapse following childbirth (Marks, Wieck, Checkley & Kumar, 1996). However, there was no statement made about the a priori probability of relapse against which to test this effect, and selecting a control group of low-risk women is an inappropriate comparison. 5.3 Summary of specific postnatal depression prevention studies Stamp et al., 1995: In an Australian randomised controlled trial, it was hypothesised that women at higher risk of developing postnatal depression attending a preventive intervention program would have a reduced frequency of postnatal depression. The incidence of postnatal depression measured by EPDS scores at six-week, twelve-week, and six-month postpartum assessments was expected to decrease from a predicted 37% to a 15% prevalence. The rationale underlying this study was that the EPDS could detect postnatal depression (Cox, Holden & Sagovsky, 1987), depressed women respond to non-directive counselling provided by health visitors (Holden, 1991), and psychosocial interventions could prevent postnatal depression (Elliott, 1989b). 249 antenatal women were screened by 24 weeks gestation using a modified Leverton Scale (Leverton & Elliott, 1988) and 58% (N = 144) of the sample were assessed as being vulnerable to postnatal depression (Stamp, Williams & Crowther, 1995). The finding that more than half the sample was screened as being vulnerable to postnatal depression seems excessive and the accuracy of the modified screening instrument could be questioned.these higher risk women were then randomly assigned to the intervention group 204 Postnatal depresssion A systematic review of published scientific literature to 1999

(N = 73, two withdrew from further involvement) or the control group (N = 71, three withdrew). The randomisation was stratified to control for the effects of parity, and there were no significant differences between groups for age, marital status, mode of delivery, or birthweight. The preventive intervention consisted of two antenatal group sessions at 32 and 36 weeks and one postnatal group session at six weeks. The sessions were conducted by a midwife educator and the content was designed to increase social support and prepare for parenthood. Group size was limited to ten people including partners if they wished to attend. No information was reported concerning partner attendance and this could have been a confounding variable. Women in the control group received routine care.the main outcome measures used were repeated EPDS scores. These results were interpreted as probable major depression for scores above 12 and minor depression for scores between 9 and 12. It has been reported previously that scores above 12 identify 80% of women with major depression and approximately 50% with minor depression, and while using cut-off scores above 10 increases the identification of minor depression to 75%, it also increases the likelihood of false positive scores (Murray, 1990). The decision to base minor depression diagnoses on scores above 9 is not based on recommended interpretations of EPDS scores (Cox, Holden & Sagovsky, 1987) and there was no attempt to randomly check the validity of major and minor depression diagnoses using standard diagnostic criteria (e.g. DSM-IV). There were no significant differences between groups for EPDS scores above 12 (probable major depression) at six weeks (intervention 13% and control 17%), at 12 weeks (intervention 11% and control 15%) or six months (intervention 15% and control 10%) post-delivery. In addition, no significant difference was found between groups for EPDS scores of 9 to 12 (probable minor depression).several difficulties limit the conclusions that can be drawn from this study including the very low group attendance rate (31%) and therefore the remaining small sample who actually completed the intervention program. However, as appropriate in a randomised controlled trial, the analysis was conducted with respect to the original intention to treat. Nevertheless the brief intervention utilised in this study did not prevent the onset or decrease the prevalence of postnatal depression, and the overall prevalence was within the range reported in most other studies (i.e. 10% - 20%). Therefore the modified Leverton Scale was not successful in defining a high-risk sample in this study, and there was insufficient power to identify a significant effect of the intervention. 5.4 Summary of studies related to training health professionals Gerrard et al., 1993: In Britain, health visitors in three different locations were invited to participate in training to improve detection of postnatal depression using the EPDS, initiate treatment with non-directive counselling and consider using prevention strategies ). The rationale was that interventions proven effective in research settings could be incorporated into training to increase the efficacy of community nursing practice by attending to the psychological well-being of postnatal women. Out of 107 health visitors in nominated areas, 88 agreed to participate in the training, however there were five withdrawals and for another three there was incomplete data, so 80 health visitors comprised the final group. Training sessions had group sizes ranging from 9 to 20 health visitors and all participants were given a training and resource manual. Health visitors were required to participate in the program for nine months to complete the follow-up program and their pre- and post- training level of skills, knowledge, attitudes and practice were assessed by questionnaires (data not included in this publication). Prior to commencement of training, each health visitor obtained a baseline Appendix 5 Prevention 205

level of postnatal depression by giving the EPDS to all women in their caseload who had a sixmonth-old infant. Following training, health visitors were encouraged to screen women using the EPDS at three specified times and to offer non-directive counselling to high scorers. Apparently, the median EPDS score during the baseline period (7), was significantly different from the median EPDS score in the post-training period (5), although inadequate data is presented to assess this properly. A comparison of EPDS scores at six months postpartum before and after training showed that participation in the program enabled health visitors to positively influence the emotional well being of postnatal women. Even though the methodology is not well described in this journal article (there was no indication whether the women refused the EPDS and no record of the numbers of women who were assessed), it demonstrated that specific health professional training could have a positive effect on clinical practice and service delivery. Pope, 1995; Watts & Pope, 1998: A series of two day health professional training programs (N = 32, 16 metropolitan and 16 rural locations) was conducted with more than 850 participants, following recommendations for universal and selective prevention strategies in the commonwealth funded Childbirth Stress and Depression Project. Participants were assessed pre- and post-training regarding knowledge of childbirth-related mental health issues and assessment approaches. There were significant gains in knowledge, ability to detect problems, and the development of appropriate treatment and management plans. Webster et al., 1997: In an Australian study to assess the impact of psychosocial risk factor screening for postnatal depression, it was found that using the EPDS was acceptable for both health professionals and women in their care. 771 women participated in the trial, with 159 (22%) acknowledging at least one risk factor for postnatal depression and 157 women completing the EPDS. A convenience sample of 41 women with risk factors completed a questionnaire about the acceptability of screening. Clearly having one risk factor does not necessarily inflate the chances of developing postnatal depression, especially when interactions between factors and the role of possible protective factors were not considered. However, it does suggest that most women will readily accept psychosocial risk assessment strategies. 206 Postnatal depresssion A systematic review of published scientific literature to 1999

APPENDIX 6 DIAGNOSTIC CRITERIA 1. DSM-IV Criteria for major depressive episode A. Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. (1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g. feels sad or empty) or observation made by others (e.g. appears tearful) (2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others) (3) significant weight loss when not dieting or weight gain (e.g. a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day (4) insomnia or hypersomnia nearly every day (5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) (6) fatigue or loss of energy nearly every day (7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self reproach or guilt about being sick) (8) diminished ability to think or concentrate, or indeciveness, nearly every day (either by subjective account or as observed by others) (9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms do not meet criteria for a Mixed Episode (see Criteria for Mixed Episode). C. The symptoms cause slinically significant distress or impairment in social, occupational, or other areas of functioning. D. The symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g hyperthyroidism). E. The symptoms are not better accounted for by Bereavement, i.e. after the loss of a loved one, the symptoms persist for longer than two months or characterised by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. Appendix 6 Diagnostic criteria 207

2. DSM-IV: Criteria for minor depression A. At least two and less than five of the following symptoms have been present during the same two-week period and represent a change from previous functioning: at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. (1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g. feels sad or empty) or observation made by others (e.g. appears tearful) (2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others) (3) significant weight loss when not dieting or weight gain (e.g. a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day (4) insomnia or hypersomnia nearly every day (5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) (6) fatigue or loss of energy nearly every day (7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self reproach or guilt about being sick) (8) diminished ability to think or concentrate, or indeciveness, nearly every day (either by subjective account or as observed by others) (9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms do not meet criteria for a Mixed Episode (see Criteria for Mixed Episode). C. The symptoms cause slinically significant distress or impairment in social, occupational, or other areas of functioning. D. The symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g hyperthyroidism). E. The symptoms are not better accounted for by Bereavement, i.e. after the loss of a loved one, the symptoms persist for longer than two months or characterised by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. 3. ICD-10: Criteria for depressive episodes Core symptoms: Depressed mood Loss of interest and enjoyment Reduced energy leading to increased fatigability and diminished activity 208 Postnatal depresssion A systematic review of published scientific literature to 1999

Other common symptoms: Reduced concentration and attention Reduced self-esteem and self-confidence Ideas of guilt and unworthiness Bleak and pessimistic views of the future Ideas or acts of self-harm or suicide Disturbed sleep Diminished appetite. 4. ICD-10: Criteria for severe depressive episodes without psychotic symptoms All three core symptoms, plus at least four other symptoms. Considerable distress or agitation unless retardation is a marked feature. Some symptoms of severe intensity. Duration of at least two weeks, but if symptoms are severe and onset rapid, this diagnosis justified after less than two weeks. 5. ICD-10: Criteria for moderate depressive episodes At least two core symptoms, plus at least three (and preferably four) of the other symptoms. Several symptoms present to a marked degree, but not essential is a particularly wide variety of symptoms is present overall. Minimum duration of whole episode is about two weeks. 6. ICD-10: Criteria for mild depressive episodes At least two core symptoms, plus at least two of the other symptoms as above. No symptoms should be present to an intense degree. Minimum duration of whole episode is about two weeks. 7. DSM-IV: Criteria for manic episode A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalisation is necessary). B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: (1) inflated self-esteem or grandiosity (2) decreased need for sleep (e.g. feels rested after only three hours of sleep) (3) more talkative than usual or pressure to keep talking (4) flight of ideas or subjective experience that thoughts are racing Appendix 6 Diagnostic criteria 209

(5) distractibility (i.e. attention too easily drawn to unimportant or irrelevant external stimuli) (6) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) The symptoms do not meet criteria for a Mixed Episode (see Criteria for Mixed Episode). D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalisation to prevent harm to self or others, or there are psychotic features. E. The symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication, or other treatment) or a general medical condition (e.g. hyperthyroidism). 8. DSM-IV: Criteria for mixed episode A. The criteria are met both for a Manic Episode (see Criteria for Manic Episode) and for a Major Depressive Episode (see Criteria for Major Depressive Episode) (except for duration) nearly every day during at least a one week period. B. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalisation to prevent harm to self or others, or there are psychotic features. C. The symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication, or other treatment) or a general medical condition (e.g. hyperthyroidism). 9. DSM-IV: Criteria for adjustment disorders The development of emotional or behavioural symptoms in response to an identifiable stressor(s) occurring within three months of the onset of the stressor(s). These symptoms or behaviours are clinically significant as evidenced by either of the following: (1) marked distress that is in excess of what would be expected from exposure to the stressor (2) significant impairment in social or occupational (academic) functioning. The stress-related disturbance does not meet the criteria for another specific Axis I disorder and is not merely an exacerbation of a pre-existing Axis I or Axis II disorder. The symptoms do not represent Bereavement. Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional six months. 210 Postnatal depresssion A systematic review of published scientific literature to 1999

Specify if: Acute: Chronic: if the disturbance lasts less than six months if the disturbance lasts for six months or longer. Adjustment Disorders are coded based on the subtype, which is selected according to the predominant symptoms. The specific stressor(s) can be specified on Axis IV. 309.0 With Depressed Mood 309.24 With Anxiety 309.28 With Mixed Anxiety and Depressed Mood 309.3 With Disturbance of Conduct 309.4 With Mixed Disturbance of Emotions and Conduct 309.9 Unspecified 10. DSM-IV: Criteria for generalised anxiety disorder A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). B. The person finds it difficult to control the worry. C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past six months). (1) restlessness or feeling keyed up or on edge (2) being easily fatigued (3) difficulty concentrating or mind going blank (4) irritability (5) muscle tension (6) sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) The focus of the anxiety and worry is not confined to features of an Axis I disorder. The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not due to the direct physiological effects of a substance (e.g. drug of abuse, a medication) or a general medical condition (e.g. hyperthyroidism) and does not occur exclusively during a Mood disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder. Appendix 6 Diagnostic criteria 211

11. DSM-IV: Criteria for panic disorder with agoraphobia A. Both (1) and (2): (1) recurrent unexpected Panic Attacks (2) at least one of the attacks has been followed bx one month (or more) of one (or more) of the following: (a) persistent concern about having additional attacks (b) worry about the implications of the attack or its consequences (e.g. losing control, having a heart attack, going crazy ) (c) a significant change in behaviour related to the attacks B. The presence of Agoraphobia. The Panic Attacks are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g. hyperthyroidism). The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g. occurring on exposure to feared social situations), Specific Phobia (e.g. on exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g. on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g. in response to stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g. in response to being away from home or close relatives). 12. DSM-IV: Criteria for panic disorder without agoraphobia A. Both (1) and (2): (1) recurrent unexpected Panic Attacks (2) at least one of the attacks has been followed by one month (or more) of one (or more) of the following: (a) persistent concern about having additional attacks (b) worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, going crazy ) (c) a significant change in behaviour related to the attacks B. Absence of Agoraphobia. C. The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism). The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives). 212 Postnatal depresssion A systematic review of published scientific literature to 1999

13. DSM-IV: Diagnostic criteria for acute stress disorder The person has been exposed to a traumatic event in which both of the following were present: (1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others (2) the person s response involved intense fear, helplessness, or horror Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms: (1) a subjective sense of numbing, detachment, or absence of emotional responsiveness (2) a reduction in awareness of his or her surroundings (e.g. being in a daze ) (3) derealisation (4) depersonalisation (5) dissociative amnesia (i.e. inability to recall an important aspect of the trauma) The traumatic event is persistently re-experienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience, or distress on exposure to reminders of the traumatic event. Marked avoidance of stimuli that arouse recollections of the trauma (e.g. thoughts, feelings, conversations, activities, places, people). Marked symptoms of anxiety or increased arousal (e.g. difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness). The disturbance causes clinically significant distress or impairment in social, occupation, or other important areas of functioning or impairs the individual s ability to pursue some necessary task, such as obtaining necessary assistance or mobilising personal resources by telling family members about the traumatic experience. The disturbance lasts for a minimum of two days and a maximum of four weeks and occurs within four weeks of the traumatic event. The disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and is not merely an exacerbation of a preexisting Axis I or Axis II disorder. 14. DSM-IV: Diagnostic criteria for posttraumatic stress disorder A. The person has been exposed to a traumatic event in which both of the following were present: (1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others (2) the person s response involved intense fear, helplessness, or horror. Appendix 6 Diagnostic criteria 213

B. The traumatic event is persistently re-experienced in one (or more) of the following ways: (1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. (2) recurrent distressing dreams of the event. (3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated) (4) intense psychological distress at exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event (5) physiological reactivity on exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: (1) efforts to avoid thoughts, feelings, or conversations associated with the trauma (2) efforts to avoid activities, places, or people that arouse recollections of the trauma (3) inability to recall an important aspect of the trauma (4) markedly diminished interest or participation in significant activities (5) feeling of detachment or estrangement from others (6) restricted range of affect (e.g. unable to have loving feelings) (7) sense of a foreshortened future (e.g. does not expect to have a career, marriage, children, or a normal life span) Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: (1) difficulty falling or staying asleep (2) irritability or outbursts of anger (3) difficulty concentrating (4) hypervigilance (5) exaggerated startle response Duration of the disturbance is more than one month. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 214 Postnatal depresssion A systematic review of published scientific literature to 1999

APPENDIX 7 PROCESS REPORT Postnatal depression was identified as a major health issue in 1989 by both the National Women s Health Policy and the Mental Health Policy. The National Health and Medical Research Council (NHMRC) was approached by the Public Health Division of the Department of Health and Aged Care in 1997 to develop evidence-based clinical practice guidelines for general practitioners for the management of postnatal depression, to ensure that women at risk of, or suffering from postnatal depression received appropriate care. The Health Advisory Committee (HAC) of NHMRC agreed to accept this commissioned work at its meeting in December 1997 with the following Terms of Reference: To develop guidelines for General Practitioners which: identify best practice in the detection, treatment and management of postnatal depression; assist GPs in devising the most appropriate treatment regimes for postnatal depression, including referral to psychiatric, and/or other specialist or community care; and reflect the principles of the National Women s Health Policy (1989). The first stage began in May 1998 with a selective tender process for the literature review element of the project. Two tender proposals were received. On the basis of this response, HAC decided at its meeting in July 1998 to undertake a more extensive selective tender process encompassing both the literature review and the development of guidelines and involving a broader range of reputable researchers who have published work on postnatal depression in peer-reviewed journals. A Steering Committee comprising Professors Lesley Barclay, Professor David Henderson- Smart and Professor David Henry managed the selective tender process and the overall development of this project. In August 1988 HAC approached seven individuals/ organisations to tender for the development of a literature review and/or guidelines. No bids were forthcoming for the development of guidelines relating to the management of postnatal depression. There appeared to be general consensus from researchers in the field that there is currently insufficient evidence to formulate guidelines on the management of postnatal depression. HAC therefore agreed to proceed with the literature review element of the project. The Women and Infants Research Foundation at the King Edward Memorial Hospital, in Western Australia, was subsequently awarded the contract to undertake the literature review element of the project. A team of researchers led by Associate Professor Sherryl Pope commenced work on the review in October 1998. The draft literature review was finalised and presented to the July 1999 HAC meeting. Members agreed that the review of the literature confirmed there was insufficient evidence to produce guidelines for the management of postnatal depression. It was agreed that with additional work to increase its utility the information gathered could usefully be released as an Information Paper. Appendix 7 Process report 215

Following consultations between the Steering Committee and the research team, a revised draft, was received in September 1999. The Committee saw potential for developing the Executive Summary into a useful reference and risk assessment tool for General Practitioners (GPs) and for developing a consumer guide based on the findings of the Literature Review. The Information Paper was assessed by an external reviewer in October 1999. The Information Paper, the GP summary document and a consumer guide along with the reviewer s report were considered by HAC at its October meeting. HAC agreed to forward these documents for endorsement to the 134 th Session of Council in November 1999. Council endorsed the release of the suite of documents on the proviso that thorough technical editing be completed before publication by an editor with expertise in women s health. An editing panel was established comprising Professor Barclay, Assoc. Professor Sherryl Pope and Ms Michelle Kosky (Consumer Representative on NHMRC) to ensure that work on these documents met the requirements of Council. Following Council the Steering Committee also felt it would be prudent to have the Information Paper reviewed by an independent psychiatrist before final editing. This review provided useful feedback about the GP summary document. The Steering Committee made the decision to defer publication of this resource to enable further consultations with GPs. An initiative is currently underway to establish a working group of GPs and specialists to develop a risk assessment and treatment resource. It is envisaged that this resource will assist practitioners in primary care to match the risk of depression or the severity of presenting symptoms with suitable prevention and treatment options. On the advice of Ms Kosky, the consumer guide was distributed to postnatal depression support groups in New South Wales, the ACT and Western Australia for feedback on its usefulness to consumers. Those comments have now been taken into account. Ms Melissa Sweet was engaged to undertake the technical editing of the documents. She liaised with the Editing Panel to finalise this task. Considerable effort was put into this editing process by all involved. The Steering Committee commended the work done by Melissa Sweet and Sherryl Pope in ensuring the documents are concise and readable while ensuring the integrity of scientific rigour. Acknowledgements This literature review is the result of complementary skills and experience, combining research, training and clinical expertise in postnatal depression with expertise in research design and methodology. The team included: Associate Professor Sherryl PopeBA(Hons), MPsych (Clinical), formerly Chief Clinical Psychologist at King Edward Memorial Hospital for Women from 1989-98 and Chief Investigator in several clinical research trials in postnatal depression from 1992-99. Sherryl was the Project Consultant for the Commonwealth funded Childbirth Stress and Depression Project in Western Australia from 1995-98. Sherryl is completing PhD research at the University of Western Australia and is an Honorary Research Fellow at the Women and Infants Research Foundation. She originally trained as a registered nurse and midwife. Ms Julie WattsBA(Hons), MPsych (Clinical), is a Clinical Psychologist who has been involved in childbirth-related mental health since 1994. She was the Project Co-ordinator of the 216 Postnatal depresssion A systematic review of published scientific literature to 1999

Childbirth Stress and Depression Project and co-authored the final project report published in 1998. Julie works in private practice and is an Honorary Research Fellow at the Women and Infants Research Foundation. Dr Sharon Evans MSc(1 st Hons), PhD, AStat, is the Senior Biostatistician with the Women and Infants Research Foundation. In the past 20 years she has evaluated research designs and conducted analyses in a variety of health-related clinical trials. As an Associate Investigator from 1992-99, Sharon has been involved in the design, implementation and analysis of several randomised controlled trials regarding postnatal depression outcomes and long-term followup. Dr Sue McDonald BApplSc, PhD, is the Senior Health Researcher for Midwifery and Nursing at the Women and Infants Research Foundation and King Edward Memorial Hospital. She has experience conducting large randomised controlled trials of clinical practice interventions in normal pregnancy and childbirth. Sue has been an international collaborative reviewer in the Pregnancy and Childbirth Module of the Cochrane Database since 1993. Ms Jenni HendersonBSc, Grad Dip Adv Nurs, is the Research Midwife at the Women and Infants Research Foundation. Between 1996-1998 she was employed on a large randomised controlled trial that investigated the effect of a debriefing intervention to prevent postnatal depression. Jenni is currently completing her Master of Public Health degree in epidemiology at the University of Western Australia. Completing this review would not have been possible without the assistance of Nicole Wreford and Bridgitte Glockner in the King Edward Memorial Hospital Library, and Megan and Polly Evans who tirelessly organised and photocopied many hundreds of research articles. Thanks are due to Professor John Newnham from the Women and Infants Research Foundation for his enthusiasm and encouragement. Technical Editor Ms Melissa Sweetis a freelance writer specialising in health and medical issues. Appendix 7 Process report 217

ABBREVIATIONS AND ACRONYMS BDI BMIS BMT BPDS BSI CASE CBT CES-D CIS CRS DACL DIS DSM ECT EPDS GHQ HAD HRSD HUGS ICD IDA IDD IPT MADRS MAMA MAOI MAQ MASQ NHMRC NPV PAS Beck Depression Inventory Bethlem Mother-Infant Interaction Scale Behavioural Marrital Therapy Bromley Postnatal Depression Scale Brief Symptom Inventory Cognitive Adaptation to Stressful Events Scale Cognitive Behavioural Therapy Centre for Epidemiological Studies Depression Scale Clinical Interview Schedule Carroll Rating Scale Depression Adjective Checklist National Institute of Mental Health (NIMH) Diagnostic Interview Schedule Diagnostic and Statistical Manual for Mental Disorders. Electroconvulsive Therapy Edinburgh Postnatal Depression Scale General Health Questionnaire Hospital Anxiety and Depression Scale Hamilton Rating Scale for Depression Happiness, Understanding, Giving and Sharing International Classification of Diseases Irritability, Depression and Anxiety Scale Inventory to Diagnose Depression Interpersonal Psychotherapy Montgomery-Asberg Depression Rating Scale Maternal Adjustment and Maternal Attitudes Questionnaire Monoamine oxidase inhibitors Maternal Assessment Questionnaire Modified Antenatal Screening Questionnaire National Health and Medical Research Council Negative Predictive Value Psychiatric Assessment Schedule Abbreviations and acronyms 219

PDC PDPI POMS PPAQ PPP PPV PSE RDC SADS SCID SCL SPI SRDS SSRIs STAI Postpartum Depression Checklist Postpartum Depression Predictors Inventory Profile of Mood States Postpartum Adjustment Questionnaire Prenatal Psychosocial Profile Positive Predictive Value Present State Examination Research Diagnostic Criteria Schedule for Affective Disorders and Schizophrenia Structured Clinical Interview for DSM Diagnosis Symptom Checklist Standardised Psychiatric Interview (Also known as the CIS) Zung Self Rating Depression Scale Selective Seratonin Reuptake Inhibitors State-Trait Anxiety Inventory 220 Postnatal depresssion A systematic review of published scientific literature to 1999

GLOSSARY AFFECTIVE: Pertaining to the external expression of emotion ANTENATAL / ANTEPARTUM: During pregnancy, prior to birth AXIS DISORDERS: Assessment of mental disorders relating to different domains and levels of functioning in the DSM-IV. AXIS I: Clinical disorders, such as delirium, schizophrenia, mood, sexual, eating or adjustment disorders AXIS II: Personality disorders and mental retardation AXIS III: General medical conditions AXIS IV: Psychosocial and environmental problems BAYLEY: The Bayley Scales of infant development (Bayley, 1969) BIPOLAR DISORDER: A mood disorder characterised by the presence or history of manic (or hypomanic) episodes usually alternated with depressive episodes BOTHER: The Degree of Bother inventory (feeding, sleeping and settling issues and how much the parent is bothered by these problems) (Broussard & Hartner, 1971) BSI: Brief Symptom Inventory (Derogatis & Spencer, 1988). This is the short form of the SCL-90R CASE: Cognitive Adaptation to Stress Events Questionnaire (Affonso et al., 1994) COGNITIVE BEHAVIOURAL THERAPY: Psychotherapy directed at altering maladaptive beliefs, perceptions and thoughts COMORBIDITY: The co-occurrence of two or more disorders, such as depressive disorder with anxiety DIAGNOSIS: The determination of the nature of a condition based on a set of symptoms and clinical judgment DIAGNOSTIC CRITERIA: Signs or symptoms that must be present in order to make a particular diagnosis DISORDER: Abnormality of function DSM: Diagnostic and Statistical Manual for Mental Disorders. The American system used to classify psychiatric disorders. The most current version is DSM-IV (American Psychiatric Association, 1994) DYSPHORIA: Anguished or distressed mood DYSTHMIA: A mood disorder characterised by depressed mood and loss of interest or pleasure in customary activities, with some additional symptoms of depression, that is present most of the time for at least two years EFFECTIVENESS: The extent to which an intervention does more good than harm Glossary 221

EXPERIMENT: A procedure done in order to discover or demonstrate some fact or general truth GESTATION: The duration of pregnancy, measured from the first day of the last menstrual period to the date in question, expressed in completed weeks GESTATIONAL AGE: The duration of pregnancy, measured from the first day of the last menstrual period to the date of expulsion or extraction of the fetus or infant, expressed in completed weeks GRAVIDITY: The number of times a woman has been pregnant INCIDENCE: the percentage of subjects in the population suffering from the disorder at some time during a specified time period such as 6 months INTERNATIONAL CLASSIFICATION OF DISEASES. The International system used to classify medical and psychiatric disorders (World Health Organization, 1978). The most current version is ICD-10 (World Health Organization, 1992) INTERPERSONAL PSYCHOTHERAPY: Time limited therapy which aims to clarify and resolve role disputes, social isolation and role transition INTIMATE BOND MEASURE: used to assess marital intimacy, care and control (Schweitzer, Logan & Strassberg, 1988) IINCIDENCE: the frequency of occurrence of a disorder MAJOR DEPRESSION: diagnosis made on the basis of DSM-IV or RCD criteria META-ANALYSIS: Systematic review that employs statistical methods to combine and summarise the results of several studies MINOR DEPRESSION: diagnosis made on the basis of DSM-IV or RCD criteria MODE OF DELIVERY: The possible ways for a fetus to be delivered: CAESAREAN SECTION: An incision through the abdominal and uterine walls for delivery of the fetus FORCEPS: Assisted passage of the fetus during birth by application of forceps to the fetal head VACUUM EXTRACTION: Assisted passage of the fetus during birth by application of a suction cap to the fetal head SPONTANEOUS VAGINAL DELIVERY: Passage of the fetus through the birth canal without mechanical assistance MODIFIED ANTENATAL SCREENING QUESTIONNAIRE : a modified version of the Leverton Scale (Leverton & Elliott, 1988) labeled to screen women antenatally (Stamp, Williams & Crowther, 1995; Stamp, Williams & Crowther, 1996) MULTIGRAVIDA: a woman who is having her second or subsequent pregnancy MULTIPAROUS: a woman who has given birth to her second or subsequent baby 222 Postnatal depresssion A systematic review of published scientific literature to 1999

PARITY: The total number of pregnancies which resulted in live births or stillbirths prior to the pregnancy under consideration, regardless of plurality PERINATAL: around the time of delivery, usually refers to 20 weeks from conception to 28 days after delivery PITT DEPRESSION SCALE : (Pitt, 1968) PLACEBO: A non-pharmacological treatment administered to the control group in a clinical trial in order that the specific and non-specific effects of the experimental treatment can be distinguished POSITIVE PREDICTIVE VALUE (of a test for depression): The probability that a person scoring in the depressed range on a test is actually depressed POSTNATAL / POSTPARTUM: occurring after birth, usually within 12 months of delivery PRETERM BIRTH: a birth occurring before 37 completed weeks of gestation PREVALENCE: The percentage of subjects in the population who are currently suffering from a disorder PRIMIGRAVIDA: a woman who is having her first pregnancy PRIMIPAROUS: a woman who has given birth to her first baby PSYCHIATRIC ASSESSMENT SCHEDULE : an adaptation of the PSE (Dean, Surtees & Sashidharan, 1983) PSYCHIATRY: The branch of medicine that deals with the study, prevention and treatment of mental disorders PSYCHOLOGY: The branch of science that deals with the mind and mental processes especially in relation to human behaviour PSYCHOTROPIC MEDICATION: medications used to treat psychiatric disorders PUERPERAL / PUERPERIUM: The period from the completion of the third stage of labour to six weeks thereafter RANDOMISATION / RANDOM ASSIGNMENT: A process whereby participants are allocated at random or by chance to receive alternate forms of care with the aim of creating unbiased groups for comparison RASKIN SCALE: The Raskin Three Area Scale for Depression (Raskin, Schulterbrandt, Reating & Rice, 1967) SATOGAERI: Japanese practice where the new mother goes home to stay with her mother for the first postnatal month SENSITIVITY (of a test for depression): The proportion of people who are correctly classified as depressed Glossary 223

SPECIFICITY (of a test for depression): The proportion of people who are correctly classified as not depressed SYMPTOM: Any subjective evidence of a patient s condition SYNDROME: Set of symptoms that occur together TERM BIRTH: a live birth occurring after 37 completed weeks of gestation VALIDITY (of a measure): The ability of a measure to assess the property that it is intended to measure (e.g. depression) 224 Postnatal depresssion A systematic review of published scientific literature to 1999

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