報 告 者 王瓊琦

postpartum depression : identification of women at risk

Objective To identify and test the predictive power of demographic ， obstetric ， and psychosocial risk factors of postpartum depression 。

Design Community-based ， prospective follow up study based on questionnaires on past history of psychiatric disease ， psychological distress and social support during pregnancy and depression at four months after delivery 。 Obstetric files were collected at time of birth 。

Setting Antenatal care clinic and delivery ward ， Aarhus University Hospital ， Denmark 。

Population 6790 women giving birth between 1January 1994 and 31 December 1995 ， who attended the antenatal clinic during pregnancy ； 5252(78%)completed all questionnaires 。 The validatiov population comprised 528 women enrolled immediately prior to and after the study period 。

Main outcome measure Postpartum depression four months after giving birth assessed by the Edinburgh Postnatal Depression Scale 。

Results 5.5% of the womem suffered from PPD ， corresponding to a score of 13 or higher on the EPD scale 。 Risk factors identified by multivariate logistic regression analysis included psychological distress in late pregnancy ， perceived social isolation during pregnancy ； high parity ； And a positive histiry of prepregnant psychiatric disease 。 No association was found between pregnancy or delivery complication ， and PPD 。 The maximum predictive power of the identified risk factors was o.3 。 According to these results ， one out of three women who suffers from psychological distress in late pregnancy with preceived social isolation will develop PPD 。

Conclusion Antenatal focus on psychosocial wellbeing may help to identify woman at risk of postpartum depression 。

Introduction Prevalence varies between 8% and 15% according to the different diagnosis criteria used 。 PPD has a long term effect on mental health since it may increase the risk of continuing or recurrent depression Adverse effects on early infant development : risk of accidents risk of accidents sudden infant death syndrome sudden infant death syndrome higher frequency of hospital admissions higher frequency of hospital admissions

Numerous studies have addressed the significance of various biological and nonbiological factors in the aetiology of PPD 。 The most consistent fiding link low socioeconomic status and previous psychiatric illness to PPD 。 The aim of the present study was to test the value of potential risk fectors measured during pregnancy and prenatal period in the prediction of PPD

Methods The population comprised a cohort of Danish speaking women attenging the programme for second trimester examination 。 The women were delivered at the Aarhus in the period from to Based data collected : to women who were enrolled about the 16th weeks of gestation 6790 women who were enrolled about the 16th weeks of gestation ， the first questionnairewhich requested : age ， parity ， socioeconomic status ， medical ， obstetric ， and psychiatric history ， use of alcohol and drugs (home and mailed)

At the 30th weeks of gestation At the 30th weeks of gestation ， the second questionnaire which asked about social support ， psychological distress and intake of alcohol 。 (fetal death were excluded) 。 PP 4 months by a third self-administered questionnaire mailed to women who had answered the two first questionnaires 。 (fetal death were excluded) 。 All obsteric data were validated by a research midwife reviewing the hospital records 。

Assessment The main outcome measure was the EPD scale 。 Using a threshold score of 12/13 the scale has been found to have a sensitivity ranging from 68% to 86% and specificity from 78% to 96% 。 The principal measure of psychological distress in the 30th weeks of gestation was the 12-item versionof the General Health Questionnaire and categorised into three levels of distress according to Goldberg

The principal measure of social support was based on the subjective feeling of perceived social isolation categorised into three levels :never 。 The principal measure of social support was based on the subjective feeling of perceived social isolation categorised into three levels :never ， occasionally ， often 。 Social support was initially covered by 15 questions 。 Perceived social support from close friends and family 。

Analyses were conducted in three phase 。 Potential risk factor were identified in the study population of 6790 women 。 Subsequently a predictive index was developed and tested on a smaller validation sample of 528 women enrolled in the months immediately before and after the study period 。 Analyses were conducted in three phase 。 Potential risk factor were identified in the study population of 6790 women 。 Subsequently ， a predictive index was developed and tested on a smaller validation sample of 528 women enrolled in the months immediately before and after the study period 。 Analysis : multivariate logistic regression multivariate logistic regression logistic regression logistic regression

Statistical methods Students test X2 test Logistic regression

Results Of the 6790 women enrolled in the study cohort 。 28women were not contacted because of child death, and 9 women were lost to follow up 。 5091 women did not miss any item 。 85 women werw enrolled twice due to repeated pregnancies, in these cases only data from the first pregnancywere used 。 Of the 6790 women enrolled in the study cohort ， 6388(94%) completed the first questionnaire ; 5866(86%) completed the second questionnaire ; 5262(78%) completed all three questionnaire 。 28women were not contacted because of child death, and 9 women were lost to follow up 。 5091 women did not miss any item 。 85 women werw enrolled twice due to repeated pregnancies, in these cases only data from the first pregnancywere used 。 A score of 13 or above was achieved by 281 women, indicating a point-prevalence of PPD of 5.5(281/5091)

Discussion To our knowledge this is the largest study of PPD 。 The systematic propectively collected information about potential riskfactors among a nonselected population and use of a standardise and well validated screening instrument provided the possibility of estimating the prevalence of PPD in a general obstetric population 。 In addition, the predictive power of some uncommon potential risk factors was estimated 。