Economic evaluation of Be a Mom, a web-based intervention to prevent postpartum depression in high-risk women alongside a randomized controlled trial.

BACKGROUND: Postpartum depression (PPD) poses significant challenges, affecting both mothers and children, with substantial societal and economic implications. Internet-based cognitive behavioral therapy interventions (iCBT) offer promise in addressing PPD, but their economic impact remains unexplored. This study aimed to evaluate the cost-utility of Be a Mom, a self-guided iCBT intervention, compared with a waiting-list control among postpartum women at high risk of PPD. METHODS: This economic evaluation was conducted alongside a 14-month randomized controlled trial adopting a societal perspective. Participants were randomized to Be a Mom (n = 542) or a waitlisted control group (n = 511). Self-report data on healthcare utilization, productivity losses, and quality-adjusted life years (QALYs) were collected at baseline, post-intervention, and 4 and 12 months post-intervention. Incremental cost-effectiveness ratios (ICERs) were calculated, and cost-effectiveness acceptability curves were generated using nonparametric bootstrapping. Sensitivity analyses were conducted to assess result robustness. RESULTS: Over 14 months, Be a Mom generated a QALY gain of 0.0184 (0.0022, 0.0346), and cost savings of EUR 34.06 (-176.16, 108.04) compared to the control group. At a willingness to pay of EUR 20,000, Be a Mom had a 97.6 % probability of cost-effectiveness. LIMITATIONS: Results have limitations due to self-selected sample, potential recall bias in self-reporting, missing data, limited follow-up, and the use of a waiting-list control group. CONCLUSIONS: This study addresses a critical gap by providing evidence on the cost-utility of an iCBT intervention tailored for PPD prevention. Further research is essential to identify scalable and cost-effective interventions for reducing the burden of PPD.

Perinatal Depression in the Spanish Context: Consensus Report from the General Council of Psychology of Spain / La depresión perinatal en el contexto español: informe de consenso del Consejo General de Psicología de España

Background: Perinatal depression is a major public health problem, with an estimated prevalence of approximately 15% during the first postpartum year. Despite the high prevalence of postpartum depression, there is no consensus regarding assessment and treatment in the Spanish context. The General Council of Psychology of Spain convened a working group of experts in the field, including both academics and healthcare professionals, to review and propose recommendations based on evidence and best practices that could be applied in the Spanish context. Method: A literature search was completed in various databases (e.g., Medline, PsychInfo) including a combination of terms related to peripartum depression (PPD) assessment and diagnosis, prevention, treatment, and cost-effectiveness. A narrative synthesis of the literature has been conducted together with a critical overview of PPD with a special focus on the Spanish context. Results: In this consensus report, developing questions including prevalence and assessment tools, comparative effectiveness of preventive and treatment interventions, and cost-effectiveness of PPD management have been analyzed. Conclusions: The General Council of Psychology of Spain network advocates the establishment of compulsory screening protocols in all the autonomous regions. Also, it is necessary to promote the inclusion in maternal education of programs for the promotion of mental well-being and selective/indicated prevention carried out by a psychology professional with specialized training in the area. This consensus document also promotes the presence of a psychology professional with specialized training in the area. (AU)

Antecedentes: La depresión perinatal es un importante problema de salud pública, con una prevalencia estimada de aproximadamente el 15% durante el primer año posparto. A pesar de la gran prevalencia de depresión posparto (DPP), no existe consenso sobre la evaluación y el tratamiento en el contexto español. El Consejo General de Psicología de España convocó a un grupo de trabajo de expertos en la materia, tanto académicos como profesionales sanitarios, para revisar y proponer recomendaciones basadas en evidencias y mejores prácticas que puedan aplicarse en el contexto español. Método: Se realizó una búsqueda bibliográfica en varias bases de datos (p. ej., Medline, PsychInfo) que incluía una combinación de términos relacionados con la evaluación y el diagnóstico de la DPP, prevención, tratamiento y coste-eficacia. Se ha realizado una síntesis narrativa de la literatura junto con una visión crítica de la DPP con un enfoque especial en el contexto español. Resultados: Las preguntas de desarrollo que incluyen prevalencia y herramientas de evaluación, la eficacia comparativa de las intervenciones preventivas y de tratamiento y la relación coste-efectividad de la gestión de la PPD se han analizado en este informe de consenso. Conclusiones: La red del Consejo General de Psicología de España aboga por el establecimiento de protocolos obligatorios de cribado en todas las Comunidades Autónomas. Asimismo, es necesario promover la inclusión en la educación materna de programas de promoción del bienestar mental y la prevención selectiva indicada llevadas a cabo por un profesional de la psicología con formación especializada en el área. (AU)

The economic toll of COVID-19: A cohort study of prevalence and economic factors associated with postpartum depression in Kenya.

OBJECTIVE: The aim of the study is to examine the risk of postpartum depression (PPD) among women who delivered during the COVID-19 pandemic compared to women who delivered before the COVID-19 pandemic and how economic challenges are associated with PPD. METHODS: Data were collected from 2332 women. This includes 1197 women from healthcare facilities in 2019 who were followed up at 2-4 and 10 weeks postpartum. Additionally, we recruited 1135 women who delivered from March 16, 2020 onward when COVID-19 restrictions were mandated in Kenya in the same catchment areas as the original sample to compare PPD rates. RESULTS: Adjusting for covariates, women who delivered during COVID-19 had 2.5 times higher odds of screening positive for PPD than women who delivered before COVID-19 (95% confidence interval [CI] 1.92-3.15). Women who reported household food insecurity, required to pay a fee to cover the cost of PPE during labor and delivery and/or postnatal visit(s), and those who reported COVID-19 employment-related impacts had a higher likelihood of screening for PPD compared to those who did not report these experiences. CONCLUSION: The COVID-19 pandemic has greatly increased the economic vulnerability of women, resulting in increases in PPD.

The Effect of the Affordable Care Act on Women's Postpartum Insurance and Depression in 5 States That Did Not Expand Medicaid, 2012-2015.

BACKGROUND: Before the Affordable Care Act (ACA), most women who gained pregnancy-related Medicaid were not eligible for Medicaid as parents postpartum. The ACA aimed to expand health insurance coverage, in part, by expanding Medicaid; introducing mandates; reforming regulations; and establishing exchanges with federal subsidies. Federal subsidies offer a means to coverage for individuals with income at 100%-400% of the federal poverty level who do not qualify for Medicaid. OBJECTIVE: The objective of this study was to identify the effects of the ACA's non-Medicaid provisions on women's postpartum insurance coverage and depressive symptoms in nonexpansion states with low parental Medicaid thresholds. PARTICIPANTS: Women with incomes at 100%-400% of the federal poverty level who had prenatal insurance and completed the Pregnancy Risk Assessment Monitoring System (2012-2015). SETTING: Five non-Medicaid expansion states with Medicaid parental eligibility thresholds below the federal poverty level. DESIGN: Interrupted time-series analyses were conducted to examine changes between pre-ACA (January 2012-November 2013) and post-ACA (December 2013-December 2015) trends for self-reported loss of postpartum insurance and symptoms of postpartum depression. RESULTS: The sample included 9,472 women. Results showed significant post-ACA improvements where the: (1) trend for loss of postpartum insurance reversed (change of -0.26 percentage points per month, P=0.047) and (2) level of postpartum depressive symptoms decreased (change of -3.5 percentage points, P=0.042). CONCLUSIONS: In these 5 states, the ACA's non-Medicaid provisions were associated with large increases in retention of postpartum insurance and reductions in postpartum depressive symptoms, although depressive symptoms findings are sensitive to model specification.

Postnatal Major Depressive Disorder in Australia: Inequalities and Costs of Healthcare to Individuals, Governments and Insurers.

BACKGROUND: Perinatal mental health has pervasive impacts on the wellbeing of both the mother and child, affecting quality of life, bonding and attachment and cognitive development. OBJECTIVES: The aim of this study was to (i) quantify the costs to government healthcare funders, private health insurers and individuals through out-of-pocket fees, of women with postnatal major depressive disorder (MDD); and (ii) identify any socioeconomic inequalities in health service use and costs amongst these women. METHODS: A whole-of-population linked administrative dataset containing the clinical records and health service use for all births in the state of Queensland, Australia between 01 July 2012 and 30 June 2015 was used (n = 189,081). Postnatal MDD was classified according to ICD-10 code, with women hospitalised for MDD in the 12 months after birth classified as having 'postnatal MDD' (n = 728). Health service use and costs from birth to 12 months post-birth were included. Total costs included cost to government funders and private health insurers and out-of-pocket fees. Total costs and costs to different funders were compared for women with postnatal MDD and for women without an inpatient event for postnatal MDD, with unadjusted means presented. A generalised linear model was used to compare the difference in total costs, adjusting for key confounders. Costs to different funders and number of different services accessed were then compared for women with postnatal MDD by socioeconomic status, with unadjusted means presented. RESULTS: The total costs from birth to 12 months post-birth were 636% higher for women with postnatal MDD than women without an inpatient event for postnatal MDD, after accounting for differences in private hospital use, mode of birth, clinical characteristics and socioeconomic status. Amongst women with postnatal MDD, the cost of all services accessed was higher for women of highest socioeconomic status than for women of lowest socioeconomic status (A$15,787.66 vs A$11,916.94). The cost of services for women of highest socioeconomic status was higher for private health insurers (A$8941.25 vs A$2555.26), but lower for public hospital funders (A$2423.39 vs A$6582.09) relative to women of lowest socioeconomic status. Outside of public hospitals, costs to government funders was higher for women of highest socioeconomic status (A$2766.80 vs A$1952.00). Women of highest socioeconomic status accessed more inpatient (8.2 vs 3.1) and specialist services (13.4 vs 5.5) and a higher proportion had access to psychiatric specialist care (39.7% vs 13.6%) and antidepressants (97.6% vs 93.8%). CONCLUSION: MDD is costly to all funders of healthcare. Amongst women with MDD, there are large differences in the types of services accessed and costs to different funders based on socioeconomic status. There may be significant financial and structural barriers preventing equal access to care for women with postnatal MDD.

Socioeconomic and psychological correlates of postpartum depression at 6 months in Dhaka, Bangladesh.

To current study aimed to estimate the point prevalence and identify correlates of postpartum depression (PPD) in a sample of mothers in Dhaka. A total of 235 participants from low- and middle-SES neighbourhoods in Dhaka completed the Edinburgh Postnatal Depression Scale (EPDS) and other assessments of socioeconomic and psychological factors at 24 weeks postpartum. Regression models were fit to explore potential correlates of PPD. The estimated prevalence of high PPD risk in the current sample is 24.3%. In multivariable linear regression models, recent life events, perceived stress and household resources (e.g., access to cooking gas, telephone, furniture, electricity, television, etc.) were significantly associated with PPD. The association of social support with PPD when controlling for other variables was sensitive to the choice of social support measure, highlighting an important methodological issue. The point prevalence of PPD among poor, urban mothers in Bangladesh ranges from 12.3 to 28.5%, with psychological risk factors and household resources as strong correlates.

Ethnic disparities in receiving benefits for disability following postpartum mental illness during first two years after delivery: an Israeli nationwide study.

BACKGROUND: Despite relatively high rates of Postpartum Depression (PPD), little is known about the granting of social security benefits to women who are disabled as a result of PPD or of other postpartum mood and anxiety disorders (PMAD). This study aims to identify populations at risk for underutilization of social security benefits due to PMAD among Israeli women, with a focus on ethnic minorities. METHODS: This retrospective cohort study is based on the National Insurance Institute (NII) database. The study population included a simple 10% random sample of 79,391 female Israeli citizens who gave birth during 2008-2016 (these women delivered a total of 143,871 infants during the study period), and who had not been eligible for NII mental health disability benefits before 2008. The dependent variable was receipt of Benefit Entitlement (BE) due to mental illness within 2 years following childbirth. Maternal age at delivery, population group, Socio-Economic Status (SES), family status, employment status of the mother and her spouse, and infant mortality were the independent variables. Left truncation COX proportional hazard model with time-dependent variables was used, and birth number served as a time discrete variable. RESULTS: Bedouin and Arab women had significantly lower likelihood of BE (2.6 times lower and twice lower) compared with other ethnic groups (HR = 0.38; 95% CI: 0.26-0.56; HR = 0.47; 95% CI: 0.37-0.60 respectively). The probability of divorced or widowed women for BE was significantly higher compared to those living with a spouse (HR = 3.64; 95% CI: 2.49-5.33). Lack of employment was associated with higher likelihood of BE (HR = 1.54; 95% CI: 1.30-1.82). Income had a dose-response relationship with BE in multivariable analysis: lower income was associated with the nearly four-fold greater probability compared to the highest income quartile (HR = 3.83; 95% CI: 2.89-5.07). CONCLUSIONS: Despite the exceptionally high prevalence of PMAD among ethnic minorities, Bedouins and Arabs had lowest likelihood of Benefit Entitlement. In addition to developing programs for early identification of postpartum emotional disorders among unprivileged ethnic groups, awareness regarding entitlement to a mental health disability allowance among ethnic minorities should be improved.

Effects of maternal depressive symptoms on sensitivity to infant distress and non-distress: Role of SES and race.

The goals of the present study were to examine the extent to which (a) maternal depressive symptoms (prenatal vs. postnatal depressive symptoms) undermine maternal sensitivity toward both infant distress and non-distress; (b) such effects are stronger in the context of socioeconomic risk. SES risk and depressive symptoms interacted such that depressive symptoms, both pre and postnatal, only predicted lower sensitivity among mothers at heightened SES risk. The effects were comparable for sensitivity to distress and non-distress and did not vary by maternal race.

Healthcare resource utilization and costs associated with postpartum depression among commercially insured households.

OBJECTIVE: To quantify the economic burden of postpartum depression (PPD) that accrues to commercially insured households in the year following childbirth. METHODS: Administrative claims data from OptumHealth Care Solutions (2009-2016) were used to identify households that included women identified with PPD per the algorithm and propensity score-matched comparison households of women who were not identified with PPD or a history of depression after childbirth. Study outcomes included direct total all-cause medical and pharmaceutical costs during the first year following childbirth and number of outpatient visits at the household level stratified by household member. RESULTS: Households affected by PPD as identified by the algorithm (N = 7769) incurred 22% higher mean total all-cause medical and pharmaceutical spending than unaffected matched controls (N = 41,308) during the first year following childbirth ($36,049 versus $29,448, p < 0.01) and an average of 16 more outpatient visits than unaffected households (p < .01). Costs accrued by mothers comprised the largest share (>50%) of total all-cause spending. Mothers identified with PPD had significantly higher annual mean direct total all-cause medical and pharmaceutical spending than their matched controls without PPD ($19,611 versus $15,410, p < .01), driven primarily by an average of 11 more outpatient visits than unaffected mothers (p < .01). CONCLUSIONS: Households affected by PPD as identified by the algorithm incurred higher mean total all-cause medical and pharmaceutical spending during the first year following childbirth than did their matched controls identified without PPD, but not all costs were attributable to maternal treatment for PPD. These findings contribute to a better understanding of the potential economic burden associated with PPD and demonstrated costs may extend beyond the mother to members of the household.

Diagnosis of Postpartum Depression and Timing and Types of Treatment Received Differ for Women with Private and Medicaid Coverage.

BACKGROUND: Postpartum depression is underdiagnosed and undertreated. The purpose of this study was to describe the prevalence and timing of depression diagnoses and treatment use in the year after childbirth among women with private and Medicaid health insurance coverage. METHODS: Using two large claims databases (private employer-sponsored and multistate Medicaid), we identified women with a live birth in 2014. We calculated the percentage of women with a depression diagnosis in the year after giving birth and identified their mental health treatment use (antidepressant medication filled and/or psychotherapy). We calculated days to diagnosis, days to treatment initiation, and number of therapy sessions. Percentages were compared using Cohen's h measure of effect size between two independent proportions (h ≥ 0.20 are meaningful). RESULTS: After childbirth, 7% of privately insured women and 13% with Medicaid were newly diagnosed with depression (h = 0.22). Those with Medicaid were diagnosed earlier (median 43 days vs. 78 days for private), but treatment initiation occurred later (h = 0.38) and at a lower rate (54% with Medicaid received some treatment vs. 71% with private insurance, h = 0.35). Many women received medication without therapy (44% with Medicaid vs. 51% with private insurance). Therapy was used more commonly by private enrollees (20% vs. 10% of Medicaid; h = 0.28). Among those who received therapy, the median was three sessions. CONCLUSIONS: Postpartum depression diagnosis was more prevalent among women with Medicaid coverage, yet the treatment gap was greater and initiation was later. These findings suggest that there is room for improvement when it comes to early intervention and treatment engagement.

Screening fathers for postpartum depression can be cost-effective: An example from Sweden.

BACKGROUND: Postpartum depression negatively affects the whole family and its prevalence in Sweden ranges between 6-10% for fathers and 13-16% for mothers. However, only mothers in Sweden are currently routinely screened. AIM: The aim of this study was to determine if a postpartum depression screening for fathers in Stockholm County could be cost-effective. METHODS: National Swedish databases were used to find registry data and a literature review was undertaken to identify the model data inputs associated with postpartum depression in Sweden. The generated evidence was used to build a Markov model in TreeAge. One-way and probabilistic sensitivity analyses were performed to account for parameter uncertainties. Alternative scenario analyses were further undertaken to test the assumptions in the base case analysis. RESULTS: A postpartum screening for depression in fathers is cost-effective in base case and alternative scenarios. The results indicate that the screening program is associated with lower costs and higher health effects. The results were sensitive to variables of quality adjusted life years for the depressed fathers, probabilities of remission in treatment and no treatment groups and start age and productivity losses. The probabilistic sensitivity analysis resulted in a 70% probability of the postnatal depression screening intervention being cost-effective. LIMITATIONS: The current study only uses secondary data; therefore future research should assess the cost-effectiveness of screening fathers for depression. CONCLUSION: The postpartum screening intervention for fathers could be cost-effective compared to no screening. Future research should replicate the potential cost-effectiveness for screening fathers for postpartum depression.

Protocol for the ROSE sustainment (ROSES) study, a sequential multiple assignment randomized trial to determine the minimum necessary intervention to maintain a postpartum depression prevention program in prenatal clinics serving low-income women.

BACKGROUND: More research on sustainment of interventions is needed, especially return on investment (ROI) studies to determine cost-benefit trade-offs for effort required to sustain and how much is gained when effective programs are sustained. The ROSE sustainment (ROSES) study uses a sequential multiple assignment randomized (SMART) design to evaluate the effectiveness and cost-effectiveness of a stepwise approach to sustainment of the ROSE postpartum depression prevention program in 90 outpatient clinics providing prenatal care to pregnant women on public assistance. Postpartum depression (PPD) is common and can have lasting consequences. Outpatient clinics offering prenatal care are an opportune place to provide PPD prevention because most women visit while pregnant. The ROSE (Reach Out, Stay Strong, Essentials for mothers of newborns) program is a group educational intervention to prevent PPD, delivered during pregnancy. ROSE has been found to reduce cases of PPD in community prenatal settings serving low-income pregnant women. METHODS: All 90 prenatal clinics will receive enhanced implementation as usual (EIAU; initial training + tools for sustainment). At the first time at which a clinic is determined to be at risk for failure to sustain (i.e., at 3, 6, 9, 12, and 15 months), that clinic will be randomized to receive either (1) no additional implementation support (i.e., EIAU only), or (2) low-intensity coaching and feedback (LICF). If clinics receiving LICF are still at risk at subsequent assessments, they will be randomized to either (1) EIAU + LICF only, or (2) high-intensity coaching and feedback (HICF). Additional follow-up interviews will occur at 18, 24, and 30 months, but no implementation intervention will occur after 18 months. Outcomes include (1) percent sustainment of core program elements at each time point, (2) health impact (PPD rates over time at each clinic) and reach, and (3) ROI (costs and cost-effectiveness) of each sustainment step. Hypothesized mechanisms include sustainment of capacity to deliver core elements and engagement/ownership. DISCUSSION: This study is the first randomized trial evaluating the ROI of a stepped approach to sustainment, a critical unanswered question in implementation science. It will also advance knowledge of implementation mechanisms and clinical care for an at-risk population. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03267563 . Registered June 14, 2018.

Cost-effectiveness of interventions for perinatal anxiety and/or depression: a systematic review.

OBJECTIVES: Anxiety and/or depression during pregnancy or year after childbirth is the most common complication of childbearing. Economic evaluations of interventions for the prevention or treatment of perinatal anxiety and/or depression (PAD) were systematically reviewed with the aim of guiding researchers and commissioners of perinatal mental health services towards potentially cost-effective strategies. METHODS: Electronic searches were conducted on the MEDLINE, PsycINFO and NHS Economic Evaluation and Health Technology Assessment databases in September 2017 to identify relevant economic evaluations published since January 2000. Two stages of screening were used with prespecified inclusion/exclusion criteria. A data extraction form was designed prior to the literature search to capture key data. A published checklist was used to assess the quality of publications identified. RESULTS: Of the 168 non-duplicate citations identified, 8 studies met the inclusion criteria for the review; all but one focussing solely on postnatal depression in mothers. Interventions included prevention (3/8), treatment (3/8) or identification plus treatment (2/8). Two interventions were likely to be cost-effective, both incorporated identification plus treatment. Where the cost per quality-adjusted life year (QALY) gained was reported, interventions ranged from being dominant (cheaper and more effective than usual care) to costing £39 875/QALY. CONCLUSIONS: Uncertainty and heterogeneity across studies in terms of setting and design make it difficult to make direct comparisons or draw strong conclusions. However, the two interventions incorporating identification plus treatment of perinatal depression were both likely to be cost-effective. Many gaps were identified in the economic evidence, such as the cost-effectiveness of interventions for perinatal anxiety, antenatal depression or interventions for fathers. PROSPERO REGISTRATION NUMBER: CRD42016051133.

Socioeconomic status and treatment of depression during pregnancy: a retrospective population-based cohort study in British Columbia, Canada.

Women at the lower end of the socioeconomic distribution have higher rates of depression in pregnancy; however, we know little about the role of socioeconomic status (SES) in determining their treatment. Herein, we investigate the relationships between income and the use of health services for depression in pregnancy. This retrospective cohort study using population-based administrative datasets included all women who delivered a live infant in the province of British Columbia, Canada (population of 4.3 million) between April 1st, 2000 and December 31st, 2009. We restricted to women with an indication of depression during pregnancy and examined their use of health services to treat depression by income quintile. Women in the highest income quintile were significantly more likely to see a psychiatrist for depression during pregnancy and to fill prescriptions for serotonin reuptake inhibitor (SRI) antidepressants than women in the lowest income quintile. Women at the lower end of the income distribution were more likely to have a GP visit for depression. Women at the low end of the income distribution were more likely to end up in hospital for depression or a mental health condition during pregnancy and more likely to receive a benzodiazepine and/or an antipsychotic medication. Our findings suggest a critical gap in access to health services for women of lower income suffering from depression during pregnancy, a time when proper access to effective treatment has the most potential to improve the long-term health of the developing child and the whole family unit.

Identifying and assessing the benefits of interventions for postnatal depression: a systematic review of economic evaluations.

BACKGROUND: Economic evaluations of interventions for postnatal depression (PND) are essential to ensure optimal healthcare decision-making. Due to the wide-ranging effects of PND on the mother, baby and whole family, there is a need to include outcomes for all those affected and to include health and non-health outcomes for accurate estimates of cost-effectiveness. This study aimed to identify interventions to prevent or treat PND for which an economic evaluation had been conducted and to evaluate the health and non-health outcomes included. METHODS: A systematic review was conducted applying a comprehensive search strategy across eight electronic databases and other sources. Full or partial economic evaluations of interventions involving preventive strategies (including screening), and any treatments for women with or at-risk of PND, conducted in OECD countries were included. We excluded epidemiological studies and those focussing on costs only. The included studies underwent a quality appraisal to inform the analysis. RESULTS: Seventeen economic evaluations met the inclusion criteria, the majority focused on psychological /psychosocial interventions. The interventions ranged from additional support from health professionals, peer support, to combined screening and treatment strategies. Maternal health outcomes were measured in all studies; however child health outcomes were included in only four of them. Across studies, the maternal health outcomes included were quality-adjusted-life-years gained, improvement in depressive symptoms, PND cases detected or recovered, whereas the child health outcomes included were cognitive functioning, depression, sleep and temperament. Non-health outcomes such as couples' relationships and parent-infant interaction were rarely included. Other methodological issues such as limitations in the time horizon and perspective(s) adopted were identified, that were likely to result in imprecise estimates of benefits. CONCLUSIONS: The exclusion of relevant health and non-health outcomes may mean that only a partial assessment of cost-effectiveness is undertaken, leading to sub-optimal resource allocation decisions. Future research should seek ways to expand the evaluative space of economic evaluations and explore approaches to integrate health and non-health outcomes for all individuals affected by this condition. There is a need to ensure that the time horizon adopted in studies is appropriate to allow true estimation of the long-term benefits and costs of PND interventions.

Screening for and Treating Postpartum Depression and Psychosis: A Cost-Effectiveness Analysis.

Objectives Postpartum depression impacts 6.5-12.9% of U.S. women. Postpartum depression is associated with impaired bonding and development, marital discord, suicide, and infanticide. However, the current standard of care is to not screen women for postpartum depression. This study modeled the cost-effectiveness of physicians screening for and treating postpartum depression and psychosis in partnership with a psychiatrist. Methods This study follows a hypothetical cohort of 1000 pregnant women experiencing one live birth over a 2-year time horizon. We used a decision tree model to obtain the outcomes of screening for and treating postpartum depression and psychosis using the Edinburgh Postnatal Depression Scale. We use a Medicaid payer perspective because they cover approximately 50% of births in the U.S. The cost-effectiveness of the intervention is measured in cost per remission achieved and cost per quality-adjusted life-year (QALY) gained. We conducted both deterministic and probabilistic sensitivity analyses. Results Screening for and treating postpartum depression and psychosis produced 29 more healthy women at a cost of $943 per woman. The incremental cost-effectiveness ratios of the intervention branch compared to usual care were $13,857 per QALY gained (below the commonly accepted willingness to pay threshold of $50,000/QALY gained) and $10,182 per remission achieved. These results were robust in both the deterministic and probabilistic sensitivity analyses of input parameters. Conclusions for Practice Screening for and treating postpartum depression is a cost-effective intervention and should be considered as part of usual postnatal care, which aligns with the recently proposed recommendations from the U.S. Preventive Services Task Force.

The effectiveness and cost-effectiveness of the peer-delivered Thinking Healthy Programme for perinatal depression in Pakistan and India: the SHARE study protocol for randomised controlled trials.

BACKGROUND: Rates of perinatal depression (antenatal and postnatal depression) in South Asia are among the highest in the world. The delivery of effective psychological treatments for perinatal depression through existing health systems is a challenge due to a lack of human resources. This paper reports on a trial protocol that aims to evaluate the effectiveness and cost-effectiveness of the Thinking Healthy Programme delivered by peers (Thinking Healthy Programme Peer-delivered; THPP), for women with moderate to severe perinatal depression in rural and urban settings in Pakistan and India. METHODS/DESIGN: THPP is evaluated with two randomised controlled trials: a cluster trial in Rawalpindi, Pakistan, and an individually randomised trial in Goa, India. Trial participants are pregnant women who are registered with the lady health workers in the study area in Pakistan and pregnant women attending outpatient antenatal clinics in India. They will be screened using the patient health questionnaire-9 (PHQ-9) for depression symptoms and will be eligible if their PHQ-9 is equal to or greater than 10 (PHQ-9 ≥ 10). The sample size will be 560 and 280 women in Pakistan and India, respectively. Women in the intervention arm (THPP) will be offered ten individual and four group sessions (Pakistan) or 6-14 individual sessions (India) delivered by a peer (defined as a mother from the same community who is trained and supervised in delivering the intervention). Women in the control arm (enhanced usual care) will receive health care as usual, enhanced by providing the gynaecologist or primary-health facilities with adapted WHO mhGAP guidelines for depression treatment, and providing the woman with her diagnosis and information on how to seek help for herself. The primary outcomes are remission and severity of depression symptoms at the 6-month postnatal follow-up. Secondary outcomes include remission and severity of depression symptoms at the 3-month postnatal follow-up, functional disability, perceived social support, breastfeeding rates, infant height and weight, and costs of health care at the 3- and 6-month postnatal follow-ups. The primary analysis will be intention-to-treat. DISCUSSION: The trials have the potential to strengthen the evidence on the effectiveness and cost-effectiveness of an evidence-based psychological treatment recommended by the World Health Organisation and delivered by peers for perinatal depression. The trials have the unique opportunity to overcome the shortage of human resources in global mental health and may advance our understanding about the use of peers who work in partnership with the existing health systems in low-resource settings. TRIAL REGISTRATION: Pakistan Trial: ClinicalTrials.gov Identifier: NCT02111915 (9 April 2014) India Trial: ClinicalTrials.gov Identifier: NCT02104232 (1 April 2014).

Changes in the Relationship Between Socioeconomic Position and Maternal Depressive Symptoms: Results from the Panel Study on Korean Children (PSKC).

Maternal depression is a common health problem during the perinatal period. The purpose of this study was to examine changes in the relationship between socioeconomic position and maternal depressive symptoms from prenatal to 3 years postpartum in Korean women. Prospective cohort data were collected from the Panel Study on Korean Children between 2008 and 2011. Maternal depression was assessed using the Kessler 6-Item Psychological Distress Scale. Socioeconomic position indicators used were maternal education, paternal education, maternal occupation, paternal occupation, and household income. Repeated-measures analyses with a generalized estimating equation approach were used to investigate relationships between socioeconomic position and maternal depressive symptoms during the study period. Low socioeconomic position was associated with greater levels of maternal depressive symptoms between 4 months after childbirth and 3 years postpartum, but the association was not evident between 1 month before and after childbirth. The magnitude of the significant association between socioeconomic position and maternal depression was the greatest at 1 year postpartum but then became smaller. Among the five socioeconomic position indicators included, maternal education, paternal education, and household income showed graded inverse relationships with maternal depressive symptoms, while no significant relationship was found for paternal occupation over the study period. Socioeconomic inequalities in maternal depressive symptoms emerged in early childhood in a prospective study of Korean mothers. These emerging inequalities may contribute to socioeconomic inequalities in childhood health and development.

Protocol for economic evaluation alongside a cluster-randomised controlled trial of a psychoeducational intervention for the primary prevention of postnatal mental health problems in first-time mothers.

INTRODUCTION: Postnatal mental health problems, which are an international public health priority, are a suitable target for preventive approaches. The financial burden of these disorders is borne across sectors in society, including health, early childhood, education, justice and the workforce. This paper describes the planned economic evaluation of What Were We Thinking, a psychoeducational intervention for the prevention of postnatal mental health problems in first-time mothers. METHODS AND ANALYSIS: The evaluation will be conducted alongside a cluster-randomised controlled trial of its clinical effectiveness. Cost-effectiveness and costs-utility analyses will be conducted, resulting in estimates of cost per percentage point reduction in combined 30-day prevalence of depression, anxiety and adjustment disorders and cost per quality-adjusted life year gained. Uncertainty surrounding these estimates will be addressed using non-parametric bootstrapping and represented using cost-effectiveness acceptability curves. Additional cost analyses relevant for implementation will also be conducted. Modelling will be employed to estimate longer term cost-effectiveness if the intervention is found to be clinically effective during the period of the trial. ETHICS AND DISSEMINATION: Approval to conduct the study was granted by the Southern Health (now Monash Health) Human Research Ethics Committee (24 April 2013; 11388B). The study was registered with the Monash University Human Research Ethics Committee (30 April 2013; CF12/1022-2012000474). The Education and Policy Research Committee, Victorian Government Department of Education and Early Childhood Development approved the study (22 March 2012; 2012_001472). Use of the EuroQol was registered with the EuroQol Group; 16 August 2012. TRIAL REGISTRATION NUMBER: The trial was registered with the Australian New Zealand Clinical Trials Registry on 7 May 2012 (registration number ACTRN12613000506796).

Sample size calculation in cost-effectiveness cluster randomized trials: optimal and maximin approaches.

In this paper, the optimal sample sizes at the cluster and person levels for each of two treatment arms are obtained for cluster randomized trials where the cost-effectiveness of treatments on a continuous scale is studied. The optimal sample sizes maximize the efficiency or power for a given budget or minimize the budget for a given efficiency or power. Optimal sample sizes require information on the intra-cluster correlations (ICCs) for effects and costs, the correlations between costs and effects at individual and cluster levels, the ratio of the variance of effects translated into costs to the variance of the costs (the variance ratio), sampling and measuring costs, and the budget. When planning, a study information on the model parameters usually is not available. To overcome this local optimality problem, the current paper also presents maximin sample sizes. The maximin sample sizes turn out to be rather robust against misspecifying the correlation between costs and effects at the cluster and individual levels but may lose much efficiency when misspecifying the variance ratio. The robustness of the maximin sample sizes against misspecifying the ICCs depends on the variance ratio. The maximin sample sizes are robust under misspecification of the ICC for costs for realistic values of the variance ratio greater than one but not robust under misspecification of the ICC for effects. Finally, we show how to calculate optimal or maximin sample sizes that yield sufficient power for a test on the cost-effectiveness of an intervention.