Research reportWhat is the best tool for screening antenatal depression?
Introduction
Antenatal depression (AD) has been described as a form of clinical depression that affects women during pregnancy and that may increase the risk of postpartum depression if not properly treated (Milgrom et al., 2008, Norhayati et al., 2015).
Moreover, AD is a highly frequent condition, with prevalence estimated as high as 18% of pregnancies (Gavin et al., 2005). The presence of AD can have multiple deleterious effects, not only on women but also on offspring and the entire family. Depressed pregnant women, for example, are more prone to exhibiting high-risk behaviors. They are more likely to use alcohol, tobacco and illicit drugs; to have unhealthy eating habits; to suffer from sleep disturbances; and to attend fewer prenatal follow-up appointments (Bennett et al., 2004a, Field et al., 2008, Hauge et al., 2012, Marcus, 2009, Orr et al., 2007, Zuckerman et al., 1989). These behaviors interact with the intrinsic biological mechanisms of depression to create an increased risk of obstetric complications, such as pre-eclampsia, pre-term birth, restricted fetal growth and/or low birth weight (Bonari et al., 2004, Davalos et al., 2012, Diego et al., 2009, Field et al., 2008, Grote et al., 2010). In addition, an increasingly large body of clinical and experimental evidence suggests that both biological markers and the physiology of the offspring of depressed females can be influenced by maternal hypothalamic–pituitary–adrenal (HPA) axis dysfunction, including increased levels of cortisol and cathecolamines (Brummelte and Galea, 2010, Frodl and O’Keane, 2013, Wadhwa et al., 2002). These abnormalities may have life-long implications for the developing brain of the fetus, such as negative consequences for neural circuits, neurotransmitter activities and epigenetic changes (Davis et al., 2011, Field et al., 2006, Frodl and O’Keane, 2013, Oberlander et al., 2008, Weinstock, 2005), rendering the offspring more vulnerable to mental health disorders later in life (Halligan et al., 2007, O’Donnel et al., 2014, Pawlby et al., 2009, Pearson et al., 2013, Santos et al., 2014, Talge et al., 2007). Finally, a positive correlation between maternal and paternal depression has been demonstrated, emphasizing that AD is not merely a women׳s issue but is a problem that affects entire families (Escriba-Àguir and Artazcoz, 2011, Paulson and Bazemore, 2010).
All of these factors illustrate that AD diagnosis and treatment should be considered a public health issue, and all pregnant women should be screened for signs of AD. Unfortunately, the rate of AD under-diagnosis can be as high as 80% (Kelly et al., 2001a) and is likely higher in areas with deficient healthcare infrastructures. Therefore, studying instruments that could be used in primary care settings by non-doctors and non-specialists is critical to enable broad screening for AD among pregnant women.
The most frequent scales used in the assessment of AD, the Beck Depression Inventory (BDI) (Beck et al., 1961) and the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al., 1987, Bennett et al., 2004a), were developed for general use with major depression across the life span and during the postpartum period, respectively. Because of the sensitivity of these instruments, however, normal symptoms in pregnancy can sometimes be misconstrued as indicators of depression, and although they may resolve as pregnancy nears completion, such symptoms can lead to higher scores on self-report measures (Matthey and Ross-Hamid, 2012). An additional concern pertains to the psychometric characteristics of these scales with regard to cultural population characteristics and their use in populations in which illiteracy remains a problem. Although scholars have debated the extent to which the psychometric properties of those scales are adequate for use in AD, the EPDS and BDI have been utilized extensively in the antenatal period (Areias et al., 1996, Buist et al., 2006, Chung et al., 2001, Da-Silva et al., 1998, Evans et al., 2001, Josefsson et al., 2001, Gotlib et al., 1989, Manikkam and Burns, 2012, Matthey and Ross-Hamid, 2012, Milgrom et al., 2008, Rochat et al., 2011, Seguin et al., 1995). However, questions remain regarding whether there are major differences between the self-fulfillment scales (EPDS and BDI) and those applied by professionals, such as the Hamilton Depression Rating Scale (HAM-D) (Hamilton, 1960).
To the best of our knowledge, none of these three depression screening tools have been validated for use in an antenatal population in Brazil. Our aim was to compare the psychometric characteristics of the EPDS, BDI and HAM-D scales to those of a structured interview (MINI-PLUS) (Amorim, 2000), which is the gold standard for AD diagnosis, in second-trimester pregnant women.
Section snippets
Research protocol
A total of 247 consecutive women who were in their second trimester of pregnancy and were attending antenatal care at a public hospital were enrolled in the study. After a full explanation of the study purpose, written informed consent was obtained from each participant. As part of the study, the patients were evaluated using the Brazilian validated version of the EPDS (Santos et al., 2007) and the BDI (Gorenstein and Andrade, 1996). A trained psychiatrist blinded to the EPDS and BDI scores
Depression prevalence and risk factors
A major depressive disorder was diagnosed during the second trimester of pregnancy or during the lifetime in 17.34% and 31.98% of the women, respectively. Table 1 contains the sociodemographic and clinical characteristics of these women diagnosed with AD.
Pregnant women with more than one child (p=0.004), those who had experienced a previous abortion (p=0.026), those who had a history of suffering aggression (p<0.001) and those who had not received support from their family or friends during
Discussion
In our sample, we found an AD prevalence rate of 17.34% in the second trimester based on the structured MINI-Plus interview, which is similar to that obtained by other researchers (Bennett et al., 2004a, Gavin et al., 2005). By contrast, the prevalence rates obtained using the EPDS, BDI and HAM-D were 32.6% (23.7–43.0), 25.0% (17.1–35.0) and 38.0% (28.6–48.5), respectively.
The results above are consistent with existing variability based on country and study methodology. In high-income countries
Conflict of interest
We declare that we have no conflicts of interest.
Role of funding source
Funding for this study was provided by the National Counsel of Technological and Scientific Development (CNPq) (Grant no. 444254/2014-5) and the Minas Gerais State Research Foundation (FAPEMIG) (Grant no. APQ-01954-14). CNPq/FAPEMIG had no further role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Acknowledgments
We thank Mr. Gustavo Coutinho Faria and Mr. Sandro Cançado Silva, who assisted with the collection of some of the data necessary for our analysis.
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