Preferences and Perceived Barriers to Treatment for Depression during the Perinatal Period

Abstract Background and methods: Little is understood about why few women during the perinatal period will use depression treatment. In particular, beliefs and barriers related to depression treatment use have not been studied. In this study, African American and white pregnant women (n = 108) who screened ≥10 on the Edinburgh Postnatal Depression Scale (EPDS) were asked about recent formal and informal treatment use in prenatal care settings. Confidence in the helpfulness of treatment, providers, and settings and perceived barriers to treatment were assessed and compared between African American and white women. Results: Pregnant women overall reported low rates of formal treatment use but frequently sought help from informal sources, such as friends, family, and printed materials. All women expressed greatest confidence in psychosocial treatments and lowest confidence in antidepressants. African American women reported less confidence in advice from family and friends and in antidepressants than did white women. Women expressed greatest confidence in treatments delivered by mental health professionals and religious leaders. African American women sought help more frequently and had significantly more confidence in religious leaders as treatment deliverers than white women. Women had greatest confidence in treatments delivered in professional and home settings, with African American women expressing greater confidence in religious settings than white women. All women reported greatest concern with structural barriers, compared with attitudinal and knowledge barriers. Conclusions: Understanding patterns of treatment use, beliefs, and barriers to depression treatment provides important information for tailoring and improving appropriate use of mental health treatment in women during the perinatal period.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63189/1/jwh.2007.0631.pd

Precision dosing-based optimisation of paroxetine during pregnancy for poor and ultrarapid CYP2D6 metabolisers:a virtual clinical trial pharmacokinetics study

Objective: Paroxetine has been demonstrated to undergo gestation-related reductions in plasma concentrations, to an extent which is dictated by the polymorphic state of CYP 2D6. However, knowledge of appropriate dose titrations is lacking. Methods: A pharmacokinetic modelling approach was applied to examine gestational changes in trough plasma concentrations for CYP 2D6 phenotypes, followed by necessary dose adjustment strategies to maintain paroxetine levels within a therapeutic range of 20–60 ng/ml. Key findings: A decrease in trough plasma concentrations was simulated throughout gestation for all phenotypes. A significant number of ultrarapid (UM) phenotype subjects possessed trough levels below 20 ng/ml (73–76%) compared to extensive metabolisers (EM) (51–53%). Conclusions: For all phenotypes studied, there was a requirement for daily doses in excess of the standard 20 mg dose throughout gestation. For EM, a dose of 30 mg daily in trimester 1 followed by 40 mg daily in trimesters 2 and 3 is suggested to be optimal. For poor metabolisers (PM), a 20 mg daily dose in trimester 1 followed by 30 mg daily in trimesters 2 and 3 is suggested to be optimal. For UM, a 40 mg daily dose throughout gestation is suggested to be optimal

Predictors of Recovery from Prenatal Depressive Symptoms from Pregnancy Through Postpartum

Abstract Background: Identifying predictors of the course of depressive symptoms from pregnancy through postpartum is important to inform clinical interventions. Methods: This longitudinal study investigated predictors of recovery from prenatal elevated depressive symptoms in the postpartum period. Forty-one pregnant women completed demographic, interpersonal, and psychosocial self-report assessment measures at 32 weeks of gestation and again 12 weeks postpartum. Results: Of those with elevated depressive symptoms, defined as a Beck Depression Inventory-II (BDI-II) score ≥10, at the prenatal baseline, 39% (n=16) recovered to nonelevated symptom levels postpartum, whereas 61% (n=25) experienced sustained elevated symptoms. Women who recovered evidenced significantly lower baseline depression severity and more frequent engagement in physical activity and cohabitated with a romantic partner. In multiparous women (n=25), history of past postpartum depression (PPD) differentiated between those with transient and those with persisting symptoms, although history of lifetime depression did not. None of the additional demographic, interpersonal, or psychosocial variables investigated differentiated between groups. Logistic regression analysis showed prenatal depression severity and exercise frequency as predictors of recovery postpartum. Conclusions: Results suggest most women will not experience spontaneous recovery. Women with prenatal heightened symptom severity and previous experiences with PPD are acutely vulnerable to experience sustained symptoms. In contrast, having a cohabitating partner and engagement in prenatal exercise predicted symptom improvement. Physical exercise may be an important clinical recommendation, as it may improve mood. Given the small sample size, these results are preliminary. Implications and future research recommendations are discussed.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/98461/1/jwh%2E2010%2E2266.pd

Is group cognitive behaviour therapy for postnatal depression evidence-based practice? A systematic review

Background: There is evidence that psychological therapies including cognitive behaviour therapy (CBT) may be effective in reducing postnatal depression (PND) when offered to individuals. In clinical practice, this is also implemented in a group therapy format, which, although not recommended in guidelines, is seen as a cost-effective alternative. To consider the extent to which group methods can be seen as evidence-based, we systematically review and synthesise the evidence for the efficacy of group CBT compared to currently used packages of care for women with PND, and we discuss further factors which may contribute to clinician confidence in implementing an intervention. Methods: Seventeen electronic databases were searched. All full papers were read by two reviewers and a third reviewer was consulted in the event of a disagreement on inclusion. Selected studies were quality assessed, using the Cochrane Risk of Bias Tool, were data extracted by two reviewers using a standardised data extraction form and statistically synthesised where appropriate using the fixed-effect inverse-variance method. Results: Seven studies met the inclusion criteria. Meta-analyses showed group CBT to be effective in reducing depression compared to routine primary care, usual care or waiting list groups. A pooled effect size of d = 0.57 (95% CI 0.34 to 0.80, p < 0.001) was observed at 10–13 weeks post-randomisation, reducing to d = 0.28 (95% CI 0.03 to 0.53, p = 0.025) at 6 months. The non-randomised comparisons against waiting list controls at 10–13 weeks was associated with a larger effect size of d = 0.94 (95% CI 0.42 to 1.47, p < 0.001). However due to the limitations of the available data, such as ill-specified definitions of the CBT component of the group programmes, these results should be interpreted with caution. Conclusions: Although the evidence available is limited, group CBT was shown to be effective. We argue, therefore, that there is sufficient evidence to implement group CBT, conditional upon routinely collected outcomes being benchmarked against those obtained in trials of individual CBT, and with other important factors such as patient preference, clinical experience, and information from the local context taken into account when making the treatment decision

A randomized controlled multicenter trial of post-suicide attempt case management for the prevention of further attempts in Japan (ACTION-J)

<p>Abstract</p> <p>Background</p> <p>A previous suicide attempt is a potent risk factor for suicide later on. Crisis intervention, psychiatric and psychosocial evaluation at emergency medical facilities, and follow-up care for suicide attempters are considered important components for suicide prevention. The Japanese Multimodal Intervention Trials for Suicide Prevention (J-MISP) includes a randomized, controlled, multicenter trial of post-suicide attempt case management for the prevention of further attempts (ACTION-J) to address the continuing increase in suicides in Japan. The primary aim of ACTION-J is to examine the effectiveness of an extensive intervention for suicide attempters in prevention of recurrent suicidal behavior, as compared with standard intervention. This paper describes the rationale and protocol of the ACTION-J trial.</p> <p>Methods/Design</p> <p>In this clinical trial, case management intervention will be provided at 19 emergency medical facilities in Japan. After crisis intervention including psychiatric evaluation, psychosocial assessment, and psychological education, subjects will be randomly assigned to either a group receiving continuous case management or a control group receiving standard care. Suicidal ideation, depressive symptoms, and general health condition will be evaluated as secondary measures. The intervention was initiated in July 2006. By December, 2009, 842 subjects will be randomized. Subject follow-up will continue for 1.5 to 5 years.</p> <p>Discussion</p> <p>Suicide is a complex phenomenon that encompasses multiple factors. Case management by multi-sector collaboration is needed. ACTION-J may provide valuable information on suicide attempters and may develop effective case management to reduce future risk for suicide attempters.</p> <p>Trial registration</p> <p>UMIN Clinical Trials Registry number, UMIN000000444. ClinicalTrials.gov number, NCT00736918.</p

Can We Really Prevent Suicide?

Every year, suicide is among the top 20 leading causes of death globally for all ages. Unfortunately, suicide is difficult to prevent, in large part because the prevalence of risk factors is high among the general population. In this review, clinical and psychological risk factors are examined and methods for suicide prevention are discussed. Prevention strategies found to be effective in suicide prevention include means restriction, responsible media coverage, and general public education, as well identification methods such as screening, gatekeeper training, and primary care physician education. Although the treatment for preventing suicide is difficult, follow-up that includes pharmacotherapy, psychotherapy, or both may be useful. However, prevention methods cannot be restricted to the individual. Community, social, and policy interventions will also be essentia

Associations of depression and depressive symptoms with preeclampsia: results from a Peruvian case-control study

<p>Abstract</p> <p>Background</p> <p>Preeclampsia involves endothelial dysfunction, platelet dysfunction/activation and sympathetic over-activity similar to cardiovascular disorders (CVD). Depression, an independent risk factor for progression of CVD, was found to be associated with an increased risk of preeclampsia among Finnish women. We examined the relation between depression/depressive symptoms and preeclampsia risk among Peruvian women.</p> <p>Methods</p> <p>The study included 339 preeclamptic cases and 337 normotensive controls. Depression and depressive symptoms during pregnancy were assessed using the Patient Health Questionnaire (PHQ-9). Odds ratios (OR) and 95% confidence intervals (CI) were estimated from logistic regression models.</p> <p>Results</p> <p>The prevalence of moderate depression was 11.5% among cases and 5.3% among controls. The corresponding figures for moderate-severe depression were 3.5% for cases and 2.1% for controls. Compared with non-depressed women, those with moderate depression had a 2.3-fold increased risk of preeclampsia (95% CI: 1.2–4.4), while moderate-severe depression was associated with a 3.2-fold (95% CI: 1.1–9.6) increased risk of preeclampsia. Associations of each of the 9-items of the PHQ-9 depression screening module with preeclampsia risk were also observed.</p> <p>Conclusion</p> <p>Our findings are consistent with the only other published report on this topic. Collectively, available data support recent calls for expanded efforts to study and address depression among pregnant women.</p

Secondary Prevention of Suicide

Leo Sher and colleagues discuss recent research on interventions to prevent secondary suicide and discuss the additional research that is needed

Depressive symptoms and suicide in 56,000 older Chinese: a Hong Kong cohort study

Objective: To examine dose-response associations between depressive symptoms and suicide and modification effects of sex, age and health status in older Chinese. Methods: We used the Chinese version of the 15-item Geriatric Depression Scale (GDS) to measure depressive symptoms (GDS score ≥ 8) and Cox regression to examine association with suicide mortality in a population-based cohort of 55,946 individuals, aged 65 years or above, enrolled from July 1998 to December 2000 at one of 18 Elderly Health Centres of Hong Kong Department of Health. The cohort was followed up for suicide mortality till 31 March 2009 (mean follow-up 8.7 years). Results: Depressive symptoms were associated with suicide in men [hazard ratio (HR) 2.03, 95% confidence interval (CI) 0.96-4.29] and women (HR = 2.36, 95% CI 1.31-4.24) after adjusting for age, education, monthly expenditure, smoking, alcohol drinking, physical activity, body mass index, health status, and self-rated health. There was no threshold for GDS score and suicide in either sex. Age, sex and health status did not modify the association. Conclusions: Depressive symptoms predict higher suicide risk in older Chinese in a dose-response pattern. These associations were not attenuated by adjustment for health status, suggesting that depressive symptoms in older people are likely to be an independent causal factor for suicide. The GDS score showed no threshold in predicting suicide risk, suggesting that older people with low GDS scores deserve further attention and those with very high scores need urgent intervention. © 2011 The Author(s).published_or_final_versionSpringer Open Choice, 21 Feb 201

Disparities in self-reported postpartum depression among Asian, Hawaiian, and Pacific Islander women in Hawai‘i: Pregnancy, Risk, Assessment, and Monitoring System (PRAMS), 2004-2007

Postpartum depression affects 10–20% of women and causes significant morbidity and mortality among mothers, children, families, and society, but little is known about postpartum depression among the individual Asian and Pacific Islander racial/ethnic groups. This study sought to identify the prevalence of postpartum depression among common Asian and Pacific Islander racial/ethnic groups. Data from the Hawaii Pregnancy Risk Assessment and Monitoring System (PRAMS), a population-based surveillance system on maternal behaviors and experiences before, during, and after the birth of a live infant, were analyzed from 2004 through 2007 and included 7,154 women. Questions on mood and interest in activities since giving birth were combined to create a measure of Self-reported Postpartum Depressive Symptoms (SRPDS). A series of generalized logit models with maternal race or ethnicity adjusted for other sociodemographic characteristics evaluated associations between SRPDS and an intermediate level of symptoms as possible indicators of possible SRPDS. Of all women in Hawaii with a recent live birth, 14.5% had SRPDS, and 30.1% had possible SRPDS. The following Asian and Pacific Islander racial or ethnic groups were studied and found to have higher odds of SRPDS compared with white women: Korean (adjusted odds ratio [AOR] = 2.8;95% confidence interval [CI]: 2.0–4.0), Filipino (AOR = 2.2;95% CI: 1.7–2.8), Chinese (AOR = 2.0;95% CI: 1.5–2.7), Samoan (AOR = 1.9;95% CI: 1.2–3.2), Japanese (AOR = 1.6;95% CI: 1.2–2.2), Hawaiian (AOR = 1.7;95% CI: 1.3–2.1), other Asian (AOR = 3.3;95% CI: 1.9–5.9), other Pacific Islander (AOR = 2.2;95% CI: 1.5–3.4), and Hispanic (AOR = 1.9;95% CI: 1.1–3.4). Women who had unintended pregnancies (AOR = 1.4;95% CI: 1.2–1.6), experienced intimate partner violence (AOR = 3.7;95% CI: 2.6–5.5), smoked (AOR = 1.5;95% CI: 1.2–2.0), used illicit drugs (AOR = 1.9;95% CI: 1.3–3.9), or received Women, Infant, and Children (WIC) benefits during pregnancy (AOR = 1.4;95% CI: 1.2–2.6) were more likely to have SRPDS. Several groups also were at increased risk for possible SRPDS, although this risk was not as prominent as seen with the risk for SRPDS. One in seven women reported SRPDS, and close to a third reported possible SRPDS. Messages about postpartum depression should be incorporated into current programs to improve screening, treatment, and prevention of SRPDS for women at risk