Apr 19, 2013 - was diagnosed with antenatal depression (Rochat et al. 2011). These figures are concerning considering that depres- sion and anxiety ...
Arch Womens Ment Health (2013) 16:371–379 DOI 10.1007/s00737-013-0343-1
ORIGINAL ARTICLE
Screening and pathways to maternal mental health care in a South African antenatal setting B. Vythilingum & S. Field & Z. Kafaar & E. Baron & D. J. Stein & L. Sanders & S. Honikman
Received: 30 August 2012 / Accepted: 17 March 2013 / Published online: 19 April 2013 # Springer-Verlag Wien 2013
Abstract In low-resource settings, a stepped care approach is necessary to screen and provide care for pregnant women with mental health problems. This study sought to identify screening items that were most robust at differentiating women experiencing psychological distress and requiring counselling [assessed by screening with the Edinburgh Postnatal Depression Scale (EPDS) and a Risk Factor Assessment (RFA)] from those with a psychiatric disorder as diagnosed by a psychiatrist. Case records of women in an antenatal mental health service in Cape Town were reviewed. Composite scores and individual items on screening scales (EPDS, RFA) of participants who qualified for counselling (n=308) were compared to those of participants who were diagnosed with a psychiatric disorder (n=58). All participants with a psychiatric disorder were diagnosed with either depression or anxiety disorders. These participants had higher mean scores on the EPDS and RFA than those who qualified for counselling (p76 % for major and minor depression combined, in a South African setting (Lawrie et al 1998). The RFA was designed by the PMHP and consists of 11 items. Each item corresponds to a risk factor which has been shown to be associated with mental disorders during pregnancy, through local clinical practice and published international research (Josefsson et al 2002; Husain et al 2006; Lusskin et al 2007). Each item, with an answer of yes or no, assesses the presence or absence of a risk factor. The 11 items pertain to: satisfaction with current pregnancy, difficult life events in the past year, partner being present and/or supportive, domestic violence, emotional or practical support from family or friends, past abuse, relationship with own mother, previous neonatal or infant death and previous history of mental illness. As this was a naturalistic study, the cut-off for referral to counselling had been pre-set at three present risk factors for reasons of pragmatic service delivery.
screening questionnaires were self-administered in private and scored by midwives. Screening questionnaires were available in English, Afrikaans, Xhosa and French. In this urban setting, the majority of participants were literate, but where necessary, midwives assisted participants who experienced difficulties. Participants with either an EPDS score of ≥13 or an RFA score of ≥3 qualified for counselling and were offered referral to an on-site counsellor. Referred participants were seen on an individual basis by counsellors, who used clinical judgement to decide when participants required referral to a psychiatrist for further assessment and treatment of a mental disorder. Though not using a standardised diagnostic tool, the psychiatrist’s diagnostic assessment was based on DSM-IV criteria. Information about gestational age at time of screening, total screening scores and the scores for each individual item on the EPDS and RFA were collected for participants in both groups. In addition, for participants in the psychiatric group only, data on current psychiatric disorder (as specified by the treating psychiatrist), past psychiatric history, alcohol and substance use, past history of abuse, social stressors, as well as obstetric history were collected from medical records.
Procedure Statistical analyses Participants were offered mental health screening once, at their first or second antenatal visit. Midwives obtained informed consent for participation in the service. The two
Data was entered on Epidata and then transferred to SPSS 20 for analysis. T tests and non-parametric tests were used to
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Table 1 Descriptive statistics for demographic information and screening scores
Age Gestation Gravidity Parity EPDS score RFA score
N
Mean
SD
Median
Range
366 366 366 366 366 366
25.26 27.55 1.72 0.55 15.55 3.00
4.99 6.39 0.96 0.82 4.96 1.93
25.0 28.0 1.0 0 15.0 3.0
24 29 6 4 29 10
examine group differences in demographic factors, as well as in RFA and EPDS total scores. Binary logistic regression analyses were performed to determine whether individual items on the EPDS, RFA and a combination of items from the scales could be used to distinguish participants diagnosed with psychiatric disorders from the group who qualified for counselling. Finally, a receiver operating characteristic (ROC) curve analysis was performed to assess the ability of identified items to discriminate between both groups.
Results Table 1 above summarises the demographic information and screening scores of the participants. Age and EPDS scores were normally distributed, whereas gestation at screening, RFA scores, gravidity and parity were not. Where appropriate, non-parametric tests were employed. A series of T tests and non-parametric tests were carried out to assess any differences between the psychiatric diagnosis group and the qualified for counselling group. There was no difference in gestational age at the time of screening. However, compared to the qualified for counselling group, participants diagnosed with a psychiatric disorder were older, had more pregnancies and had more children (p
