La aventura:Primer encuentro: Diagnóstico

Introduction

Childbirth represents for women a time of great vulnerability to become mentally unwell, with postpartum mood disorders representing the most frequent form of maternal morbidity following delivery. While postpartum depression is a major health issue for many women from diverse cultures, this affective condition often remains undiagnosed resulting in limited management. The objective of this chapter is to critically review the literature to determine the current state of scientific knowledge related to the detection, prevention, and treatment of postpartum depression.

Methods

Databases relating to the medical, psychological and social science literature were searched using specific inclusion criteria and search terms to identify studies, which examined screening procedures and/or the effect of various preventive and treatment interventions on depressive symptomatology among expectant and new mothers. Randomized controlled trials, meta-analyses, and several studies with diverse designs were identified and critically appraised in order to synthesize the current findings. The search resulted in the identification of numerous postpartum depression detection studies and over 58 trials evaluating preventive and treatment intervention. The criteria used to evaluate the interventions outlined in this chapter were based on the standardized methodology developed by the Canadian Task Force on Preventive Health Care.

Key Findings

Today, both general and postpartum-specific depression instruments have been utilized to measure depressive symptomatology. By far the most widely used instrument in postpartum depression studies and for population-based screening is the Edinburgh Postnatal Depression Scale (EPDS), a 10-item self-report scale specifically designed to screen for postpartum depression in community samples. While this measure has been validated among diverse cultures resulting in varying sensitivity and specificity values, diversity and inconsistency in assessment procedures have hampered the meaningful comparison of studies and compromised the development of a cumulative body of knowledge. Although these psychometric limitations are not unique to the EPDS, the methodological explanations justify only some of the discrepancies found between the EPDS translation and validation investigations. Significant differences in the proportion of high EPDS scores across different cultural contexts were noted in an international multi-site study suggesting that cultural factors merit more attention. In addition, further research is required to determine if indeed the EPDS is the most appropriate screening instrument as new measures are being developed based on qualitative investigations.

While determining the most appropriate instrument to detect postpartum depression is challenging, immense efforts have also been undertaken to identify pregnant women who are at-risk of developing

systematic review of 16 antenatal screening studies, where sufficient data was available to calculate specific screening properties, was conducted. No screening instrument met the researchers’ outlined criteria for routine application in the antenatal period and the unacceptably low positive predictive values in the included studies make it difficult to recommend the use of screening tools in routine antenatal care. It is noteworthy that the predictive power of maternal mood in the immediate postpartum period (e.g., first 2 weeks postpartum) in the development of postpartum depression has consistently been reported and warrants further investigation.

The overarching question – whether screening and subsequent management is superior to management based on usual means of identification as ‘high-risk’– is controversial. It is equivocal whether further support beyond identification improves management adherence and clinical outcomes. The trade-offs between benefits and harms are an important component in the decision of whether to screen or not. Currently, there is limited information about the harms of screening and despite a wealth of studies concerning the prevalence of postpartum depression and screening accuracy, key elements of the evidence base for screening remains insufficiently developed. As such, a strong recommendation to implement screening procedures cannot be justified until further research has been completed.

The long-term consequences of postpartum depression suggest preventive approaches are warranted. Manipulation of a risk factor may improve the associated likelihood of developing postpartum depression through many different ways. The most obvious is to decrease the amount of exposure to a given risk factor or, alternatively, reduce the strength or mechanism of the relationship between the risk factor and postpartum depression. However, translating risk factor research into predictive screening protocols and preventive interventions has met with limited success, as complex interactions of biopsychosocial risk factors with individual variations need to be contemplated. Numerous studies have been examined in this review with the diverse aetiology of postpartum depression reflected in the broad range of approaches considered. Although theoretical justifications for many of these approaches have been presented, methodological limitations render intervention efficacy equivocal with scant evidence available to guide practice or policy recommendations. Despite the recent upsurge of interest in this area, many questions remain unanswered resulting in a myriad of research implications. Similarly, definite conclusions cannot be reached about the relative effectiveness of treatment approaches due to the lack of well-designed investigations. Randomized controlled trials with large and representative samples are needed to compare different treatment modalities, examine the effectiveness of individual treatment components, and determine which treatments are most useful for women with different risk factors or clinical presentations of postpartum depression.

to be made regarding: (1) the most accurate screening test that is culturally sensitive, quick to administer, easy to interpret, and readily incorporated into practice; and (2) health care system issues such as cost- effectiveness, potential harm, and policies for referral. Auspiciously, research suggests postpartum depression is amenable to preventive and treatment interventions, thus providing a rationale for the development of a screening program. However, limited research has been conducted demonstrating screening improves clinical outcomes. Furthermore, few well-designed randomized controlled trials have been conducted to effectively guide practice and policy recommendations and further research is warranted if evidence-based programs are to be implemented. As there is no single etiological pathway by which women develop postpartum depression, it is improbable that a single preventive/treatment modality will be effective for all women. A multifactorial approach, which combines the contributions of the psychological, psychosocial, and biological factors, is likely to be most beneficial as it recognizes various etiological factors and individual variations.