PREVENTION AND EARLY TREATMENT OF PERINATAL DEPRESSION

1. PREVENTION AND EARLY TREATMENT OF PERINATAL DEPRESSION MARIANO BASSI MENTAL HEALTH DEPARTMENT AZIENDA OSPEDALIERA NIGUARDA CA’ GRANDA MILAN, ITALY

2. THE REASONS FOR PREVENTING PERINATAL MENTAL DISORDERS-1- Throughout the western developed world, for women aged 15 to 44 years, depression is second only to the consequences of HIV / AIDS in terms of total disability and is the leading cause of hospitalizations for female patients, excluding gynecological diseases The post-partum depression (PPD) is often defined by research such as clinical depression that occurs within the first year following childbirth The results of all studies of prevalence and meta-analyses tell us that 7.1% of mothers in a major depressive episode occurs in the first 12 weeks postpartum If instead we consider the symptomatic manifestations that may be included in the nosological frame of "minor depression", the prevalence rate increases to 19.2% (Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, & Swinson T., 2005)

3. THE REASONS FOR PREVENTING PERINATAL MENTAL DISORDERS-2- • Perinatal depression can have devastating consequences for the affected woman, her children, and family and has been linked to poor childbirth outcomes, such as preterm delivery and low birth weight and to detrimental effects on maternal sensitivity in the postpartum period • The perinatal period has been documented to be a time of high risk for psychiatric hospitalization, particularly in women with bipolar disorder and those with past episodes of MDD Meltzer-Brody S. (2011)

5. THE REASONS FOR PREVENTING PERINATAL MENTAL DISORDERS-3- Unlike other stressful events associated with psychiatric illness, childbirth is accurately predictable and is known to be associated with an increased risk of mental disorders Furthermore, the perinatal period is a time in a woman’s life when she is in frequent contact with health professionals and it therefore provides opportunities for predicting and preventing mental disorders This requires the coordinated participation of professionals in primary care, maternity services and mental health, working closely with women and their families

6. BIOLOGICAL RISK FACTORS FOR PERINATAL DEPRESSION Hormonal dysregulation during pregnancy or parturition Abnormalities in hypothalamic-pituitary-adrenal (HPA) axis activity The contributions of genetics and epigenetics

7. PSYCHOSOCIAL RISK FACTORS FOR PERINATAL DEPRESSION lack of a close confiding relationship or poor relationship with partner chronic stressors such as housing or financial problems, unemployment and having other young children to look after recent adverse life events (family deaths, job loss, end of a loving relationship) unwanted or unplanned pregnancy woman’s poor relationship with her own mother and possibly father lower socioeconomic status perception of poor obstetric experience

8. RISK FACTORS EMERGING CONSISTENTLY IN THE LITERATURE (Cantwell R., Smith S., 2006)

9. PRIMARY PREVENTION • Primary prevention aims to prevent the occurrence of a disorder by reducing or counteracting factors before they can cause it • Measures can be divided into universal, selective and indicate • Interventions before the onset of the disorder are very common, aimed at reducing the depression risk (for example prenatal mother’s groups, training of medical, social and cultural issues related to postpartum depression risk factors and symptoms)

10. PRIMARY PREVENTIONUNIVERSAL MEASURES Universal measures target the whole population rather than any particular risk group, for example, by encouraging healthier lifestyles or enhancing skills for coping with stress Many of the rituals surrounding the transition to parenthood (such as ‘lying in’ periods involving intensive support from family members) are now missing in western cultures and it has been argued that this may contribute to loss of psychological well-being around this time Many women underestimate the life-changing aspects of having children, and are reluctant to adapt and to seek or accept help and support from their social networks

11. PRIMARY PREVENTIONSELECTIVE MEASURES Selective measures target all people known to be at risk for a particular disorder Antenatal classes and prenatal mother’s groups provide an ideal forum for informing mothers and couples about mental health issues. They should be prepared before birth for protecting themselves. These preparations include: maximizing available support (emotional and practical) from partner, family and friends once the baby arrives avoiding major stresses where possible (such as moving house) planning relief (e.g. with baby care, cooking) maintaining social contact with others

12. PRIMARY PREVENTIONINDICATED MEASURES Women who have been identified as vulnerable by possessing recognized risk factors can be targeted with specific preventative measures To achieve this, primary care, maternity and mental health services need to understand these risk factors, and have routine processes for identifying them and agreed procedures for management or referral

13. WOMEN AT RISK OF POSTNATAL DEPRESSION Women with a history of depression, particularly postnatal depression, are often keen to receive help and advice on how they can reduce the risk of recurrence Options which should be discussed with the woman in the light of her individual circumstances and wishes include use of prophylactic antidepressants, but evidence is conflicting on this Alternatively, ‘watchful waiting’ with discussion of early warning signs (relapse profiling) may be helpful

14. PSYCHOSOCIAL MEASURES Giving an opportunity to talk about their concerns, discussion about prevention and treatment options and reassurance that health professionals are willing to help Minimizing avoidable life changes Partner’s engagement in the antenatal care Enhancement of the woman’s social networks during pregnancy Social support, antenatal groups and activities, contacts and relationships with friends and family

15. SECONDARY PREVENTION • Secondary prevention reduces the prevalence of a disorder by reducing the duration of illness, minimizing the chances of transmission and limiting adverse consequences of the disorder • In perinatal psychiatry it is based on early detection and rapid effective treatment • One way of trying to achieve early detection is screening

16. SCREENING The routine search for undetected illness is an essential component of medical assessment and, to some extent, occurs in almost all clinical interactions (e.g. in routine questions on alcohol intake or change of bowel habit) Such screening programmes include not only the screening tool or test itself, but further diagnostic procedures and appropriate treatments They are most effective when the untreated condition being screened carries a poor prognosis and when effective treatment exists for those detected

17. LIMITATIONS OF SCREENING Problems may also arise when there is no clear cut-off between mental health problems and wellbeing such as in depression A decision has to be made on where the cut-off lies in the screening tool and it is therefore important to remember that a negative screen does not imply an absence of illness or risk By definition, screening leads to earlier identification of disease. There must also be evidence that earlier intervention brings about more benefit. If this is not the case, a screening programme may be an unnecessary and intrusive waste of resources

18. THE REASONS OF THE SECONDARY PREVENTION DURING PREGNANCY Many of the postpartum depression risk factors may already be present during pregnancy: problems related to conflict within the husband/partner and the family lack of emotional and warm relationships characterized by intimacy and mutual trust socio-economic difficulties a history of mental disorders (O'Hara & Zekoski 1988,Romito 1989)

19. SECONDARY PREVENTION : “LISTENING INTERVENTION” • A structured listening and support intervention, involving women selected as 'at risk' of postnatal depression in weekly sessions, has proven to be an effective treatment, reducing from 62% to 31%, the number of women still depressed at six months (Holden et al 1989) • Further studies have confirmed the efficacy of these listening and support interventions to improve the emotional wellbeing of women at postnatal depression risk (Cullinan 1991, Gerrard et al 1993, Ring & McLean, 1995)

22. MAIN RISK FACTORS FOR THE MIGRANT WOMEN • Stress from the acculturation process • Lack of social support • Economic and housing instability • Services difficult to reach for social, cultural and language reasons

23. In the process of acculturation the migrant woman has to adapt to : • a new language • new values • new behaviors and habits • new rules of social interaction • new laws • new lifestyles

24. A DIFFERENT BIRTHRATE IN ITALY(2010) Fonte: elaborazione Censis su dati Istat 2010 Ketty Vaccaro Censis

25. HOW IS CHANGING THE BIRTH RATE IN ITALY number of foreign newborns every 100 births (2010) Fonte: elaborazione Censis su dati Istat 2010 Ketty Vaccaro Censis

26. PRIMARY PREVENTION FOR MIGRANT WOMEN • Distributing information in the language spoken by the migrant woman • Prenatal mother’s specific groups for migrant women • Training of medical, social and cultural issues related to postpartum depression risk factors and symptoms, but also related to different conceptualizations of motherhood and to the different expression of depressive symptoms in different cultures

27. PREVENTION AND EARLY TREATMENT NIGUARDA HOSPITAL CENTER MILAN, ITALY It is aimed at: • - Pregnant women found to be at risk of PPD by the screening • - Pregnant women who access directly and spontaneously to the Hospital Center • - Pregnant women sent to our Center from the Department of Obstetrics and Gynecology staff The Hospital Center offers the following kind of treatments: • - Psychological (individual psychotherapy and counseling) • - Psychiatric (psychiatric clinical monitoring and drug therapy supervision) • - Social structured support • - Obstetrics and gynecological continuity of care • For foreign women a specific care is implemented through the involvement of a cultural mediator

28. THE MILAN RESEARCH GOAL: • Assessing the risk of PPD among migrant women (Arab and Latin American) compared to an Italian women control group SETTING: • Niguarda Ca 'Granda Hospital, Milan • St. Paul's Hospital, Milan • Fatebenefratelli and Ophthalmic Hospital, Milan METHOD: • Administration of an admission questionnaire and three rating scales (Edinburgh Postnatal Depression Scale, Beck Depression Inventory, and Social Provision Scale) during the period of pregnancy PARTICIPANTS: • A group of Arab ethnicity women • A group of South American ethnicity women • A control group of Italian women

29. NIGUARDA HOSPITAL DATA 2009/2011 • Pregnant women in touch = 832 • Italians = 586 (70%) • Foreigners = 246 (30%)

30. FIRST CONCLUSIONS FROM THE PRELIMINARY DATA OF THE RESEARCH • Immigrant, asylum-seeking, and refugee women have higher PPD risk factors than Italian women • They also report receiving less prenatal care and social support • Increased psychological and social support during the pregnancy might help prevent PPD risk factors and depressive symptoms in migrant women • The most significant factors for the PPD risk are Arab ethnicity, poor education level, lack of knowledge of Italian language and strong religious faith • Inquiries about PPD risk factors should be made to all pregnant women, but especially to those who are newcomers to the country

31. Mariano.Bassi@ospedaleniguarda.it