A Brief Depression Screening Tool for Perinatal Clinical Practice: The Performance of the PHQ-2 Compared with the PHQ-9

Introduction There is ongoing interest in using brief screening instruments to identify perinatal depression in clinical practice. One ultra-brief screening instrument for depression is the Patient Health Questionnaire-2 (PHQ-2), but thus far its accuracy in perinatal clinical practice has been barely researched. In the present study, we aimed to assess the screening accuracy of the PHQ-2 against the Patient Health Questionnaire-9 (PHQ-9) in a large sample of perinatal women. Method A total of 1155 consecutive women attending 11 health care centers throughout Italy completed the PHQ-9 (which includes the PHQ-2) during pregnancy (27-40 weeks) or postpartum (1-13 weeks). Sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratio positive, likelihood ratio negative, and overall accuracy were calculated using cut points 3 or greater and 2 or greater. Results During pregnancy, PHQ-2 greater than or equal to 3 revealed low sensitivity (38.4%-44.7%) but high specificity (97.8%-99.3%). In postpartum, it revealed moderate sensitivity (56.9%-70.6%), high specificity (95.8%-99.8%), and fair overall accuracy in pregnancy (70%). The alternative threshold greater than or equal to 2 revealed very high sensitivity (pregnancy: 92.1%-95.2%; postpartum: 87.1%-95.2%), moderate specificity (pregnancy: 78.1%-83.2%; postpartum: 68.8%-81.1%) and good overall accuracy, both during pregnancy (87%) and postpartum (84%). Discussion The PHQ-2 provided acceptable accuracy for screening for depression compared with the PHQ-9. In perinatal screening practice, a threshold of 2 or greater should be preferred as this ensures high sensitivity, missing only approximately 6% to 8% of cases, and a false-positive rate (percentage of women classified as affected with depressive symptoms when they are not) of 19% to 25%

Poor social support is associated with preterm birth rather than maternal prenatal anxiety and depression: a retrospective case-control study

Maternal psychological adversities experienced during pregnancy appear to be associated with a trend towards suboptimal birth outcomes, including a shorter gestation period . Preterm birth (i.e. birth before 37 completed weeks of gestation) is the leading cause of neonatal morbidity and mortality, and is associated with adverse effects on mothers’ mental health as well as mother-child relationships . This indicates that preterm birth has a significant emotional impact on families, as well as economic implications for public-sector services. However, despite growing research on this topic, evidence of the specific effects of women’s prenatal mental health on birth outcomes remains unclear and conflicting at times. Therefore, we aimed to examine the impact of pregnant women’s psychosocial distress (specifically, anxiety, depressive symptoms, and level of perceived social support) on preterm birth. The sample for this retrospective case-control study included participants from a longitudinal investigation (2017–2018) of maternal perinatal mental health. Participant recruitment was carried out in perinatal health care centres, facilities associated with the Observatory of Perinatal Clinical Psychology, Department of Clinical and Experimental Sciences, University of Brescia, Italy. This study was conducted in collaboration with the Italian National Institute of Health (Istituto Superiore di Sanità). The inclusion criteria were being pregnant or having a biological child aged ≤6 months, and being able to speak and read Italian. Exclusion criteria were being under 18 years of age, having current psychotic symptoms, or having issues with substance misuse. All participants provided written informed consent prior to entering the study. Before signing the consent form, a healthcare professional involved in the study provided each potential participant with detailed information about the study’s aims and methods, as well as the observational nature of the study. The participant information sheets and consent form made explicit the voluntary nature of their involvement and the right to wthdraw from the study at any time. Ethical approval for the study was obtained from the ethics committee of the Healthcare Centre of Bologna Hospital (Register Number: 0077805, June 27, 2017) The Psychosocial and Clinical Assessment (PCA) form was used to collect information about participants’ sociodemographic characteristics as well as obstetric, clinical, and treatment-related factors. An unstructured clinical interview was used to collect information on both past and current emotional and psychiatric conditions. Both, the PCA and the clinical interview, were administered in person by female clinical psychologists trained in perinatal mental health assessment. To compare categorical data, a X2 test or the exact Fisher’s test, whenever appropriate (n <5 in any cell), were used. All tests were two-tailed with statistical significance set at p = 0.05. All data were coded and analysed using the Statistical Package for the Social Sciences (SPSS, version 26 for Windows Chicago, Illinois 69606, USA). Two hundred and sixty-four Italian women (mean age: 34.2 years, SD: 4.8) were included in the analysis. The total sample comprised 43 mothers who had delivered preterm infants, born before 37 gestational weeks (i.e. cases), and 221 mothers who had had full-term deliveries (i.e. controls). The mean gestational age at delivery in the cases and controls was 34.4 ± 2.9 and 39.6 ± 1.1 weeks, respectively. The two groups did not differ in any sociodemographic characteristics (i.e. age, marital status, educational level, employment status, and socioeconomic status), excluding confounding for the main confounding variables, obstetric aspects (i.e. first pregnancy, history of abortions, and assisted reproductive technology), and mental health features (i.e. mild to severe anxiety or depressive symptoms during pregnancy and number of participants taking medication for anxiety or depression). Furthermore, the two groups did not differ in levels of perceived support from partners (it must be noted that more than 80% of full-term mothers and 90% of preterm mothers reported receiving enough or more than enough emotional as well as practical support from their partner). However, compared to the controls, the cases were significantly more likely to perceive less or no practical (X2 = 7.1, p = 0.029) and emotional (X2 = 6.2, p = 0.045) support from friends and relatives during pregnancy. This study contributed to the relatively scarce literature investigating the association between preterm birth and prenatal maternal mental health and social support characteristics. Our findings align with prior studies that indicated that poor social support enhanced expectant mothers’ stress levels [7], which is a significant predictive factor for preterm birth [8]. Furthermore, recent evidence suggests that support from friends attenuates pregnant women’s psychological stress across the transition to parenthood . Healthcare professionals engaged in providing care to pregnant women, such as medical general practitioners, gynaecologists, and mental health specialists need to assess the quantity and quality of future mothers’ social support (which is a factor that can affect stress levels in pregnant women), even if the pregnant woman does not have anxiety or depressive symptoms. This is necessary in order to help expectant mothers and to prevent possible adverse effects on the foetus and the neonate. In this sense, our findings can provide useful information to Italian health policy planners to consider developing cost-effective programs for the prevention of premature birth, focused on enhancing the levels of social support for pregnant women. In addition, this study may represent the first step to a more in-depth analysis investigating the perception of support from friends and relatives for mothers of preterm children. However, findings from the current study must be interpreted in light of three main limitations: i) a limited sample size, ii) lack of assessment of the level of prenatal psychological stress as a variable, and iii) lack of a structured diagnostic interview to diagnose anxiety and depressive symptoms according to DSM-5 criteria. However, it should be noted that the third limitation was attenuated by the fact that all participants were assessed by licensed clinical psychologists trained in perinatal mental health assessment. Poor social support appears to be a greater risk factor than maternal prenatal anxiety and depressive symptoms, for preterm birth. Thus, it is important for mental health specialists to consider the health and well-being of pregnant women and their future children beyond mental health symptomatology and diagnosis

Outcome assessment of the VADO approach in psychiatric rehabilitation: a partially randomised multicentric trial

BACKGROUND: Recent studies on representative samples of psychiatric services have shown that low proportions of cases received effective rehabilitation interventions. The following are likely to be the most important causes: the scarcity of mental health workers trained in social and work skills strategies and the absence of a structured framework to formulate rehabilitation practices. The aim of this study was to assess if a specific structured planning and evaluation manual, called VADO (Valutazione delle Abilità e Definizione degli Obiettivi – in english: Skills Assessment and Definition of Goals), is more effective than routine interventions in reducing disability in patients with schizophrenia. METHOD: Each of 10 mental health services were invited to recruit 10 patients with a schizophrenic disorder. Altogether 98 patients were recruited. Of these, 62 patients were randomly allocated to the intervention/experimental or a control group. The remaining group of 36 patients was not randomised and it was considered as a parallel effectiveness study. Assessment measures at the beginning of the study and at the one-year follow-up included the FPS scale of social functioning and the BPRS 4.0. Between group (VADO vs. Routine) and time effects were examined with ANOVA, Chi-square or Fisher exact. Clinical "improvement" was defined as an increase of at least ten points on the FPS or a decrease of at least 20% on BPRS scores. RESULTS: 31 of the 62 randomized patients received the experimental interventions, while 31 followed the routine ones. At follow-up, the experimental group showed statistically and clinically greater improvements in psychopathology and social functioning. Better outcomes of both social functioning and symptom severity were observed in non randomised patients (parallel effectiveness study). CONCLUSION: The results suggest that setting personalised and measurable objectives, as recommended by the manual, can improve the outcome of rehabilitation of severe mental disorders. Better outcomes in the parallel effectiveness study could be attributed to the greater confidence and enthusiasm of staff in centres where the VADO approach originated

The Impact of the COVID-19 Pandemic on Women's Perinatal Mental Health: Preliminary Data on the Risk of Perinatal Depression/Anxiety from a National Survey in Italy

Increasing evidence suggests that during the COVID-19 pandemic, anxiety and depression during the perinatal period increased. The aim of the study is to estimate the prevalence of risk for both maternal depression and anxiety among women attending 18 healthcare centres in Italy during the SARS-COV-2 pandemic and to investigate the psychosocial risks and protective factors associated. It was divided into a retrospective phase (2019, 2020, and the first nine months of 2021) and a prospective phase (which began in November 2021 and it is still ongoing), which screened 12,479 and 2349 women, respectively, for a total of 14,828 women in the perinatal period. To evaluate the risk of anxiety and depression, the General Anxiety Disorder-7 (GAD-7), the Edinburgh Postnatal Depression Scale (EPDS), and an ad hoc form were used to collect sociodemographic variables. In the prospective study, the average age of the women is 31 (range 18-52) years. Results showed that the percentage of women who had EPDS score ≥9 increased from 11.6% in 2019 to 25.5% in the period ranging from November 2021 to April 2022. In logistic regression models, the variables associated with the risk of depression at a level ≤0.01 include having economic problems (OR 2.16) and not being able to rely on support from relatives or friends (OR 2.36). Having the professional status of the housewife is a lower risk (OR 0.52). Those associated with the risk of anxiety include being Italian (OR 2.97), having an education below secondary school level (OR 0.47), having some or many economic problems (OR 2.87), being unable to rely on support from relatives or friends (OR 2.48), and not having attended an antenatal course (OR 1.41). The data from this survey could be useful to determine the impact of the SARS-COV-2 pandemic on women and to establish a screening program with common and uniformly applied criteria which are consistent with national and international women's mental health programs

Forensic mental health in Europe: some key figures

Purpose. While the number of forensic beds and the duration of psychiatric forensic psychiatric treatment have increased in several European Union (EU) states, this is not observed in others. Patient demographics, average lengths of stay and legal frameworks also differ substantially. The lack of basic epidemiological information on forensic patients and of shared indicators on forensic care within Europe is an obstacle to comparative research. The reasons for such variation are not well understood. Methods. Experts from seventeen EU states submitted data on forensic bed prevalence rates, gender distributions and average length of stay in forensic in-patient facilities. Average length of stay and bed prevalence rates were examined for associations with country-level variables including Gross Domestic Product (GDP), expenditure on healthcare, prison population, general psychiatric bed prevalence rates and democracy index scores. Results. The data demonstrated substantial differences between states. Average length of stay was approximately ten times greater in the Netherlands than Slovenia. In England and Wales, 18% of patients were female compared to 5% in Slovenia. There was a 17-fold difference in forensic bed rates per 100,000 between the Netherlands and Spain. Exploratory analyses suggested average length of stay was associated with GDP, expenditure on healthcare and democracy index scores. Conclusion. The data presented in this study represent the most recent overview of key epidemiological data in forensic services across seventeen EU states. However, systematically collected epidemiological data of good quality remain elusive in forensic psychiatry. States need to develop common definitions and recording practices and contribute to a publicly available database of such epidemiological indicators

Prevalence of Maternal Postnatal Anxiety and Its Association With Demographic and Socioeconomic Factors: A Multicentre Study in Italy

Anxiety is a common perinatal disorder that can cause severe adverse consequences. This study (a) assesses the prevalence of maternal postnatal anxious symptomatology, and (b) analyses its association with demographic and socioeconomic variables as well as obstetric and other psychosocial variables. The assessment included 307 mothers aged ≥18 years with a biological baby aged ≤52 weeks and from seven Italian healthcare centres, evaluated using a Psychosocial and Clinical Assessment Form (also covering demographic and socioeconomic factors), and the state scale of the State-Trait Anxiety Inventory. We found an overall prevalence of self-reported postnatal anxious symptoms of 34.2%. More specifically, the prevalence was 34.5% at 1–24 weeks postpartum, and 30.8% at >24 weeks postpartum. No associations between postnatal anxious symptoms and demographic or socioeconomic variables were observed. As regards the other variables, the findings indicated antenatal depression or anxiety, parity, and current psychological support from the partner as having the strongest relationships

Cena Loredana, Mirabella, F., Palumbo, G., Gigantesco, A., Trainini, A., & Stefana, A. (2021). Prevalence of maternal antenatal and postnatal depression and their association with sociodemographic and socioeconomic factors: A multicentre study in Italy. Journal of Affective Disorders, 279, 217-221. doi: 10.1016/j.jad.2020.09.136

Background: Perinatal depression is a widespread and burdensome mental disorder. The objectives of this study were to assess the prevalence of both antenatal and postnatal depression in a large sample of women in Italy and to analyse their association with sociodemographic and socioeconomic factors. Methods: Cross-sectional data from eleven healthcare centres located throughout Italy (2017-2018) were analysed (n = 1471). Depressive disorder was assessed with the Edinburgh Postnatal Depression Scale (EPDS), and sociodemographic and socioeconomic factors were also measured. Prevalences by perinatal period and by sociodemographic and socioeconomic factors were estimated, and their associations were evaluated using logistic regression models. All analyses were stratified by perinatal period: antenatal (i.e., from conception to delivery) vs. postnatal (i.e., the nine months after delivery). Results: With a cut-off score set at 12 points, the prevalence of perinatal depression was 6.4% during pregnancy and 19.9% in the postnatal period, and the odds ratio for postpartum vs. antepartum depression was 3.65 (2.56-5.39). High economic status was associated with an approximate fivefold reduction in odds of depression in the antenatal period (ORa: 0.23, 95%CI: 0.10-0.54) and about a sixfold reduction in the postnatal period (ORa: 0.15, 95%CI: 0.05-0.45). Limitations: The data were cross-sectional. The EPDS has a sensitivity of 55.6%. Conclusion: The prevalence of perinatal depression in Italy is strongly associated with socioeconomic disadvantages. Early procedures to evaluate socioeconomic status and the provision of economical support for mothers might reduce the prevalence of perinatal depression and its direct and indirect costs

Stefana Alberto, Cena Loredana, Trainini Alice, Palumbo Gabriella, Gigantesco Antonella, Mirabella Fiorino "Screening for antenatal maternal depression: comparative performance of the Edinburgh postnatal depression scale and patient health questionnaire"

Abstract Background: Maternal antenatal depression affects 21-28% of expectants globally and negatively impacts both maternal and child health in the short and long term. Objective: To compare the psychometric properties and clinical utility of the Edinburgh Postnatal Depression Scale (EPDS) and the Patient Health Questionnaire (PHQ-9) in pregnant individuals. Methods: In this cross-sectional study, 953 third-trimester pregnant Italian individuals completed both the EPDS and the PHQ-9. Results: Both scales demonstrated good internal consistency (EPDS ω=.83, PHQ-9 ω=.80) and a moderate correlation between their scores (r=.59). Concordance at recommended cut-off points (≥14 for both) was moderate (k=.55). Factor analyses indicated a bifactor solution for the EPDS (dimensions: 'Depression' and 'Anxiety') and for the PHQ-9 (dimensions: 'Depression,' 'Pregnancy Symptoms,' 'Somatic'). Benchmarks for clinical change were also established. Conclusion: The EPDS and PHQ-9 capture distinct aspects of perinatal depressive symptomatology. Clinically, these findings recommend using both scales in obstetric and gynaecologic settings to minimize false positives and negatives

Development of a short version of the Spielberger state and trait anxiety inventory for pregnant women

The Spielberger state-trait anxiety inventory (STAI) is a widely recognized tool for assessing state and trait anxiety components in the general population. While reliable and valid, each scale in the STAI has 20 items, which limits its usability in certain real-world clinical settings. Additionally, certain items can inaccurately increase anxiety scores among expectant women. This study aimed to develop a concise yet dependable and valid version of these scales tailored for pregnant individuals. We engaged 1,158 expectant women who completed the STAI and other assessments to determine criterion validity. Our methodology incorporated item response theory to select the most discriminating items for pregnant people, confirmatory factor analysis to evaluate the fit of the factor solution for the abbreviated versions, and k-fold cross-validation to ensure the robustness of the models. Additionally, Bland-Altman regressions and plots assisted in gauging score accuracy, and receiver operating characteristic analyses determined discriminative validity. We also set clinical change benchmarks. The resulting five-item STAI short forms manifested robust psychometric attributes and reliability, providing a theoretically grounded and reliable anxiety assessment during pregnancy. This can be effectively applied in obstetric and gynecological settings, offering a streamlined response experience for expectant women

Comparing the factor structures and reliabilities of the EPDS and the PHQ‑9 for screening antepartum and postpartum depression: a multigroup confrmatory factor analysis Comparing the factor structures and reliabilities of the EPDS and the PHQ‑9 for screening antepartum and postpartum depression: a multigroup confrmatory factor analysis Alberto Stefana, Joshua A. Langfus, Gabriella Palumbo, · Loredana Cena, · Alice Trainini, Antonella Gigantesco, · Fiorino Mirabella

Abstract To evaluate and compare the factor structure and reliability of EPDS and PHQ in antepartum and postpartum samples. Paral lel analysis and exploratory factor analysis were conducted to determine the structure of both scales in the entire sample as well as in the antepartum and postpartum groups. McDonald’s omega statistics examined the utility of treating items as a single scale versus multiple factors. Multigroup confrmatory factor analysis (MCFA) was utilized to test the measurement invariance between the antepartum and postpartum groups. Two-factor models ft best for the EPDS in both the antepar tum and postpartum groups; however, the most reliable score variance was attributable to a general factor for each scale. MCFA provided evidence of weak invariance across groups regarding factor loadings and partial invariance regarding item thresholds. PHQ-9 showed a two-factor model in the antepartum group; however, the same model did not ft well in the postpartum group. EPDS should be preferred to PHQ-9 for measuring depressive symptoms in peripartum populations. Both scales should be used as a single-factor scale. Caution is required when comparing the antepartum and postpartum scores