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Prevalence and Incidence of Perinatal Depression and Depressive Symptoms among Mexican Women Ma. Asunción Lara, Laura Navarrete, Lourdes Nieto, Juan Pablo Barba Martín, José Luis Navarro, Héctor Lara-Tapia
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Received date: 24 November 2014 Revised date: 5 December 2014 Accepted date: 11 December 2014 Cite this article as: Ma. Asunción Lara, Laura Navarrete, Lourdes Nieto, Juan Pablo Barba Martín, José Luis Navarro, Héctor Lara-Tapia, Prevalence and Incidence of Perinatal Depression and Depressive Symptoms among Mexican Women, Journal of Affective Disorders, http://dx.doi.org/10.1016/j.jad.2014.12.035 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Prevalence and Incidence of Perinatal Depression and Depressive Symptoms among Mexican Women
Ma. Asunción Lara, Ph.D.,a,* Laura Navarrete, M.Sc.,a Lourdes Nieto, Ph.D.a, Juan Pablo Barba Martín, MD,b José Luis Navarro, MD,c Dr. Héctor Lara-Tapia, MDb
a
Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz. Calzada México-Xochimilco
101, San Lorenzo Huipulco, Tlalpan, México, D. F., 14370 b
Hospital Regional “Lic. Adolfo Lopez Mateos” Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, ISSSTE. México, D. F. c
Delegación Regional Poniente. Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, ISSSTE. México, D. F. México, D. F.
*
Corresponding author’s address: Instituto Nacional de Psiquiatría Ramón de la Fuente
Muñiz. Calzada México-Xochimilco 101, San Lorenzo Huipulco, Tlalpan, Mexico, D. F. 14370. Tel.: +52 55 416 05170. Fax: 55133446 E-mail address: [email protected]
Abstract Background: The aim of this study was to assess point and period prevalence and incidence of perinatal depression in Mexican women. Methods: The Structured Clinical Interview for DSM-IV and the Patient Health Questionnaire (PHQ-9) were administered at three points in time to 210 women: during the third trimester of pregnancy, at six weeks and at six months after delivery. Results: Prevalence of prenatal depression was 9.0%, and 13.8% at six weeks and 13.3% at six months postpartum. Incidence of postpartum depression (PPD) was 10.0% at six weeks and 8.2% at six months. Prevalence of prenatal depressive symptoms was 16.6%; and 17.1% at six weeks and 20.0% at six months postpartum. Incidence of postpartum depressive symptoms (PPDS) was 11.4% at six weeks and 9.0% at six months. At six months postpartum, women with depression were younger (OR=2.45, p=0.02), had fewer years’ schooling (OR=5.61, p=0.00), were unpartnered (OR=3.03, p=0.01), unemployed (OR=3.48, p=0.00) and poorer (OR=4.00, p=0.00) than women without depression. Limitations: 25% of the initial sample was not retained to complete the three assessments. Non completers were younger, less educated and reported more depressive symptoms. This may have resulted in an underestimation of prevalence. Conclusions: This is the first longitudinal study in Latin America to assess perinatal depression at three different points in times, reporting point and period prevalence and incidence of clinical depression and depressive symptoms. Most LA countries have yet to recognize the importance of providing mental health care for expectant and postpartum mothers to reduce disability in mothers and infants.
Key words: Prevalence, incidence, pregnancy depression, postpartum depression, middlelow income country, perinatal depression.
1. Introduction Perinatal depression is a common condition affecting large numbers of women worldwide. According to the DSM-V (APA, 2013), perinatal or peripartum depression is a phenomenon that is undistinguishable from major depression except for its timing, having its onset during pregnancy or within the first four weeks postpartum. However, in clinical practice and many research studies time frames range up to one year postpartum (O’Hara and McCabe, 2013). The fact that it may occur during a vulnerable period in women’s lives creates enormous concern among mental health professionals, since it has extremely severe effects on the health of both mother and baby. Prenatal depression, one of the strongest predictors of postpartum depression (PPD), is associated with poor health behaviour and risk-taking behaviour (Bennett et al., 2004a). Depressed pregnant women are also more likely to deliver prematurely, and neonates are at a greater risk for low birth weight and being small for gestational age (Field et al., 2006). PPD often inhibits the woman’s ability to perform daily activities, which may have detrimental effects on her capacity to care effectively for herself and her baby. PPD has been associated with greater use of emergency department services, malnutrition, developmental delay, and lower quality interactions between mother and baby, which is
associated with high rate of insecure attachment in the latter (Murray et al., 1997; Field, 2010). A review study on the prevalence of depression in pregnancy measured through structured interviews, including data mostly from developed countries, reports a prevalence of 2% to 21% (Bennett et al., 2004a). Another systematic review, which included studies using structured interviews and excluded studies from less developed countries, found a prevalence of 8.5% to 11% for major and minor depression (3.1 - 4.9 for major depression alone) (Gayness et al., 2005). Bennett et al. (2004a) also reviewed the prevalence of depressive symptoms in pregnancy based on self-report questionnaires; the prevalence found varied from 8% to31%. In Latin America), research using clinical interviews finds rates of 12.3% to 14% (Ocampo et al., 2007; Gómez et al., 2007), while depressive symptoms are reported in 24.3% (Edinburgh Postnatal Depression Scale, EPDS12) (Melo et al., 2012), 30.7% (Centre for Epidemiologic Studies Depression Scale, CES-D16) (Lara et al., 2006), and 34.7% (EPDS13.5) (Bao-Alonso et al., 2010). For PPD, Gaynes et al.’s (2005) systematic review estimates a6.5% to 12.9% prevalence for major and minor depression and of 1.0% to 5.9% for major depression alone during the first year postpartum. O’Hara and Swain (1996) estimate the prevalence of PPD using a meta-analysis including data mainly but not exclusively from developed countries. In their study, PPD prevalence based on interviews was 12% (95% CI 11.3-12.7) and on self-report measurements was 14% (95% CI 13.1-14.9). In Latin America, the prevalence of PPD using clinical interviews varies widely from 13.8% to 24.1% (Ocampo et al., 2007; Alvarado-Esquivel, et al., 2010; Almanza-Muñoz et al., 2011; Álvarez et al., 2008; Alvarado et al., 2000; Aramburú et al., 2004), while PPDS measured by the EPDS is 10.8% (EPDS12) (Melo et al., 2012) and 14.2% (EPDS13) (DeCastro et al., 2011).
Gaynes et al. (2005) found very few studies reporting measurements other than point prevalence such as incidence and period prevalence. Their estimate for new PPD cases is 14.5% within the first three months postpartum (6.5% of major depression alone) while their estimate for period prevalence was19.2% (7.1% for major depression only). To our knowledge, in Latin America there is only one study reporting the incidence of PPD, finding 8.8% of new cases during the first two months postpartum (Alvarado et al., 2000) with no studies reporting period prevalence. Some of the methodological problems when interpreting the prevalence of PPD are due to population characteristics but more often to the use of different measures of depression (Gaynes et al., 2005). Prevalence based on structured interviews is considered to provide more accurate estimates of the disease burden for targeting health care expenditure (Gavin et al., 2005), while self-report scales tend to yield higher rates than those based on clinical interviews (Halbreich and Karkun, 2006; Austin, 2014). Nevertheless, estimates based on self-report questionnaires are used worldwide because of their ease and cost efficiency, as they do not require trained clinicians to be administered (Robertson et al., 2003). Estimates of depression prevalence based on self-reports, apart from their use as screening tools, have clinical significance. Persons diagnosed with these instruments experience disability and need treatment (Gjerdingen, et al., 2011). During the perinatal period, depressive symptoms may be very debilitating and are associated with adverse pregnancy outcomes (Marcus et al., 2003). Measurements of depressive symptoms based on self-report scales have the advantage of reflecting a broader spectrum of postpartum depression (Halbreich and Karkun, 2006). Other issues that affect the interpretation of estimates of PPD include the small number of studies reporting whether the prevalence of PPD refers to new cases or those that
were already present in pregnancy, or the failure to distinguish point prevalence from period prevalence (Halbreich and Karkun, 2006). Lastly, most studies assess PPD up to three months postpartum, whereas depression may remain high for several more months (Gaynes et al., 2005). The aim of this paper is therefore to provide estimates of: (1) the prevalence of prenatal depression (structured interview) and depressive symptoms (self-report questionnaire); (2) point and period prevalence and incidence of PPD and postpartum depressive symptoms (PPDS), and (3) demographic and clinical characteristics of depressed and nondepressed mothers in a naturalistic, longitudinal study of a selected group of Mexican women recruited during the third trimester of pregnancy and followed at six weeks and six months after delivery. This study constitutes a unique attempt in Latin America to explore these aspects in relation to perinatal depression and depressive symptoms in a longitudinal study. The results will contribute to a more accurate understanding of perinatal depression and may serve as a starting point for estimating the health resources required to ensure perinatal women and their babies minimum mental health care, virtually absent in most Latin American countries.
2. Method 2.1. Participants Pregnant women receiving antenatal care were invited to participate in the study. They were approached in the waiting rooms of two institutions in Mexico City: (1) a hospital that provides comprehensive medical care for state workers, and (2) a community health care centre that provides prenatal and other medical care for the local population.
Convenience sampling to determine the sample size was estimated considering 15% prevalence based on estimates of 22.5% by García et al. (1991) and 6.6% by Ocampo et al. (2007) with an error margin of 5%. The required sample size was 196 women corresponding to the three periods assessed. Given the high attrition in this population (Le et al., 2008, Lara et al., 2010), an additional 40% were recruited, resulting in 280 participants approached during pregnancy. Women were eligible if a screening checklist determined that they: were 20 years, 26 weeks pregnant, did not have a bipolar condition, and lived in the metropolitan area of Mexico City. Eligible participants who agreed to be interviewed completed a written consent form. 2.2. Instruments Demographic and obstetric data included age, educational attainment, monthly family income, marital status, paid work in the last 6 months, first pregnancy and planned pregnancy. For the purpose of this study, family income reported was converted into two categories: 1) low income ( $5,246 Mexican pesos), which corresponds to deciles 1-3, comprising families with the highest poverty level in Mexico, and 2) medium and high income (> $5,246 Mexican pesos) corresponding to deciles 4-10, according to statistics provided by the Instituto Nacional de Estadística y Geografía (INEGI, 2013). Depression was assessed by the mood disorders module of the Structured Clinical Interview (SCID-I; First et al., 1996). The SCID-I is a semi structured interview for diagnosing current major depression according to DSM-IV criteria. The interview, used internationally, has previously been used with perinatal Mexican women (Lara et al., 2010). The diagnostic assessment was conducted by the undergraduate psychologists who conducted the whole interview. They received 15 hours’ training on the SCID, in addition to the training in the general interview, by a certified psychiatrist with extensive
experience, and met with her for supervision at four different points during the data collection stage. Depressive symptoms were measured using the Patient Health Questionnaire (PHQ9) (Spitzer, Kroenke and Williams, 1999). This is a 9-item depression module from the full PHQ, specifically developed for use in primary care. According to Kroenke et al. (2001) a score 10 indicates risk of depression.
The PHQ-9 has proved its usefulness as an
assessment tool for the diagnosis of depression with acceptable reliability, validity, sensitivity, and specificity (Kroenke et al., 2001). It has been used by Chae et al. (2012) for screening for PPD and by Romo et al. (2013) in the Mexican population. Since it had not been previously used with perinatal Mexican women internal consistency was assessed for this sample. Cronbach alpha coefficients were adequate in the three assessment periods (pregnancy: Į = .78; six-weeks postpartum: Į = .80; six months postpartum: Į = .85).
2.3. Procedure Pregnant women in the waiting rooms of the health care institutions were invited to participate. Interviews took place at 26 weeks pregnant (Time 1), and six weeks (Time 2) and six months postpartum (Time 3). Time 1 interview was conducted at the clinic, and subsequent interviews were conducted in any location defined by the participant: home, workplace, health institution, or other. For the postpartum interviews, appointments and venues were arranged by phone and were, in most cases conducted by the same interviewer. Participants who answered any of the three ‘Whooley (1997) and Arroll et al. (2005) questions recommended for case finding by the NICE Guideline (National Institute for Health and Care Excellence, 2007) affirmatively were advised to seek treatment. However, no one reported having received any treatment when asked about this at Time 3, due to the
various obstacles encountered. All participation was contingent on standard informed consent procedures. The informed consent letter specified that participants would be interviewed across three time periods and that the data would be used for research purposes. The study was approved by the Institutional Review Board (IRB) of the Ramón de la Fuente National Institute of Psychiatry.
2.4. Data analysis Frequencies were calculated for categorical data and means and standard deviations for continuous variables. The point prevalence of depression and depressive symptoms was calculated as the percentage of women with depression and depressive symptoms at each point of assessment (Times 1, 2 &3). Period prevalence was defined as the proportion of total cases (prevalence and incidence) of depression/depressive symptoms at Times 2 and 3; and the incidence referred to new cases of depression/depressive symptom occurring at Times 2 and 3 in relation to Time 1. Final analyses examined women with or without depression/depressive symptoms and compared their sociodemographic characteristics. Prevalence is reported as odds ratios and with 95%-likelihood ratio confidence intervals. Statistical analyses were conducted using SPSS 19 and STATA 12.
3. Results 3.1. Participants Of the 694 women contacted, 445 were eligible and 280 agreed to participate, yielding a response rate of 62.9% (Figure 1). Women who declined to participate (n=165) mentioned lack of time, lack of interest in the study, or failed to give an explanation.
Overall, 210 of the women assessed in Time 1 completed assessments at Times 2 and 3, meaning that 70/280 (25%) participants were unable to be followed up. ------------------Figure 1-------------------The sample mean age was 29.5 years (SD= 6.3), and respondents had had 13.0 (SD=3.8) years of schooling, and most were married or living with a partner (80.5%). Over half had had some type of paid work in the previous six months (62.4%). Almost half had a low family income (46.7%). Thirty three percent were primiparous, and just over half (54.3%) had planned the pregnancy (Table 1). -------------------Table 1-------------------3.2. Dropout analysis Comparisons of the sociodemographic and clinical characteristics of the women who could not be followed-up (n=70) and those who had completed the three assessments (n = 210) showed no significant differences in marital status, monthly family income, paid work, first pregnancy, unplanned pregnancy and depression (SCID). Conversely, those who dropped out were significantly younger (M= 27.3, SD= 5.5 vs M= 29.5, SD= 6.3; t= 2.5, p0.01), had had fewer years of schooling (M= 11.7, SD= 3.8 vs. M= 13.0, SD= 3.8; t= 2.4, p0.01) and reported more depressive symptoms (PHQ-9 10) (31.4% vs. 16.7%, Ȥ2 [1]= 7.05, p0.01).
3.3. Prevalence and Incidence of Perinatal Depression Point prevalence of perinatal depression (SCID) was 9.0% (95% CI, 5.1-12.9) in Time 1, 13.8% (95% CI, 9.1-18.5) in Time 2 and 13.3% (95% CI, 8.6-17.9) in Time 3 (Table 2). Incidence of PPD was 10.0% (95% CI, 5.9-14.0) in Time 2 and 8.2% (95% CI,
4.1-12.8) in Time 3. Perinatal period prevalence (Time 1-Time 3) was 17.6% (95% CI, 12.4-22.7). 3.4 Prevalence and Incidence of Perinatal Depressive Symptoms Prevalence of prenatal depressive symptoms (PHQ-910) was 16.6% (95% CI, 11.5-21.7) in Time 1, 17.1% (95% CI, 12.0-22.2) in Time 2, and 20.0% (95% CI, 14.525.4) in Time 3. Incidence of PPDS was 11.4% (95% CI, 6.7-16.3) at Time 2, and 9.0% (95% CI, 4.5-13.5) at Time 3 (Table 2). Perinatal period prevalence (Time 1-Time 3) was 16.2% (95% CI, 11.2-21.1). -------------------Table 2-------------------3.4. Sociodemographic and obstetric differences between women with and without perinatal depression and depressive symptoms Women with and without depression (SCID) did not differ as regards sociodemographic and obstetric characteristics at Times 1 and 2 (Table 3). However, at six months postpartum (Time 3), they differed in age (OR=2.45, p=0.02), educational attainment (OR=5.61, p=0.00), marital status (OR=3.03, p=0.01), employment (OR=3.48, p=0.00) and family income (OR=4.00, p=0.00). In other words, women with depression were younger, had had fewer years of schooling, were unpartnered, unemployed and poorer. --------------------Table 3-------------------As for depressive symptoms (PHQ-9), participants with and without depressive symptoms differed as regards educational attainment during pregnancy and at six weeks postpartum (Time 1: OR=3.11, p=0.00; Time 2: OR=3.26, p=0.00). At Time 3, there were also significant differences in depressive symptoms regarding educational attainment
(OR=3.05, p=0.00), marital status (OR=2.50, p=0.01), employment (OR=2.14, p=0.02) and family income (OR=2.45, p=0.00) (Table 4). Again, women with depressive symptoms were less educated, unpartnered, unemployed and poorer. Multiparity and unplanned pregnancy did not differ between women with or without depression/depressive symptoms at any time in the assessment. -------------------Table 4-------------------4. Discussion The aim of this study was to assess point and period prevalence and incidence of perinatal depression through two measurements of depression: structured clinical interviews and self-report scales during the third trimester of pregnancy and followed at six weeks and six months after delivery in Mexican perinatal women. Prenatal depression prevalence (SCID) in this study was 9.0%, (95% CI 5.1-12.9), which is slightly lower than Ocampo et al.’s (2007) (12.3%) and lower than Gómez et al.’s (2007) (14%) in Latin America, in samples of women with high risk pregnancies, but similar to that of Bennett et al. (2004b) 8.8% during the third trimester in a systematic review that included studies mostly from developed countries. Conversely, this figure is much higher than the combined estimates reported by Gaynes et al. (2005) of 3.4% (in the third trimester) for major depression alone in developed countries. The use of very conservative inclusion criteria in Gaynes et al.’s review complicates the interpretation of differences. Depressive symptoms in pregnancy (PHQ-9) were observed in 16.6% (95% CI 11.5-21.7) of the sample, which is significantly lower than in other studies in Latin America: 24.3% (EPDS12) (Melo et al., 2012), 30.7% (CES-D16) (Lara et al., 2006), and 34.7% (EPDS13.5) (Bao-Alonso et al., 2010). Conversely, our prevalence is in line
with that reported by Bennett et al. (2004b) (13.2%). There are no obvious factors to explain the differences between the Latin American studies, although they could be partly accounted for by the use of different self-report scales and of different cut-off scores, a problem often reported in the literature (Bennett el a., 2004a; Gaynes et al., 2005). Although the PHQ-9 has not been used in previous studies on perinatal women in Latin America, it was selected because of its solid psychometric properties (Kroenke et al., 2001), its brevity and ease of answering. Moreover, the fact that it is designed for primary care made it an attractive tool for future use in screening in settings outside obstetric clinics, such as family medicine and paediatric care. In line with other findings self-report depression was higher than depression measured with clinical interviews (Halbreich and Karkun, 2006; Austin, 2014). As mentioned earlier, perinatal depressive symptoms appear to have equally significant clinical value as clinical depression since they show detrimental effects on women’s health and adverse pregnancy outcomes (Marcus et al., 2003). In this respect, self-report scales are not only useful as screening tools for further diagnostic assessment, but also show that depression as measured by these scales should be recognized and timely treated. Point prevalence of major PPD at six weeks (13.8% [95% CI 9.1-18.5]) was similar to that previously found in Latin America in similar timeframes (13.8% - 17.4%) (Ocampo et al., 2007; Alvarado-Esquivel, et al., 2010; Almanza-Muñoz et al., 2011). However, other studies in Latin America report higher prevalence: from 22.4% (Alvarado et al., 2000) to 24.6% (Alvarez et al., 2008). It is difficult to explain both the similarities and differences on the basis of variables such as treatment (Alvarado-Esquivel et al., 2010) or the inclusion of mothers under the age of 20 (Alvarado et al., 2000; Alvarez et al., 2008), as the results do not vary in a consistent fashion according with what would be expected. Future
comparative studies using standard methodologies are needed to determine whether the different prevalence estimates are related to specific population characteristics rather than to methodological issues. PPD prevalence in our study is in line with O’Hara and Swain’s (1996) 12%,estimated in a meta-analysis comprising mainly, but not exclusively, studies from middle and high income countries, which are similar to more recent studies by Dietz et al. (2007) (10.4%) and Banti et al. (2011) (9.6%). However, our prevalence is higher than Gaynes’s et al. (2005) for major depression alone of 6.8%. It is difficult to ascertain whether the higher rates in the current study compared with the latter reflect the true differences due to the social and economic disadvantages experienced by women living in low- and lower-middle income countries (Matijasevich et al., 2009; Fisher et al., 2012) or to the methodological differences mentioned earlier in the case of Gaynes et al. (2005). PPD at six months postpartum (13.3% [95% CI 8.6-17.9]) was similar to that at six weeks, confirming the assertion that depression may remain high after the third month for several more months (Gaynes et al., 2005). PPDS at six weeks (17% (95% CI 12.0-22.2)) were higher than Melo et al.’s. (2012) (EPDS12:10.8%) in Latin America, and similar to O’Hara and Swain’s (1996) (14%). At six months, a 20% (95% CI 14.5-25.4) rate of depressive symptoms was in line with Latin American studies (DeCastro’s et al., 2011) (EPDS13: 14.2%) up to nine months postpartum. Perinatal PPDS period prevalence was 16.2% (95% CI, 11.2-21.7), reported in this region for the first time. New cases of depression were observed at six weeks: 10.0% (95% CI 5.9-14.0) and at six months postpartum: 8.2% (95% CI 4.1-12.8). These figures are similar to 8.8% in Latin American mothers at two months’ postpartum (Alvarado et al., 2000). The incidence
of depressive symptoms was 11.4% (95% CI, 6.7-16.3) 9.0% (95% CI, 4.5-13.5) in the same period, with no references to previous data in this aspects in Latin America. One of the implications of this finding is that, new cases of PPD may be averted if risk factors (such as depressive symptoms, low income, low educational attainment) are identified during pregnancy and the early postnatal period and prevention strategies are implemented (Lara et al, 2010). An analysis of the differences between depressed and non-depressed mothers shows that they were found almost exclusively in the 6th postpartum month. A higher percentage of women with depression in this period had low educational attainment (ORs= SCID: 5.61; PHQ-9: 3.05), were unpartnered (ORs= SCID: 3.03, PHQ-9: 2.50), unemployed (ORs= SCID: 3.48; PHQ-9: 2.14) and poorer (ORs= SCID: 4.05; PHQ-9: 2.45). Being younger was also related to PPD at six months postpartum (OR=2.45), with low educational attainment being linked to depressive symptoms in pregnancy (OR=3.11) and at six weeks postpartum (OR=3.26). In general terms, the relation between these factors and postpartum depression/symptoms has been reported previously (O’Hara and Swaim, 1996; Alvarado et al., 2000; Bennett et al., 2004b; Aramburú et al., 2008; Alvarado-Esquivel et al., 2010; Almanza- Muñoz, et al., 2011; O’Hara and McCabe, 2013). However, what is interesting about this finding is that these factors distinguish between depressed and nondepressed women at sixth months postpartum but not earlier. It can be hypothesized that as the baby grows older, it makes specific demands on mother’s internal and external resources, which are more difficult to meet if she has a lower income, less education, is unemployed and unpartnered. Among other consequences, low educational attainment reduces the ability to cope with stress (Kubzansky et al., 1999). Poverty, on the other hand, as O’Hara and
McCabe (2013) suggest, may be the common element underlying all these factors. Additionally, women in poverty are more likely to lack access to health services, infant care and information. 4.1 Limitations This longitudinal naturalistic study has a number of constraints. The first concerns the observed response rate of 62.9%, which although somewhat better than that observed in similar studies, such as 41.2% (Kitamura et al., 2001) and 49.9% (Banti et al., 2011), is not sufficiently high, potentially affecting the accuracy of the prevalence estimates. The second limitation refers to the 25% attrition of the initial sample, which was not retained to complete the three assessments. Women who failed to complete these assessments were younger, had fewer years of schooling and reported more depressive symptoms, which may have meant that the prevalence reported may underestimate the actual prevalence. Third, our data was collected in urban health facilities, meaning that the prevalence of perinatal depression may not be generalized to rural settings, although the PPD rate found in this context is not that different (12.9%) (Alvarado-Esquivel et al., 2010). Fourth, measurements of the history of depression were not included, making it impossible to determine whether the onset of depression occurs during the perinatal period or whether there have been depressive episodes prior to the current pregnancy. Fifth, we decided on a convenient nonprobabilistic sampling procedure. As observed elsewhere, non-randomized sampling limits the scope of generalization to the population as a whole, since some of its characteristics (e. g. age groups, type of schooling) may not be well represented in the sample (Vivanco 2005). 5. Conclusion
Some important conclusions can be drawn from this carefully designed longitudinal study to assess perinatal depression in Latin American women at three different points in time: reporting point, period prevalence and incidence using both structural interviews and self-report scales. Most of the prevalence rates (Pregnancy: SCID: 9%; PHQ-9: 16.6%; Six weeks postpartum: SCID: 13.8%; PHQ-9: 17.1%. Six months postpartum: SCID: 13.3; PHQ-9: 20%) are within the range of previous estimates in a review and a meta-analysis (O´Hara and Swaim, 1996; Bennett, et al., 2004b) and share many features with studies in Latin America (Ocampo et al., 2007; Alvarado-Esquivel, et al., 2010; Almanza-Muñoz et al., 2011). New cases were found at six weeks (SCID: 10%; PHQ-9:11.4%) and six months PP (SCID: 8.2%; PHQ-9:9%). These results, though, may be an underestimation of “actual” prevalence due to sample attrition. Despite the similarities found in depression prevalence in this study as compared to more developed countries, the consequences of this disorder in developing countries may be more detrimental to the health of mother and baby. In Mexico, as in other resourceconstrained countries, perinatal depression is more likely to go undetected and untreated, due to greater underutilization of mental health services than in high income countries (Halbreich & Karkun, 2006; Borges et al., 2006; Matijasevich et al., 2009; Fisher et al., 2012). Moreover, less awareness and higher perceived stigma regarding perinatal depression may also prevent more women from seeking treatment (Lara et al., 2014). Women more frequent contact with health services during the perinatal period represents an opportunity for education, prevention and treatment of depression. Even in countries with more limited mental health care infrastructure, there are a number of lowcost interventions that may be undertaken to potentially impact perinatal depression. These include increasing awareness of pre and postnatal depression by educating health providers
and expectant and postnatal mothers in prenatal care services; offering training to raise the involvement of primary health care providers in screening for depression and assessing more vulnerable mothers (less educated, single, unemployed and poorer) to provide support and empathic responses, and to implement low impact interventions (Dennis et al., 2009; Lara et al., 2014). Resources permitting, treatment should be provided for depressed mothers (Dennis and Hodnett, 2007; Rojas et al, 2007; Patel et al., 2011). Efforts should also be made to lobby for mental health care to be included in the official norms regulating the health care of mothers and babies during the perinatal period (Rahman et al., 2013).
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Austin, M.P., 2014. Marcé International Society position statement on psychosocial assessment and depression screening in perinatal women. Best Pract Res Clin Obstet Gynaecol. 28, 179–187. Banti, S., Mauri, M., Oppo, A., Borri, C., Rambelli, C., Ramacciotti, D., Montagnani, M.S., Camilleri, V., Cortopassi, S., Rucci, P., Cassano, G.B., 2011. From the third month of pregnancy to 1 year postpartum. Prevalence, incidence, recurrence, and new onset of depression. Results from the perinatal depression-research & screening unit study. Compr Psychiatry. 52(4), 343-51. Bao-Alonso, M.P. Vega-Dienstmaier, J.M., Saona-Ugarte, P., 2010. Prevalencia de depresión durante la gestación. Rev Neuropsiquiatr. 73(3), 95-103. Bennett, H.A., Einarson, A., Taddio, A., Koren, G., Einarson, T.R., 2004a. Depression during Pregnancy. Overview of Clinical Factors. Clin Drug Invest. 24(3), 157-179. Bennett HA, Einarson A, Taddio A, Koren G, Einarson TR., 2004b. Prevalence of depression during pregnancy: systematic review. Obstet Gynecol. 103(4), 698-709. Borges, G., Medina-Mora, M.E., Wang, P.S., Lara, C., Berglund, P., Walters, E., 2006. Treatment and adequacy of treatment of mental disorders among respondents to the Mexico National Comorbidity Survey. Am J Psychiatry. 163(8), 1371-378. Chae, S.Y., Chae, M.H., Tyndall, A., Ramirez, M.R., Winter, R.O., 2012. Can we effectively use the two-item PHQ-2 to screen for postpartum depression? Fam Med. 44(10), 698-703. DeCastro, F., Hinojosa-Ayala, N., Hernández-Prado, B., 2011. Risk and protective factors associated with postnatal depression in Mexican adolescents. J Psychosom Obstet Gynaecol. 32(4), 210–217.
Dennis, C.L., Hodnett, E., 2007.Psychosocial and psychological interventions for treating postpartum depression. Cochrane Database Syst Rev. 17;(4), CD006116. Dennis, C. L., Hodnett, E., Kenton, L., Weston, J., Zupancic, J., Stewart, D.E., Kiss, A., 2009. Effect of peer support on prevention of postnatal depression among high risk women: multisite randomised controlled trial. BMJ. 15;338:a3064. Dietz, P.M., Williams, S.B., Callaghan, W.M., Bachman, D.J., Whitlock, E.P., Hornbrook, M.C., 2007. Clinically identified maternal depression before, during, and after pregnancies ending in live births. Am J Psychiatry. 164(10), 1515-1520. Field, T., Diego, M., Hernandez-Reif, M., 2006. Prenatal depression effects on the fetus and newborn: a review. Infant Behav Dev. 29, 445–455. Field, T., 2010. Postpartum depression effects on early interactions, parenting, and safety practices: A review. Infant Behav Dev. 33, 1–6. First, M., Spitzer, R., Gibbon, M., Williams, J., 1996. Structures Clinical Interview for DSM-IV Axis I Disorders (SCID-I), Clinical Version. American Psychiatric Press, Washington, DC. Fisher, J., Cabral de Mello, M., Patel, V., Rahman, A., Tran, T., Holton, S., Holmes, W., 2012. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. Bull World Health Organ. 90, 139–149G. García, L., Ortega-Soto, H, Ontiveros, M., Cortés, J., 1991. La incidencia de la depresión en el postparto. Anales del Instituto Mexicano de Psiquiatría 2, 54–59.
Gavin, N.I., Gaynes, B.N., Lohr, K.N, Meltzer-Brody, S., Gartlehner, G., Swinson, T., 2005. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol IO6 (5 Pt l), 1071-1083. Gaynes, B.N., Gavin, N., Meltzer-Brody, S., Lohr, K.N., Swinson, T., Gartlehner, G., Brody, S., Miller, W.C., 2005. Perinatal depression: prevalence, screening accuracy, and screening outcomes. Evidence Report/Technology Assessment (Summary) (119), 1–8. Gjerdingen, D., Crow, S., McGovern, P., Miner, M., Center, B., 2011. Changes in depressive symptoms over 0-9 months postpartum. J Womens Health. 20 (3), 381386. Gómez, L.M.E., Aldana, C.E., 2007. Alteraciones psicológicas en la mujer con embarazo de alto riesgo. Psicología y Salud. 17 (1), 53-61. Halbreich, U., Karkun, S., 2006. Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms. J Affect Disord. 91, 97–111. INEGI, Instituto Nacional de Estadística y Geografía, 2013. www.inegi.org.mx. Kroenke, K., Spitzer, R.L., Williams, J.B.W., 2001. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 16, 606–613. Kubzansky, L.D., Kawachi, I., Sparrow, D. 1999. Socioeconomic status, hostility, and risk factor clustering in the normative aging study: Any help from the concept of allostatic load? SBM. 21, 330-338. Lara, M.A., Navarro, C., Navarrete, L., Cabrera, A., Almanza, J., Morales, F.J., 2006. Síntomas depresivos en el embarazo y factores asociados, en pacientes de tres instituciones de salud de la Ciudad de México. Salud Ment. 29 (4), 55-62.
Lara, M.A., Navarro, C., Navarrete, L., Le, H.N., 2010. Retention rates and potential predictors in a longitudinal randomized control trial to prevent postpartum depression. Salud Ment. 33, 429-436. Lara, M.A, Navarrete, L., Nieto, L., Berenzon, S., 2014. Acceptability and barriers to treatment for perinatal depression. An exploratory study in Mexican women. Salud Ment. 37, 293-301. Le, H.N., Lara, M.A., 2008. Perry, D. Recruiting Latino women in the U.S. and women in Mexico in postpartum depression prevention research. Archiv Women Ment Health. 11, 159–169. Marcus, S.M., Flynn, H.A., Blow, F.C., Barry, K., 2003. Depressive symptoms among pregnant women screened in obstetrics settings. J Womens Health. 12 (4), 373-380. Matijasevich, A. Golding, J., Smith, G.D., Santos, I.S., Barros, A.J., Victora, C.G., 2009. Differentials and income-related inequalities in maternal depression during the first two years after childbirth: birth cohort studies from Brazil and the UK. Clin Pract Epidemiol Ment Health 5, 1-12. Melo, E.F.Jr, Cecatti, J.G., Pacagnella, R.C., Leite, D.F., Vulcani, D.E., Makuch, M.Y., 2012. The prevalence of perinatal depression and its associated factors in two different settings in Brazil. J Affect Disord. 136, 1204–1208. Murray, L., Cooper, P.J., 1997. Postpartum depression and child development. Psychol Med. 27(2), 253–60. NICE Guideline. Antenatal and Postnatal Mental Health. The Nice Guideline on Clinical Management and Service Guidance. The British Psychological Society, 2007. Great Britain by Alden Press. http://www.nice.org.uk/nicemedia/pdf/CG45fullguideline.pdf
Ocampo, R., Heinze, G., Ontiveros, M.P., 2007. Detección de depresión postparto en el Instituto Nacional de Perinatología. Psiquiatría. 23, 18-22. O'Hara, M.W., Swain, A.M., 1996. Rates and risk of postpartum depression-a metaanalysis. Int Rev Psychiatry. 8 (1), 1-52. O’Hara, M.W., McCabe, J.E., 2013. Postpartum Depression: Current Status and Future Directions. Annu. Rev. Clin. Psychol. 9, 379–407. Patel, V., Chowdhary, N., Rahman, A., Verdeli, H., 2011.Improving access to psychological treatments: lessons from developing countries. Behav Res Ther. 49(9), 523-528. Rahman, A., Surkan, P.J., Cayetano, C.E., Rwagatare, P., Dickson, K.E., 2013.Grand challenges: integrating maternal mental health into maternal and child health programmes. PLoS Med. 10(5):e1001442. Robertson, E., Celasun, N., Stewart, D.E., 2003. Risk factors for postpartum depression. In: Stewart, D.E., Robertson, E., Dennis, C.-L., Grace, S.L., & Wallington, T. (Eds.), Postpartum depression: literature review of risk factors and interventions. University Health Network Women’s Health Program. Toronto, pp. 71-196. Rojas, G., Fritsch, R., Solis, J., Jadresic, E., Castillo, C., González, M., Guajardo, V., Lewis, G., Peters, T.J., Araya, R., 2007.Treatment of postnatal depression in lowincome mothers in primary-care clinics in Santiago, Chile: a randomised controlled trial. Lancet. 370(9599), 1629-1637. Romo, N.F., Tafoya, A.S., Heinze, G., 2013. Estudio comparativo sobre depresión y los factores asociados en alumnos del primer año de la Facultad de Medicina y del Internado. Salud Ment. 36, 375-379.
Spitzer, R.L., Kroenke, K., Williams, J.B., 1999. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA. 282(18), 1737-44. Vivanco, M. 2005. Muestreo Estadístico: Diseño y Aplicaciones, Editorial Universitaria, Santiago. Chile. Whooley, M. A., Avins, A. L., Miranda, J., Browner, W.S., 1997. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med. 12, 439–445.
Table 1. Demographic and Obstetric Characteristics (n= 210). M
(SD)
Age
29.50
(6.34)
Years of schooling
13.01
(3.83)
n
(%)
Low income
98
46.7
Medium and high income
112
53.3
Partnered
169
(80.5)
Single
41
(19.5)
Yes
131
(62.4)
No
79
(37.6)
Yes
70
(33.3)
No
140
(66.6)
Monthly family income
Marital status
Paid Work
First pregnancy
Planned pregnancy
Yes
114
(54.3)
No
96
(45.7)
SCID Prevalence
f
Time 1
Time 2
Time 3
Pregnancy
6th postpartum week
6th postpartum month
%
19 (9.0%)
CI 5.1-12.9
Incidence PHQ-9 (10) Prevalence Incidence
f
%
35 (16.6%)
CI 11.5-21.7
f
%
CI
f
%
CI
29 (13.8%)
9.1-18.5
28 (13.3%)
8.6-17.9
21 (10.0%)
5.9-14.0
14 (8.2%)
4.1-12.8
f
%
CI
f
%
CI
36 (17.1%) 12.0-22.2
42 (20.0%)
14.5-25.4
20 (11.4%)
14 (9.0%)
4.5-13.5
6.7-16.3
Table 2. Prevalence and Incidence of Perinatal Depression (n=210).
Table 3. Maternal Characteristics of Depressed and Nondepressed (SCID) Perinatal Women and Odds ratios and 95% Confidence Intervals for the Association of Maternal Characteristics of Depression.
Depressed
Non depressed
n=19
n=191
Age 28
47.36%
44.50%
Secondary school
68.42%
Unpartnered
OR
95% CI
0.49
1.12
0.43-2.88
54.97%
0.18
1.77
0.64-4.86
26.31%
19.37%
0.32
1.48
0.50-4.38
Unemployed
37.69%
36.84%
0.57
1.03
0.36-2.56
Low Income
51.72%
45.85%
0.69
1.26
0.57-2.77
Multiparous
68.42%
66.49%
0.54
1.09
0.39-3.00
Unplanned pregnancy
47.36%
45.54%
0.53
1.07
0.41-2.76
n=29
n=181
Age 28
48.27%
44.19%
0.41
1.17
0.53-2.58
Secondary school
68.96%
54.14%
0.09
1.88
0.81-4.35
Unpartnered
24.13%
19.33%
0.35
1.32
0.52-3.35
Unemployed
41.37%
37.01%
0.39
1.20
0.54-2.66
Low Income
52.63%
46.07%
0.63
1.30
0.50-3.34
Multiparous
68.96%
66.29%
0.47
1.12
0.48-2.62
Unplanned pregnancy
62.06%
53.03%
0.24
1.44
0.64-3.24
n=28
n=182
Age 28
64.28%
42.23%
0.02
2.45
1.07-5.61
Secondary school or less
85.71%
51.64%
0.00
5.61
1.87-16.80
Time 1. Pregnancy
Time 2. 6th postpartum week
Time 3. 6th postpartum month
P
Unpartnered
39.28%
17.58%
0.01
3.03
1.29-7.08
Unemployed
64.28%
34.06%
0.00
3.48
1.51-8.00
Low Income
75.00%
42.54%
0.00
4.05
1.63-10.01
Multiparous
67.85%
67.03%
0.55
1.03
0.44-2.43
Unplanned pregnancy
53.57%
45.05%
0.26
1.40
0.63-3.12
Table 4. Maternal Characteristics of Depressed and Non depressed (PHQ-9) Perinatal Women and Odds ratios and 95% Confidence Intervals for the Association of Maternal Characteristics of Depression. Depressive symptoms
No depressive symptoms
n=35
n=175
Age 28
45.71%
44.57%
Secondary school
77.14%
Unpartnered
OR
95% CI
0.52
1.04
0.50-2.17
52.00%
0.00
3.11
1.34-7.23
22.85%
19.42%
0.39
1.22
0.51-2.94
Unemployed
45.71%
36.00%
0.18
1.49
0.71-3.11
Low income
60.00%
44.00%
0.06
1.90
0.91-3.99
Multiparous
74.28%
65.14%
0.19
1.54
0.68-3.50
Unplanned pregnancy
60.00%
53.14%
0.28
1.32
0.63-2.76
n=36
n=174
Age 28
63.88%
53.44%
0.16
1.54
0.73-3.23
Secondary school
77.77%
51.72%
0.00
3.26
1.41-7.56
Unpartnered
25.00%
18.96%
0.26
1.42
0.61-3.31
Unemployed
44.44%
36.20%
0.22
1.40
0.68-2.91
Low income
58.33%
44.25%
0.08
1.76
0.85-3.64
Multiparous
69.44%
66.09%
0.42
1.16
0.53-2.53
Unplanned pregnancy
42.22%
45.40%
0.49
1.07
0.52-2.20
n=42
n=168
54.76%
42.26%
0.09
1.65
0.83-3.26
Time 1. Pregnancy
Time 2. 6th postpartum week
Time 3. 6th postpartum month Age 28
P
Secondary school
76.19%
51.19%
0.00
3.05
1.41-6.60
Unpartnered
33.33%
16.66%
0.01
2.50
1.17-5.34
Unemployed
52.38%
33.92%
0.02
2.14
1.08-4.24
Low income
64.28%
42.26%
0.00
2.45
1.21-4.95
Multiparous
76.19%
64.28%
0.09
1.77
0.81-3.86
Unplanned pregnancy
54.76%
43.45%
0.12
1.57
0.79-3.10
ACKNOWLEDGEMENTS This study was supported by the Consejo Nacional de Ciencia y Tecnología (CONACyT, CB-2009-01 133923). We are grateful to the staff and patients of the Centro de Salud Dr. Ángel Brioso Vasconcelos and of the Hospital Regional del ISSSTE Lic. Adolfo López Mateos; to Dr. Carmen Lara, for training and supervising the use of the SCID; and to the research team: Yadira Ramos, Karla Alcántara, Valeria Zempoalteca, Lilian Delgado and Araceli Aguilar.
Contributors
Laura Navarrete participated in the field work, in the analyses of the data and preparing the manuscript. Lourdes Nieto participated in the in the literature review and preparing the manuscript. Juan Pablo Barba participated in the field work and in discussing the results José Luis Navarro participated in the field work and in discussing the results Héctor Lara-Tapia participated in the field work and in discussing the results !"##$!%&&$"&!'(
Figure(s)
Figure 1. Participant flow.
Screened (n=694)
Did not meet inclusion criteria (n=249) Eligible (n=445) Refused to be interviewed (n=165)
Time 1 >26 weeks pregnancy (n=280)
Time 2 6 postpartum week (n=234) th
Time 3 6th postpartum month (n=210)
Prevalence and Incidence of Perinatal Depression and Depressive Symptoms among Mexican Women Ma. Asunción Lara, Laura Navarrete, Lourdes Nieto, Juan Pablo Barba Martín, José Luis Navarro, Héctor Lara-Tapia
www.elsevier.com/locate/jad
PII: DOI: Reference:
S0165-0327(14)00821-0 http://dx.doi.org/10.1016/j.jad.2014.12.035 JAD7187
To appear in:
Journal of Affective Disorders
Received date: 24 November 2014 Revised date: 5 December 2014 Accepted date: 11 December 2014 Cite this article as: Ma. Asunción Lara, Laura Navarrete, Lourdes Nieto, Juan Pablo Barba Martín, José Luis Navarro, Héctor Lara-Tapia, Prevalence and Incidence of Perinatal Depression and Depressive Symptoms among Mexican Women, Journal of Affective Disorders, http://dx.doi.org/10.1016/j.jad.2014.12.035 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Prevalence and Incidence of Perinatal Depression and Depressive Symptoms among Mexican Women
Ma. Asunción Lara, Ph.D.,a,* Laura Navarrete, M.Sc.,a Lourdes Nieto, Ph.D.a, Juan Pablo Barba Martín, MD,b José Luis Navarro, MD,c Dr. Héctor Lara-Tapia, MDb
a
Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz. Calzada México-Xochimilco
101, San Lorenzo Huipulco, Tlalpan, México, D. F., 14370 b
Hospital Regional “Lic. Adolfo Lopez Mateos” Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, ISSSTE. México, D. F. c
Delegación Regional Poniente. Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, ISSSTE. México, D. F. México, D. F.
*
Corresponding author’s address: Instituto Nacional de Psiquiatría Ramón de la Fuente
Muñiz. Calzada México-Xochimilco 101, San Lorenzo Huipulco, Tlalpan, Mexico, D. F. 14370. Tel.: +52 55 416 05170. Fax: 55133446 E-mail address: [email protected]
Abstract Background: The aim of this study was to assess point and period prevalence and incidence of perinatal depression in Mexican women. Methods: The Structured Clinical Interview for DSM-IV and the Patient Health Questionnaire (PHQ-9) were administered at three points in time to 210 women: during the third trimester of pregnancy, at six weeks and at six months after delivery. Results: Prevalence of prenatal depression was 9.0%, and 13.8% at six weeks and 13.3% at six months postpartum. Incidence of postpartum depression (PPD) was 10.0% at six weeks and 8.2% at six months. Prevalence of prenatal depressive symptoms was 16.6%; and 17.1% at six weeks and 20.0% at six months postpartum. Incidence of postpartum depressive symptoms (PPDS) was 11.4% at six weeks and 9.0% at six months. At six months postpartum, women with depression were younger (OR=2.45, p=0.02), had fewer years’ schooling (OR=5.61, p=0.00), were unpartnered (OR=3.03, p=0.01), unemployed (OR=3.48, p=0.00) and poorer (OR=4.00, p=0.00) than women without depression. Limitations: 25% of the initial sample was not retained to complete the three assessments. Non completers were younger, less educated and reported more depressive symptoms. This may have resulted in an underestimation of prevalence. Conclusions: This is the first longitudinal study in Latin America to assess perinatal depression at three different points in times, reporting point and period prevalence and incidence of clinical depression and depressive symptoms. Most LA countries have yet to recognize the importance of providing mental health care for expectant and postpartum mothers to reduce disability in mothers and infants.
Key words: Prevalence, incidence, pregnancy depression, postpartum depression, middlelow income country, perinatal depression.
1. Introduction Perinatal depression is a common condition affecting large numbers of women worldwide. According to the DSM-V (APA, 2013), perinatal or peripartum depression is a phenomenon that is undistinguishable from major depression except for its timing, having its onset during pregnancy or within the first four weeks postpartum. However, in clinical practice and many research studies time frames range up to one year postpartum (O’Hara and McCabe, 2013). The fact that it may occur during a vulnerable period in women’s lives creates enormous concern among mental health professionals, since it has extremely severe effects on the health of both mother and baby. Prenatal depression, one of the strongest predictors of postpartum depression (PPD), is associated with poor health behaviour and risk-taking behaviour (Bennett et al., 2004a). Depressed pregnant women are also more likely to deliver prematurely, and neonates are at a greater risk for low birth weight and being small for gestational age (Field et al., 2006). PPD often inhibits the woman’s ability to perform daily activities, which may have detrimental effects on her capacity to care effectively for herself and her baby. PPD has been associated with greater use of emergency department services, malnutrition, developmental delay, and lower quality interactions between mother and baby, which is
associated with high rate of insecure attachment in the latter (Murray et al., 1997; Field, 2010). A review study on the prevalence of depression in pregnancy measured through structured interviews, including data mostly from developed countries, reports a prevalence of 2% to 21% (Bennett et al., 2004a). Another systematic review, which included studies using structured interviews and excluded studies from less developed countries, found a prevalence of 8.5% to 11% for major and minor depression (3.1 - 4.9 for major depression alone) (Gayness et al., 2005). Bennett et al. (2004a) also reviewed the prevalence of depressive symptoms in pregnancy based on self-report questionnaires; the prevalence found varied from 8% to31%. In Latin America), research using clinical interviews finds rates of 12.3% to 14% (Ocampo et al., 2007; Gómez et al., 2007), while depressive symptoms are reported in 24.3% (Edinburgh Postnatal Depression Scale, EPDS12) (Melo et al., 2012), 30.7% (Centre for Epidemiologic Studies Depression Scale, CES-D16) (Lara et al., 2006), and 34.7% (EPDS13.5) (Bao-Alonso et al., 2010). For PPD, Gaynes et al.’s (2005) systematic review estimates a6.5% to 12.9% prevalence for major and minor depression and of 1.0% to 5.9% for major depression alone during the first year postpartum. O’Hara and Swain (1996) estimate the prevalence of PPD using a meta-analysis including data mainly but not exclusively from developed countries. In their study, PPD prevalence based on interviews was 12% (95% CI 11.3-12.7) and on self-report measurements was 14% (95% CI 13.1-14.9). In Latin America, the prevalence of PPD using clinical interviews varies widely from 13.8% to 24.1% (Ocampo et al., 2007; Alvarado-Esquivel, et al., 2010; Almanza-Muñoz et al., 2011; Álvarez et al., 2008; Alvarado et al., 2000; Aramburú et al., 2004), while PPDS measured by the EPDS is 10.8% (EPDS12) (Melo et al., 2012) and 14.2% (EPDS13) (DeCastro et al., 2011).
Gaynes et al. (2005) found very few studies reporting measurements other than point prevalence such as incidence and period prevalence. Their estimate for new PPD cases is 14.5% within the first three months postpartum (6.5% of major depression alone) while their estimate for period prevalence was19.2% (7.1% for major depression only). To our knowledge, in Latin America there is only one study reporting the incidence of PPD, finding 8.8% of new cases during the first two months postpartum (Alvarado et al., 2000) with no studies reporting period prevalence. Some of the methodological problems when interpreting the prevalence of PPD are due to population characteristics but more often to the use of different measures of depression (Gaynes et al., 2005). Prevalence based on structured interviews is considered to provide more accurate estimates of the disease burden for targeting health care expenditure (Gavin et al., 2005), while self-report scales tend to yield higher rates than those based on clinical interviews (Halbreich and Karkun, 2006; Austin, 2014). Nevertheless, estimates based on self-report questionnaires are used worldwide because of their ease and cost efficiency, as they do not require trained clinicians to be administered (Robertson et al., 2003). Estimates of depression prevalence based on self-reports, apart from their use as screening tools, have clinical significance. Persons diagnosed with these instruments experience disability and need treatment (Gjerdingen, et al., 2011). During the perinatal period, depressive symptoms may be very debilitating and are associated with adverse pregnancy outcomes (Marcus et al., 2003). Measurements of depressive symptoms based on self-report scales have the advantage of reflecting a broader spectrum of postpartum depression (Halbreich and Karkun, 2006). Other issues that affect the interpretation of estimates of PPD include the small number of studies reporting whether the prevalence of PPD refers to new cases or those that
were already present in pregnancy, or the failure to distinguish point prevalence from period prevalence (Halbreich and Karkun, 2006). Lastly, most studies assess PPD up to three months postpartum, whereas depression may remain high for several more months (Gaynes et al., 2005). The aim of this paper is therefore to provide estimates of: (1) the prevalence of prenatal depression (structured interview) and depressive symptoms (self-report questionnaire); (2) point and period prevalence and incidence of PPD and postpartum depressive symptoms (PPDS), and (3) demographic and clinical characteristics of depressed and nondepressed mothers in a naturalistic, longitudinal study of a selected group of Mexican women recruited during the third trimester of pregnancy and followed at six weeks and six months after delivery. This study constitutes a unique attempt in Latin America to explore these aspects in relation to perinatal depression and depressive symptoms in a longitudinal study. The results will contribute to a more accurate understanding of perinatal depression and may serve as a starting point for estimating the health resources required to ensure perinatal women and their babies minimum mental health care, virtually absent in most Latin American countries.
2. Method 2.1. Participants Pregnant women receiving antenatal care were invited to participate in the study. They were approached in the waiting rooms of two institutions in Mexico City: (1) a hospital that provides comprehensive medical care for state workers, and (2) a community health care centre that provides prenatal and other medical care for the local population.
Convenience sampling to determine the sample size was estimated considering 15% prevalence based on estimates of 22.5% by García et al. (1991) and 6.6% by Ocampo et al. (2007) with an error margin of 5%. The required sample size was 196 women corresponding to the three periods assessed. Given the high attrition in this population (Le et al., 2008, Lara et al., 2010), an additional 40% were recruited, resulting in 280 participants approached during pregnancy. Women were eligible if a screening checklist determined that they: were 20 years, 26 weeks pregnant, did not have a bipolar condition, and lived in the metropolitan area of Mexico City. Eligible participants who agreed to be interviewed completed a written consent form. 2.2. Instruments Demographic and obstetric data included age, educational attainment, monthly family income, marital status, paid work in the last 6 months, first pregnancy and planned pregnancy. For the purpose of this study, family income reported was converted into two categories: 1) low income ( $5,246 Mexican pesos), which corresponds to deciles 1-3, comprising families with the highest poverty level in Mexico, and 2) medium and high income (> $5,246 Mexican pesos) corresponding to deciles 4-10, according to statistics provided by the Instituto Nacional de Estadística y Geografía (INEGI, 2013). Depression was assessed by the mood disorders module of the Structured Clinical Interview (SCID-I; First et al., 1996). The SCID-I is a semi structured interview for diagnosing current major depression according to DSM-IV criteria. The interview, used internationally, has previously been used with perinatal Mexican women (Lara et al., 2010). The diagnostic assessment was conducted by the undergraduate psychologists who conducted the whole interview. They received 15 hours’ training on the SCID, in addition to the training in the general interview, by a certified psychiatrist with extensive
experience, and met with her for supervision at four different points during the data collection stage. Depressive symptoms were measured using the Patient Health Questionnaire (PHQ9) (Spitzer, Kroenke and Williams, 1999). This is a 9-item depression module from the full PHQ, specifically developed for use in primary care. According to Kroenke et al. (2001) a score 10 indicates risk of depression.
The PHQ-9 has proved its usefulness as an
assessment tool for the diagnosis of depression with acceptable reliability, validity, sensitivity, and specificity (Kroenke et al., 2001). It has been used by Chae et al. (2012) for screening for PPD and by Romo et al. (2013) in the Mexican population. Since it had not been previously used with perinatal Mexican women internal consistency was assessed for this sample. Cronbach alpha coefficients were adequate in the three assessment periods (pregnancy: Į = .78; six-weeks postpartum: Į = .80; six months postpartum: Į = .85).
2.3. Procedure Pregnant women in the waiting rooms of the health care institutions were invited to participate. Interviews took place at 26 weeks pregnant (Time 1), and six weeks (Time 2) and six months postpartum (Time 3). Time 1 interview was conducted at the clinic, and subsequent interviews were conducted in any location defined by the participant: home, workplace, health institution, or other. For the postpartum interviews, appointments and venues were arranged by phone and were, in most cases conducted by the same interviewer. Participants who answered any of the three ‘Whooley (1997) and Arroll et al. (2005) questions recommended for case finding by the NICE Guideline (National Institute for Health and Care Excellence, 2007) affirmatively were advised to seek treatment. However, no one reported having received any treatment when asked about this at Time 3, due to the
various obstacles encountered. All participation was contingent on standard informed consent procedures. The informed consent letter specified that participants would be interviewed across three time periods and that the data would be used for research purposes. The study was approved by the Institutional Review Board (IRB) of the Ramón de la Fuente National Institute of Psychiatry.
2.4. Data analysis Frequencies were calculated for categorical data and means and standard deviations for continuous variables. The point prevalence of depression and depressive symptoms was calculated as the percentage of women with depression and depressive symptoms at each point of assessment (Times 1, 2 &3). Period prevalence was defined as the proportion of total cases (prevalence and incidence) of depression/depressive symptoms at Times 2 and 3; and the incidence referred to new cases of depression/depressive symptom occurring at Times 2 and 3 in relation to Time 1. Final analyses examined women with or without depression/depressive symptoms and compared their sociodemographic characteristics. Prevalence is reported as odds ratios and with 95%-likelihood ratio confidence intervals. Statistical analyses were conducted using SPSS 19 and STATA 12.
3. Results 3.1. Participants Of the 694 women contacted, 445 were eligible and 280 agreed to participate, yielding a response rate of 62.9% (Figure 1). Women who declined to participate (n=165) mentioned lack of time, lack of interest in the study, or failed to give an explanation.
Overall, 210 of the women assessed in Time 1 completed assessments at Times 2 and 3, meaning that 70/280 (25%) participants were unable to be followed up. ------------------Figure 1-------------------The sample mean age was 29.5 years (SD= 6.3), and respondents had had 13.0 (SD=3.8) years of schooling, and most were married or living with a partner (80.5%). Over half had had some type of paid work in the previous six months (62.4%). Almost half had a low family income (46.7%). Thirty three percent were primiparous, and just over half (54.3%) had planned the pregnancy (Table 1). -------------------Table 1-------------------3.2. Dropout analysis Comparisons of the sociodemographic and clinical characteristics of the women who could not be followed-up (n=70) and those who had completed the three assessments (n = 210) showed no significant differences in marital status, monthly family income, paid work, first pregnancy, unplanned pregnancy and depression (SCID). Conversely, those who dropped out were significantly younger (M= 27.3, SD= 5.5 vs M= 29.5, SD= 6.3; t= 2.5, p0.01), had had fewer years of schooling (M= 11.7, SD= 3.8 vs. M= 13.0, SD= 3.8; t= 2.4, p0.01) and reported more depressive symptoms (PHQ-9 10) (31.4% vs. 16.7%, Ȥ2 [1]= 7.05, p0.01).
3.3. Prevalence and Incidence of Perinatal Depression Point prevalence of perinatal depression (SCID) was 9.0% (95% CI, 5.1-12.9) in Time 1, 13.8% (95% CI, 9.1-18.5) in Time 2 and 13.3% (95% CI, 8.6-17.9) in Time 3 (Table 2). Incidence of PPD was 10.0% (95% CI, 5.9-14.0) in Time 2 and 8.2% (95% CI,
4.1-12.8) in Time 3. Perinatal period prevalence (Time 1-Time 3) was 17.6% (95% CI, 12.4-22.7). 3.4 Prevalence and Incidence of Perinatal Depressive Symptoms Prevalence of prenatal depressive symptoms (PHQ-910) was 16.6% (95% CI, 11.5-21.7) in Time 1, 17.1% (95% CI, 12.0-22.2) in Time 2, and 20.0% (95% CI, 14.525.4) in Time 3. Incidence of PPDS was 11.4% (95% CI, 6.7-16.3) at Time 2, and 9.0% (95% CI, 4.5-13.5) at Time 3 (Table 2). Perinatal period prevalence (Time 1-Time 3) was 16.2% (95% CI, 11.2-21.1). -------------------Table 2-------------------3.4. Sociodemographic and obstetric differences between women with and without perinatal depression and depressive symptoms Women with and without depression (SCID) did not differ as regards sociodemographic and obstetric characteristics at Times 1 and 2 (Table 3). However, at six months postpartum (Time 3), they differed in age (OR=2.45, p=0.02), educational attainment (OR=5.61, p=0.00), marital status (OR=3.03, p=0.01), employment (OR=3.48, p=0.00) and family income (OR=4.00, p=0.00). In other words, women with depression were younger, had had fewer years of schooling, were unpartnered, unemployed and poorer. --------------------Table 3-------------------As for depressive symptoms (PHQ-9), participants with and without depressive symptoms differed as regards educational attainment during pregnancy and at six weeks postpartum (Time 1: OR=3.11, p=0.00; Time 2: OR=3.26, p=0.00). At Time 3, there were also significant differences in depressive symptoms regarding educational attainment
(OR=3.05, p=0.00), marital status (OR=2.50, p=0.01), employment (OR=2.14, p=0.02) and family income (OR=2.45, p=0.00) (Table 4). Again, women with depressive symptoms were less educated, unpartnered, unemployed and poorer. Multiparity and unplanned pregnancy did not differ between women with or without depression/depressive symptoms at any time in the assessment. -------------------Table 4-------------------4. Discussion The aim of this study was to assess point and period prevalence and incidence of perinatal depression through two measurements of depression: structured clinical interviews and self-report scales during the third trimester of pregnancy and followed at six weeks and six months after delivery in Mexican perinatal women. Prenatal depression prevalence (SCID) in this study was 9.0%, (95% CI 5.1-12.9), which is slightly lower than Ocampo et al.’s (2007) (12.3%) and lower than Gómez et al.’s (2007) (14%) in Latin America, in samples of women with high risk pregnancies, but similar to that of Bennett et al. (2004b) 8.8% during the third trimester in a systematic review that included studies mostly from developed countries. Conversely, this figure is much higher than the combined estimates reported by Gaynes et al. (2005) of 3.4% (in the third trimester) for major depression alone in developed countries. The use of very conservative inclusion criteria in Gaynes et al.’s review complicates the interpretation of differences. Depressive symptoms in pregnancy (PHQ-9) were observed in 16.6% (95% CI 11.5-21.7) of the sample, which is significantly lower than in other studies in Latin America: 24.3% (EPDS12) (Melo et al., 2012), 30.7% (CES-D16) (Lara et al., 2006), and 34.7% (EPDS13.5) (Bao-Alonso et al., 2010). Conversely, our prevalence is in line
with that reported by Bennett et al. (2004b) (13.2%). There are no obvious factors to explain the differences between the Latin American studies, although they could be partly accounted for by the use of different self-report scales and of different cut-off scores, a problem often reported in the literature (Bennett el a., 2004a; Gaynes et al., 2005). Although the PHQ-9 has not been used in previous studies on perinatal women in Latin America, it was selected because of its solid psychometric properties (Kroenke et al., 2001), its brevity and ease of answering. Moreover, the fact that it is designed for primary care made it an attractive tool for future use in screening in settings outside obstetric clinics, such as family medicine and paediatric care. In line with other findings self-report depression was higher than depression measured with clinical interviews (Halbreich and Karkun, 2006; Austin, 2014). As mentioned earlier, perinatal depressive symptoms appear to have equally significant clinical value as clinical depression since they show detrimental effects on women’s health and adverse pregnancy outcomes (Marcus et al., 2003). In this respect, self-report scales are not only useful as screening tools for further diagnostic assessment, but also show that depression as measured by these scales should be recognized and timely treated. Point prevalence of major PPD at six weeks (13.8% [95% CI 9.1-18.5]) was similar to that previously found in Latin America in similar timeframes (13.8% - 17.4%) (Ocampo et al., 2007; Alvarado-Esquivel, et al., 2010; Almanza-Muñoz et al., 2011). However, other studies in Latin America report higher prevalence: from 22.4% (Alvarado et al., 2000) to 24.6% (Alvarez et al., 2008). It is difficult to explain both the similarities and differences on the basis of variables such as treatment (Alvarado-Esquivel et al., 2010) or the inclusion of mothers under the age of 20 (Alvarado et al., 2000; Alvarez et al., 2008), as the results do not vary in a consistent fashion according with what would be expected. Future
comparative studies using standard methodologies are needed to determine whether the different prevalence estimates are related to specific population characteristics rather than to methodological issues. PPD prevalence in our study is in line with O’Hara and Swain’s (1996) 12%,estimated in a meta-analysis comprising mainly, but not exclusively, studies from middle and high income countries, which are similar to more recent studies by Dietz et al. (2007) (10.4%) and Banti et al. (2011) (9.6%). However, our prevalence is higher than Gaynes’s et al. (2005) for major depression alone of 6.8%. It is difficult to ascertain whether the higher rates in the current study compared with the latter reflect the true differences due to the social and economic disadvantages experienced by women living in low- and lower-middle income countries (Matijasevich et al., 2009; Fisher et al., 2012) or to the methodological differences mentioned earlier in the case of Gaynes et al. (2005). PPD at six months postpartum (13.3% [95% CI 8.6-17.9]) was similar to that at six weeks, confirming the assertion that depression may remain high after the third month for several more months (Gaynes et al., 2005). PPDS at six weeks (17% (95% CI 12.0-22.2)) were higher than Melo et al.’s. (2012) (EPDS12:10.8%) in Latin America, and similar to O’Hara and Swain’s (1996) (14%). At six months, a 20% (95% CI 14.5-25.4) rate of depressive symptoms was in line with Latin American studies (DeCastro’s et al., 2011) (EPDS13: 14.2%) up to nine months postpartum. Perinatal PPDS period prevalence was 16.2% (95% CI, 11.2-21.7), reported in this region for the first time. New cases of depression were observed at six weeks: 10.0% (95% CI 5.9-14.0) and at six months postpartum: 8.2% (95% CI 4.1-12.8). These figures are similar to 8.8% in Latin American mothers at two months’ postpartum (Alvarado et al., 2000). The incidence
of depressive symptoms was 11.4% (95% CI, 6.7-16.3) 9.0% (95% CI, 4.5-13.5) in the same period, with no references to previous data in this aspects in Latin America. One of the implications of this finding is that, new cases of PPD may be averted if risk factors (such as depressive symptoms, low income, low educational attainment) are identified during pregnancy and the early postnatal period and prevention strategies are implemented (Lara et al, 2010). An analysis of the differences between depressed and non-depressed mothers shows that they were found almost exclusively in the 6th postpartum month. A higher percentage of women with depression in this period had low educational attainment (ORs= SCID: 5.61; PHQ-9: 3.05), were unpartnered (ORs= SCID: 3.03, PHQ-9: 2.50), unemployed (ORs= SCID: 3.48; PHQ-9: 2.14) and poorer (ORs= SCID: 4.05; PHQ-9: 2.45). Being younger was also related to PPD at six months postpartum (OR=2.45), with low educational attainment being linked to depressive symptoms in pregnancy (OR=3.11) and at six weeks postpartum (OR=3.26). In general terms, the relation between these factors and postpartum depression/symptoms has been reported previously (O’Hara and Swaim, 1996; Alvarado et al., 2000; Bennett et al., 2004b; Aramburú et al., 2008; Alvarado-Esquivel et al., 2010; Almanza- Muñoz, et al., 2011; O’Hara and McCabe, 2013). However, what is interesting about this finding is that these factors distinguish between depressed and nondepressed women at sixth months postpartum but not earlier. It can be hypothesized that as the baby grows older, it makes specific demands on mother’s internal and external resources, which are more difficult to meet if she has a lower income, less education, is unemployed and unpartnered. Among other consequences, low educational attainment reduces the ability to cope with stress (Kubzansky et al., 1999). Poverty, on the other hand, as O’Hara and
McCabe (2013) suggest, may be the common element underlying all these factors. Additionally, women in poverty are more likely to lack access to health services, infant care and information. 4.1 Limitations This longitudinal naturalistic study has a number of constraints. The first concerns the observed response rate of 62.9%, which although somewhat better than that observed in similar studies, such as 41.2% (Kitamura et al., 2001) and 49.9% (Banti et al., 2011), is not sufficiently high, potentially affecting the accuracy of the prevalence estimates. The second limitation refers to the 25% attrition of the initial sample, which was not retained to complete the three assessments. Women who failed to complete these assessments were younger, had fewer years of schooling and reported more depressive symptoms, which may have meant that the prevalence reported may underestimate the actual prevalence. Third, our data was collected in urban health facilities, meaning that the prevalence of perinatal depression may not be generalized to rural settings, although the PPD rate found in this context is not that different (12.9%) (Alvarado-Esquivel et al., 2010). Fourth, measurements of the history of depression were not included, making it impossible to determine whether the onset of depression occurs during the perinatal period or whether there have been depressive episodes prior to the current pregnancy. Fifth, we decided on a convenient nonprobabilistic sampling procedure. As observed elsewhere, non-randomized sampling limits the scope of generalization to the population as a whole, since some of its characteristics (e. g. age groups, type of schooling) may not be well represented in the sample (Vivanco 2005). 5. Conclusion
Some important conclusions can be drawn from this carefully designed longitudinal study to assess perinatal depression in Latin American women at three different points in time: reporting point, period prevalence and incidence using both structural interviews and self-report scales. Most of the prevalence rates (Pregnancy: SCID: 9%; PHQ-9: 16.6%; Six weeks postpartum: SCID: 13.8%; PHQ-9: 17.1%. Six months postpartum: SCID: 13.3; PHQ-9: 20%) are within the range of previous estimates in a review and a meta-analysis (O´Hara and Swaim, 1996; Bennett, et al., 2004b) and share many features with studies in Latin America (Ocampo et al., 2007; Alvarado-Esquivel, et al., 2010; Almanza-Muñoz et al., 2011). New cases were found at six weeks (SCID: 10%; PHQ-9:11.4%) and six months PP (SCID: 8.2%; PHQ-9:9%). These results, though, may be an underestimation of “actual” prevalence due to sample attrition. Despite the similarities found in depression prevalence in this study as compared to more developed countries, the consequences of this disorder in developing countries may be more detrimental to the health of mother and baby. In Mexico, as in other resourceconstrained countries, perinatal depression is more likely to go undetected and untreated, due to greater underutilization of mental health services than in high income countries (Halbreich & Karkun, 2006; Borges et al., 2006; Matijasevich et al., 2009; Fisher et al., 2012). Moreover, less awareness and higher perceived stigma regarding perinatal depression may also prevent more women from seeking treatment (Lara et al., 2014). Women more frequent contact with health services during the perinatal period represents an opportunity for education, prevention and treatment of depression. Even in countries with more limited mental health care infrastructure, there are a number of lowcost interventions that may be undertaken to potentially impact perinatal depression. These include increasing awareness of pre and postnatal depression by educating health providers
and expectant and postnatal mothers in prenatal care services; offering training to raise the involvement of primary health care providers in screening for depression and assessing more vulnerable mothers (less educated, single, unemployed and poorer) to provide support and empathic responses, and to implement low impact interventions (Dennis et al., 2009; Lara et al., 2014). Resources permitting, treatment should be provided for depressed mothers (Dennis and Hodnett, 2007; Rojas et al, 2007; Patel et al., 2011). Efforts should also be made to lobby for mental health care to be included in the official norms regulating the health care of mothers and babies during the perinatal period (Rahman et al., 2013).
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Table 1. Demographic and Obstetric Characteristics (n= 210). M
(SD)
Age
29.50
(6.34)
Years of schooling
13.01
(3.83)
n
(%)
Low income
98
46.7
Medium and high income
112
53.3
Partnered
169
(80.5)
Single
41
(19.5)
Yes
131
(62.4)
No
79
(37.6)
Yes
70
(33.3)
No
140
(66.6)
Monthly family income
Marital status
Paid Work
First pregnancy
Planned pregnancy
Yes
114
(54.3)
No
96
(45.7)
SCID Prevalence
f
Time 1
Time 2
Time 3
Pregnancy
6th postpartum week
6th postpartum month
%
19 (9.0%)
CI 5.1-12.9
Incidence PHQ-9 (10) Prevalence Incidence
f
%
35 (16.6%)
CI 11.5-21.7
f
%
CI
f
%
CI
29 (13.8%)
9.1-18.5
28 (13.3%)
8.6-17.9
21 (10.0%)
5.9-14.0
14 (8.2%)
4.1-12.8
f
%
CI
f
%
CI
36 (17.1%) 12.0-22.2
42 (20.0%)
14.5-25.4
20 (11.4%)
14 (9.0%)
4.5-13.5
6.7-16.3
Table 2. Prevalence and Incidence of Perinatal Depression (n=210).
Table 3. Maternal Characteristics of Depressed and Nondepressed (SCID) Perinatal Women and Odds ratios and 95% Confidence Intervals for the Association of Maternal Characteristics of Depression.
Depressed
Non depressed
n=19
n=191
Age 28
47.36%
44.50%
Secondary school
68.42%
Unpartnered
OR
95% CI
0.49
1.12
0.43-2.88
54.97%
0.18
1.77
0.64-4.86
26.31%
19.37%
0.32
1.48
0.50-4.38
Unemployed
37.69%
36.84%
0.57
1.03
0.36-2.56
Low Income
51.72%
45.85%
0.69
1.26
0.57-2.77
Multiparous
68.42%
66.49%
0.54
1.09
0.39-3.00
Unplanned pregnancy
47.36%
45.54%
0.53
1.07
0.41-2.76
n=29
n=181
Age 28
48.27%
44.19%
0.41
1.17
0.53-2.58
Secondary school
68.96%
54.14%
0.09
1.88
0.81-4.35
Unpartnered
24.13%
19.33%
0.35
1.32
0.52-3.35
Unemployed
41.37%
37.01%
0.39
1.20
0.54-2.66
Low Income
52.63%
46.07%
0.63
1.30
0.50-3.34
Multiparous
68.96%
66.29%
0.47
1.12
0.48-2.62
Unplanned pregnancy
62.06%
53.03%
0.24
1.44
0.64-3.24
n=28
n=182
Age 28
64.28%
42.23%
0.02
2.45
1.07-5.61
Secondary school or less
85.71%
51.64%
0.00
5.61
1.87-16.80
Time 1. Pregnancy
Time 2. 6th postpartum week
Time 3. 6th postpartum month
P
Unpartnered
39.28%
17.58%
0.01
3.03
1.29-7.08
Unemployed
64.28%
34.06%
0.00
3.48
1.51-8.00
Low Income
75.00%
42.54%
0.00
4.05
1.63-10.01
Multiparous
67.85%
67.03%
0.55
1.03
0.44-2.43
Unplanned pregnancy
53.57%
45.05%
0.26
1.40
0.63-3.12
Table 4. Maternal Characteristics of Depressed and Non depressed (PHQ-9) Perinatal Women and Odds ratios and 95% Confidence Intervals for the Association of Maternal Characteristics of Depression. Depressive symptoms
No depressive symptoms
n=35
n=175
Age 28
45.71%
44.57%
Secondary school
77.14%
Unpartnered
OR
95% CI
0.52
1.04
0.50-2.17
52.00%
0.00
3.11
1.34-7.23
22.85%
19.42%
0.39
1.22
0.51-2.94
Unemployed
45.71%
36.00%
0.18
1.49
0.71-3.11
Low income
60.00%
44.00%
0.06
1.90
0.91-3.99
Multiparous
74.28%
65.14%
0.19
1.54
0.68-3.50
Unplanned pregnancy
60.00%
53.14%
0.28
1.32
0.63-2.76
n=36
n=174
Age 28
63.88%
53.44%
0.16
1.54
0.73-3.23
Secondary school
77.77%
51.72%
0.00
3.26
1.41-7.56
Unpartnered
25.00%
18.96%
0.26
1.42
0.61-3.31
Unemployed
44.44%
36.20%
0.22
1.40
0.68-2.91
Low income
58.33%
44.25%
0.08
1.76
0.85-3.64
Multiparous
69.44%
66.09%
0.42
1.16
0.53-2.53
Unplanned pregnancy
42.22%
45.40%
0.49
1.07
0.52-2.20
n=42
n=168
54.76%
42.26%
0.09
1.65
0.83-3.26
Time 1. Pregnancy
Time 2. 6th postpartum week
Time 3. 6th postpartum month Age 28
P
Secondary school
76.19%
51.19%
0.00
3.05
1.41-6.60
Unpartnered
33.33%
16.66%
0.01
2.50
1.17-5.34
Unemployed
52.38%
33.92%
0.02
2.14
1.08-4.24
Low income
64.28%
42.26%
0.00
2.45
1.21-4.95
Multiparous
76.19%
64.28%
0.09
1.77
0.81-3.86
Unplanned pregnancy
54.76%
43.45%
0.12
1.57
0.79-3.10
ACKNOWLEDGEMENTS This study was supported by the Consejo Nacional de Ciencia y Tecnología (CONACyT, CB-2009-01 133923). We are grateful to the staff and patients of the Centro de Salud Dr. Ángel Brioso Vasconcelos and of the Hospital Regional del ISSSTE Lic. Adolfo López Mateos; to Dr. Carmen Lara, for training and supervising the use of the SCID; and to the research team: Yadira Ramos, Karla Alcántara, Valeria Zempoalteca, Lilian Delgado and Araceli Aguilar.
Contributors
Laura Navarrete participated in the field work, in the analyses of the data and preparing the manuscript. Lourdes Nieto participated in the in the literature review and preparing the manuscript. Juan Pablo Barba participated in the field work and in discussing the results José Luis Navarro participated in the field work and in discussing the results Héctor Lara-Tapia participated in the field work and in discussing the results !"##$!%&&$"&!'(
Figure(s)
Figure 1. Participant flow.
Screened (n=694)
Did not meet inclusion criteria (n=249) Eligible (n=445) Refused to be interviewed (n=165)
Time 1 >26 weeks pregnancy (n=280)
Time 2 6 postpartum week (n=234) th
Time 3 6th postpartum month (n=210)
