Psychological treatment of perinatal depression: a meta-analysis.

BACKGROUND: Depression during pregnancy and after the birth of a child is highly prevalent and an important public health problem. Psychological interventions are the first-line treatment and, although a considerable number of randomized trials have been conducted, no recent comprehensive meta-analysis has evaluated treatment effects. METHODS: We used an existing database of randomized controlled trials of psychotherapies for adult depression and included studies aimed at perinatal depression. Random effects models were used in all analyses. We examined the effects of the interventions in the short and long term, and also examined secondary outcomes. RESULTS: Forty-three studies with 49 comparisons and 6270 participants between an intervention and control group were included. The overall effect size was g = 0.67 [95% confidence interval (CI) 0.45~0.89; numbers needed-to-be-treated = 4.39] with high heterogeneity (I2 = 80%; 95% CI 75~85). This effect size remained largely unchanged and significant in a series of sensitivity analyses, although some publication bias was found. The effects remained significant at 6-12 months follow-up. Significant effects were also found for social support, anxiety, functional limitations, parental stress and marital stress, although the number of studies for each outcome was low. All results should be considered with caution because of the high levels of heterogeneity in most analyses. CONCLUSIONS: Psychological interventions are probably effective in the treatment of perinatal depression, with effects that last at least up to 6-12 months and probably also have effects on social support, anxiety, functional impairment, parental stress, and marital stress.

A Randomized Controlled Trial of Listening Visits for Mothers of Hospitalized Newborns.

BACKGROUND: Emotional distress is frequently experienced by mothers whose newborns are hospitalized in a neonatal intensive care unit (NICU). Among these women, there is a critical need for emotional support conveniently delivered at the newborn's point of care by a trusted and medically knowledgeable professional: a NICU nurse. One promising way to enhance in situ delivery of emotional care is to have a NICU nurse provide Listening Visits (LVs), a brief support intervention developed expressly for delivery by nurses to depressed postpartum women. OBJECTIVES: This trial assessed the feasibility of having NICU nurses deliver LVs to emotionally distressed mothers of hospitalized newborns and compared depression outcomes in a small sample of participants randomized to LVs or usual care (UC). METHODS: In this pilot randomized controlled trial, emotionally distressed mothers of hospitalized newborns were randomized to receive up to six LVs from a NICU nurse or UC from a NICU social worker. To assess change in depression symptoms, women were invited to complete the Inventory of Depression and Anxiety Symptoms-General Depression Scale at enrollment and 4 and 8 weeks post-enrollment. RESULTS: Depression symptoms declined over time for both groups, with no difference between the two groups. A post hoc analysis of reliable change found higher rates of improvement at the 4-week assessment among recipients of LVs than UC. DISCUSSION: NICU nurses successfully implemented LVs during this trial. Depression symptom scores did not significantly differ in the two groups posttreatment or at follow-up. Nevertheless, post hoc analyses indicated comparatively higher rates of clinical improvement immediately after LVs, suggesting the intervention can reduce maternal depression early on when women are most distressed.

Listening Visits for maternal depression: a meta-analysis.

Listening Visits are a non-directive counseling intervention delivered by nurses to depressed postpartum women. In 2007, Listening Visits were listed as a recommended treatment in British national guidelines. They were removed from the guideline update, due to the small effect size drawn from a meta-analysis of five clinical trials with depressed and non-depressed postpartum women. The purpose of this meta-analysis is to provide an estimate of the true population effect of Listening Visits as a treatment for maternal depression compared to control conditions. A meta-analytic review was conducted of studies published before October 2020. Inclusion criteria required that the study was a pragmatic or randomized trial of Listening Visits delivered by non-mental health specialists to mothers with elevated symptoms of maternal depression. Post-treatment depression rates for the treatment and control groups were extracted from eligible studies. Six studies met eligibility criteria which included 703 participants. Analyses of observed effect sizes corrected for study artifacts revealed an estimate of 0.66 (95% CI: 0.32, 0.99) with high heterogeneity (Q = 17.95, p = 0.003, I2 = 72.14). After removing outliers and addressing heterogeneity across observed effect sizes, the meta-analytic estimate across four methodologically similar studies and 651 participants was 0.43 (95% CI: 0.24, 0.62). The moderate effect size for Listening Visits, considered together with the advantages afforded by how, where, and who provides this treatment, supports Listening Visits as a first-line intervention in a stepped care approach for mothers with mild to moderately severe depression symptoms.

Pathways from pain to physical and mental health-related quality of life during the third trimester of pregnancy: an exploratory mediation analysis.

AIMS AND OBJECTIVES: To understand how pain affects physical and mental health-related quality of life during the third trimester of pregnancy. BACKGROUND: Poor health-related quality of life during pregnancy is associated with adverse maternal foetal health outcomes such as increased risk of low-birth-weight neonates. Poor health-related quality of life is linked to pain, pain interference and anxiety in the general adult population. However, we do not know how pain, pain interference (i.e., interference of pain with patient function), and anxiety are interrelated during the third trimester of pregnancy. METHODS: This exploratory cross-sectional study followed STROBE guidelines. A mobile educational and tracking pregnancy application was used to obtain a racially/ethnically diverse convenience sample of 141 third trimester pregnant women from the U. S. In this sample, 58.2% of women had commercial health insurance, 68.8% were Caucasian, 86.5% were younger than 35 years, and 85.1% had a partner. Women completed demographics, Edinburgh Postnatal Depression Scale and the Brief Pain Inventory on REDCap. Path analysis was used to investigate a model for the relationships among pain intensity, pain interference, anxiety and physical and mental health-related quality of life. RESULTS: Pain intensity affected health-related quality of life indirectly by increasing pain interference, which in turn, decreased both physical and mental health-related quality of life. In addition, pain interference also increased anxiety, which in turn worsened mental health-related quality of life, but not physical health-related quality of life. CONCLUSIONS: Treating perinatal pain may improve health-related quality of life by decreasing pain interference and anxiety. RELEVANCE TO CLINICAL PRACTICE: Nurses should assess for pain interference and anxiety in women experiencing moderate to severe pain during the third trimester of pregnancy. With this knowledge, nurses may advocate for women in receiving effective treatment for their conditions and improvements in their physical and mental health-related quality of life.

Use and Misuse of Opioid Pain Medications by Pregnant and Nonpregnant Women.

BACKGROUND: The use and misuse of opioid pain medication is a public health problem that has extended to pregnant women. Assessing both the use and misuse of opioid pain medication had been limited. AIMS: The aim of the present study was to disseminate data from a national sample of pregnant and nonpregnant women, tracking the rate and predictors of opioid use and misuse. METHODS: In 2015 the National Survey on Drug Use and Health expanded the assessment of opioid pain reliever use and misuse. Here, a secondary analysis of 2 years of National Survey on Drug Use and Health expanded data assesses the use and misuse of opioids in pregnant and nonpregnant women ranging in age from 18 to 44 years (N = 46,229). RESULTS: Opioid medication use was reported by 31.89% of pregnant women and 38.87% of nonpregnant women. Race and pregnancy status were associated with risk, with pregnancy being protective and White women having significantly higher risk. CONCLUSIONS: The high rates of use and misuse of opioids in pregnant women underscores a critical need for screening for opioid use and misuse, particularly among White women. Pregnancy provides a unique window of opportunity to educate, screen, and provide treatment.

Maternal depression and breastfeeding in home visitation.

BACKGROUND: Home visitation is a popular mechanism for supporting parents and their young children. Breastfeeding is often promoted by home visitors due to its health benefits. However, maternal depression may interfere with breastfeeding. Thus, home visitors may be attempting to encourage health-promoting behaviors like breastfeeding, but maternal depression may interfere with engagement in those behaviors. METHOD: The data for this study were provided by the Des Moines Healthy Start and the Empowerment Family Support Project (DMHSP). We analyzed the relation between depression and breastfeeding for 364 women. RESULTS: First, rates of elevated depression scores in this sample of women (8.7%-21.4% of women) were lower than rates of elevated depression scores reported in other studies of women enrolled in home visitation (30%-50% of women). Second, rates of breastfeeding at 3 months postpartum in this sample (56% of women) were higher than rates of breastfeeding reported in the general population (51% of women). Third, Non-Hispanic White women were significantly less likely to breastfeed compared to other racial groups. Fourth, average Edinburgh Postnatal Depression Scale (EPDS) scores during the first 3 months postpartum, but not during pregnancy, were predictive of likelihood to breastfeed at 3 months postpartum, even after accounting for demographic characteristics. CONCLUSION: Addressing maternal depression during the early postpartum period may increase the likelihood of engaging in breastfeeding.

Using mobile health applications for the rapid recruitment of perinatal women.

This article describes how two research teams recruited participants using a mobile application for pregnant women. In both studies, a study description appeared on the home screen of a pregnancy application. Interested women were directed to a secure research website to enroll. Enrollment goals were rapidly exceeded. Both studies enrolled participants from across the USA. Demographic diversity was achieved by one study. Mobile health applications are innovative venues for recruiting research participants.

Depression Treatment by Non-Mental-Health Providers: Incremental Evidence for the Effectiveness of Listening Visits.

Maternal depression is a prevalent public health problem, particularly for low-income mothers of young children. Intervention development efforts, which often focus on surmounting instrumental barriers to care, have not successfully engaged and retained women in treatment. Task-sharing approaches like Listening Visits (LV) could overcome key instrumental and psychological barriers by leveraging the access of trusted, community caregivers to deliver treatment. A recent randomized controlled trial (RCT) demonstrated the efficacy of LV delivered by non-mental-health providers as compared to usual care. The present report presents results from a follow-up phase of that RCT during which participants who had completed LV were followed for an additional 8 weeks and completed measures of depression and quality of life. In addition, participants who were initially randomized to the wait-list control group received LV and were assessed. Treatment gains previously observed in participants completing LV were enhanced during the 8-week follow-up period. Participants receiving LV during the follow-up period experienced significant improvement in depressive symptoms. Results demonstrate the sustainability of LV delivered by non-mental-health providers, and provide preliminary evidence for the replicability of this approach in a sample of predominately low-income pregnant women and mothers of young children.

The Postpartum Worry Scale-Revised: continuing validation with a sample of NICU mothers.

This study represents the second validation phase of the Postpartum Worry Scale-Revised (PWS-R). As the PWS-R includes items tapping infant health and development concerns, we compare its psychometric properties with a sample of NICU mothers and the online sample used in the initial validation. We conduct a confirmatory factor analysis (CFA) to fit the latent factor structure previously validated with the online sample to the NICU sample. We also examine the reliability and construct validity of the PWS-R when used with a NICU sample. The PWS-R's reliability remains good and moderate concurrent correlations with theoretically similar constructs are shown with the newly created PWS-R factors. Model testing with the NICU sample reveals a different three factor structure than the four factor structure previously revealed with the online sample. The psychometric findings for the PWS-R provide continuing support for its use as a measure of postpartum worry; however, the differences in factor structure suggest that the PWS-R scores of high risk samples such as NICU parents should not be compared to those of community samples. Next steps in the iterative validation process and recommendations for use are considered, particularly with regard to high-risk samples.

Implementation of an innovative nurse-delivered depression intervention for mothers of NICU infants.

Depression affects approximately 19% of all postpartum women, and mounting evidence indicates increased risk for mothers of preterm infants, with prevalence estimates ranging from 28% to 67%. The current approach to management of maternal symptoms related to postpartum depression in the neonatal intensive care unit (NICU) ranges from no intervention to depression screening and referral. For depressed mothers of NICU infants, obtaining treatment is especially difficult and usually becomes a secondary priority; thus, we looked to a nurse-delivered counseling model. Listening visits (LV) are an empirically supported nurse-delivered intervention that focuses on relationship building and exploration of a mother's problems through active reflective listening and collaborative problem solving. An LV open trial in the NICU has been conducted to evaluate the effectiveness of this intervention for mothers of hospitalized infants. Results indicate that LV are associated with a reduction in both maternal depressive and anxiety symptoms. This case study following the description of the intervention demonstrates how the authors used the experiences from the NICU open trial to expand the application of LV to this new setting.

Depression and anxiety symptoms in mothers of newborns hospitalized on the neonatal intensive care unit.

BACKGROUND: Mothers of infants hospitalized in the neonatal intensive care unit (NICU) are at risk for clinically significant levels of depression and anxiety symptoms; however, the maternal/infant characteristics that predict risk have been difficult to determine. Previous studies have conceptualized depression and anxiety symptoms separately, ignoring their comorbidity. Moreover, risk factors for these symptoms have not been assessed together in one study sample. OBJECTIVES: The primary aim of this study was to determine whether a diagnostic classification approach or a common factor model better explained the pattern of symptoms reported by NICU mothers, including depression, generalized anxiety, panic, and trauma. A secondary aim was to assess risk factors of aversive emotional states in NICU mothers based on the supported conceptual model. METHOD: In this cross-sectional study, a nonprobability convenience sample of 200 NICU mothers completed questionnaires assessing maternal demographic and infant health characteristics, as well as maternal depression and anxiety symptoms. Structural equation modeling was used to test a diagnostic classification model and a common factor model of aversive emotional states and the risk factors of aversive emotional states in mothers in the NICU. RESULTS: Maximum likelihood estimates indicated that examining symptoms of depression and anxiety disorders as separate diagnostic classifications did not fit the data well, whereas examining the common factor of negative emotionality rendered an adequate fit to the data and identified a history of depression, infant illness, and infant prematurity as significant risk factors. DISCUSSION: This study supports a multidimensional view of depression and should guide both clinical practice and future research with NICU mothers.

Depression screening on a maternity unit: a mixed-methods evaluation of nurses' views and implementation strategies.

Postpartum women often suffer clinically significant depressive symptoms, a problem addressed by nurse-delivered screening programs. In the past, success of these identification programs was measured in terms of screening rates; however, merely evaluating the screening rate does little to inform how to implement depression screening in clinical practice. This article describes the experiences of nurses in implementing depression screening on a maternity unit. We evaluate the practice qualitatively, by asking nurses to describe their screening strategies and their views about implementation, as well as quantitatively by assessing their screening rates and the number of women identified. Utilizing a framework of program evaluation, 20 maternity unit nurses completed qualitative assessments investigating their day-to-day experiences with this practice. To include the perspectives of nurses that declined to participate in qualitative assessments, 14 additional maternity unit nurses completed a brief survey assessing their views. We also assessed screening rates, defined as the number of women screened divided by the number eligible for screening. Maternity unit nurses viewed depression screening positively and were able to screen patients in relatively few steps, which they implemented using strategies they had developed themselves. Despite nurses' ongoing concern about finding time to screen, they achieved high screening rates and, with one exception, indicated they would opt to continue voluntarily. Depression screening on the maternity unit is feasible and embraced by attending nurses. The clinical strategies used to implement screening are extensively described and provide a basis for implementation in other settings that serve perinatal women.

Improving Maternal Depression Screening in the Neonatal Intensive Care Unit.

PURPOSE: To examine whether self-perceived benefits of mental health treatment differed between mothers of babies in the neonatal intensive care unit with and without a positive screen for depression based on their Edinburgh Postnatal Depression score. STUDY DESIGN AND METHODS: Mothers were recruited in person pre-COVID-19 pandemic, and via phone call and online advertisement during the pandemic. Mothers completed a 10-item depression scale and whether they believed they would benefit from mental health treatment. A chi-square test determined the difference in perceived benefit between mothers who screened positively for depression and those who did not. RESULTS: This secondary analysis included 205 mothers, with an average age of 29. Of the 68 mothers who screened positively for depression, 12 believed that would not benefit from mental health intervention. Of the 137 who screened negatively for depression, 18 believed they would benefit from mental health intervention. Mothers who screened negatively for depression were significantly less likely to believe they would benefit from mental health intervention. CLINICAL IMPLICATIONS: Depression screening scales offer guidance on which mothers to flag for follow-up, but neither on how a mother will respond nor how to effectively approach a mother about her mental health. Nurses can improve identification and follow-up of depressed mothers in the neonatal intensive care unit by asking mothers about their perceived need for mental health treatment.

Compassionate Care: Listening Visits Provided by Neonatal Intensive Care Unit Nurses.

PURPOSE: Although mothers of infants hospitalized in a neonatal intensive care unit (NICU) often experience clinically significant levels of depression symptoms, accessing mental-health treatment may be difficult. NICU mothers need emotional support that is conveniently delivered at the infant's point-of-care by a trusted professional who is knowledgeable about the medical and nursing care in the NICU. Listening Visits are an effective and accessible, nurse-delivered depression intervention, yet little is known about what mothers discuss during these sessions. This analysis of sessions recorded during the randomized controlled trial evaluation of Listening Visits in the NICU provides a glimpse into NICU mothers' concerns and experiences. STUDY DESIGN AND METHODS: This is a secondary, qualitative case analysis of the recorded Listening Visits sessions of four depressed NICU mothers as indicated by a score of 12 or above on the Edinburgh Postnatal Depression Scale. The mothers, who were all White, varied in their economic resources, educational level, availability of support, and infant illness severity. RESULTS: Mothers discussed similar concerns and experiences, often at analogous temporal points in the six Listening Visit sessions, as well as one common concern they voiced throughout: family and friends do not understand what it is like to have an infant in the NICU. CLINICAL IMPLICATIONS: For mildly to moderately depressed mothers of infants hospitalized in the NICU, Listening Visits provide a way for bedside nurses to deliver compassionate care by listening to mothers' concerns and experiences.

Perinatal depression: a review of US legislation and law.

Accumulating research documenting the prevalence and negative effects of perinatal depression, together with highly publicized tragic critical incidents of suicide and filicide by mothers with postpartum psychosis, have fueled a continuum of legislation. Specialists in perinatal mental health should recognize how their work influences legislative initiatives and penal codes, and take this into consideration when developing perinatal services and research. Yet, without legal expertise, the status of legislative initiatives can be confusing. To address this shortfall, we assembled an interdisciplinary team of academics specializing in law, as well as perinatal mental health, to summarize these issues. This review presents the relevant federal and state legislation and summarizes the criminal codes that governed the court decisions on cases in which a mother committed filicide because of postpartum psychosis. Moreover, the review aims to help researchers and providers who specialize in perinatal depression understand their role in this legal landscape.

Perinatal depression screening in healthy start: an evaluation of the acceptability of technical assistance consultation.

In 2001, Healthy Start was required to screen for maternal depression. To support this mandate, technical assistance (TA) consultations were provided to eleven programs. Participant evaluations assessed TA recipients' views, a foundational level of program evaluation. Staff evaluated TA presentations immediately; and directors assessed its helpfulness in a 6-month and a 5-year follow-up. Staff believed their knowledge increased significantly; the majority rated TA presentations as "useful" to "very useful." Most directors rated TA as "useful" or "very useful" in achieving TA goals, reported having "few" or "no" obstacles in screening, and rated staff as "willing" or "very willing" to screen. A range of educational programs have been developed to assist the implementation of maternal depression screening. The current evaluation indicates that diverse types of programs held positive views of TA consultation and believed it was effective. The success of the method argues for further development.

Over-the-Counter Pain Medication Use During Pregnancy.

PURPOSE: To examine over-the-counter pain medication use in pregnancy. STUDY DESIGN AND METHODS: Secondary analysis of a weighted surveillance survey using the 2019 Iowa Pregnancy Risk Assessment Monitoring System (PRAMS) data. A sample of 759 pregnant women of childbearing age from Iowa was weighted to represent 31,728 Iowa mothers. The weighted sample represents 80% non-Hispanic White mothers, with smaller percentages of Hispanic (10%) mothers and non-Hispanic Black (7%) mothers, consistent with the population of Iowa. Approximately two-thirds of women had commercial insurance (66%), some college or greater education (62%), and were from urban areas (59%). ANALYSIS: Descriptive statistics were calculated. Variables include over-the-counter pain reliever usage among all respondents and by race/ethnicity and education level. RESULTS: Seventy-six percent of women reported taking over-the-counter pain relievers during pregnancy. Of these, 71% reported taking acetaminophen, 11% reported taking ibuprofen, 8% aspirin, and 3% naproxen. Nearly 80% of non-Hispanic White mothers reported taking an over-the-counter pain reliever during pregnancy compared to just 64% of mothers reported as Hispanic. Iowa mothers with a college education or greater were more likely to report over-the-counter pain reliever use during pregnancy (84%) than their counterparts with a high school education or less (64%). CLINICAL IMPLICATIONS: Some medications may cause harm to the fetus if taken at specific time during pregnancy. Reinforcement of current pain medication education, including risks to fetus throughout pregnancy may be needed.

Creating affiliations, learning, and mindfulness for in vitro fertilization patients (CALM IVF): a clinical trial.

Objective: Determine if group psychoeducational support can improve in vitro fertilization (IVF) patients' quality of life (QoL). Design: Randomized controlled trial (NCT04048772). Setting: University-affiliated IVF clinic. Patients: Women (n = 76) and male partners undergoing initial autologous IVF cycle from August 2019, to December 2020. Interventions: Couples were assigned to groups based on projected oocyte retrieval date. Groups were randomly assigned to the control or intervention arm. Clinic closures because of the COVID-19 pandemic delayed treatment for a portion of participants. Groups were conducted in person before and virtually during the pandemic. Main Outcome Measures: The primary outcome was a change in fertility quality of life (FertiQoL) from baseline to 3 days after retrieval. Secondary outcomes were changes in depression (Patient Health Questionnaire 9), anxiety (Generalized Anxiety Disorder 7), resilience (Connor-Davidson Resilience scale), IVF knowledge scores, and the likelihood of return to treatment. Results: Knowledge scores among women in Creating Affiliations, Learning, and Mindfulness (CALM) for IVF groups significantly increased compared with control (mean difference 13.19 [3.53 - 22.84]) before the pandemic. During the pandemic, women in CALM IVF had significant improvement in the social FertiQoL score compared with controls (10.42 [1.79 - 19.04]). Compared with controls, male CALM IVF participants had significantly greater improvement in total FertiQoL (mean difference 6.68 [0.39 - 12.98]), treatment FertiQoL (8.26 [0.69 - 15.82]), and resilience (Connor-Davidson 1.13 [0.54 - 1.72]). Immediate return to care did not significantly differ between arms. Conclusions: For women undergoing IVF, group psychoeducational programs can improve IVF knowledge and social QoL during a pandemic. Participation in a group psychoeducational program can improve QoL and resilience in IVF dyad male partners. Clinical Trial Registration Number: Trial registration NCT04048772.

Implementation of an evidence-based depression treatment into social service settings: the relative importance of acceptability and contextual factors.

Listening Visits (LV), an empirically supported depression treatment delivered by non mental health specialists, were implemented into two distinctly structured programs. The relative importance of providers' views and organizational context on implementation were examined. Thirty-seven home visitors completed pre- and post-LV training surveys assessing their views toward implementing LV. Implementation rates markedly differed in the two organizations (73.9% vs. 35.7%). Logistic regression results showed that when predicting the implementation rate, the impact of the organizational setting outweighed home visitors' personal views. These results underscore the importance of organizational context in the implementation of empirically supported treatments.