Postpartum depression epidemiology in a Brazilian sample

Abstracts

INTRODUÇÃO: Sintomas psiquiátricos são freqüentes após o parto, momento marcado por alterações hormonais e mudanças no caráter social, na organização familiar e na identidade feminina. A Escala de Depressão Pós-Parto de Edimburgo (EPDS) é instrumento de auto-avaliação para rastrear depressão após a gestação, nem sempre adequadamente reconhecida pelos profissionais de saúde. O objetivo deste estudo foi avaliar prevalência de depressão pós-parto em mulheres atendidas em unidades básicas de saúde. MÉTODOS: Estudo transversal com aplicação da EPDS em 292 mulheres que se encontravam entre 31 e 180 dias após o parto. Adotamos o ponto de corte < 12 na EPDS como depressão. RESULTADOS: Do total, 115 (39,4%) apresentaram escores < 12, na EPDS, foram consideradas deprimidas; 177 (60,6%), com escores < 12, foram consideradas não-deprimidas. Mulheres com menor escolaridade, maior número de gestações, maior paridade, maior número de filhos vivos e menor tempo de relacionamento apresentaram mais depressão. CONCLUSÃO: A elevada freqüência de depressão pós-parto está relacionada com fatores sociais, demonstrando a importância dos profissionais de atenção básica na detecção precoce da depressão, tendo como auxílio instrumentos como a EPDS, pela sua eficácia e praticidade.

Depressão pós-parto; epidemiologia; escala de Edimburgo

ORIGINAL ARTICLE

Postpartum depression epidemiology in a Brazilian sample

Gustavo Enrico Cabral Ruschi^I; Sue Yazaki Sun^II; Rosiane Mattar^III; Antônio Chambô Filho^IV; Eliana Zandonade^V; Valmir José de Lima^VI

^IMSc. Physician

^IIPhD. Head, Pathological Obstetrics and Operative Delivery, Universidade Federal de São Paulo - Escola Paulista de Medicina (UNIFESP-EPM), São Paulo, SP, Brazil

^IIIProfessor. Coordinator, Graduate Program in Obstetrics, UNIFESP-EPM

^IVPhD. Head, Department of Gynecology and Obstetrics, Escola de Ciências Superiores, Santa Casa de Misericórdia do Espírito Santo, Vitória, ES, Brazil

^VPhD. Department of Statistics, Universidade Federal do Espírito Santo (UFES), Vitória, ES, Brazil

^VIGraduate student in Obstetrics, UNIFESP-EPM

^{Correspondence}

ABSTRACT

INTRODUCTION: Psychiatric symptoms are frequent in the postpartum period, a moment marked by hormonal alterations and changes in social character, family organization and women's identity. The Edinburgh Postnatal Depression Scale (EPDS) is a self-reporting instrument to track depression after pregnancy, unfortunately not always properly supported by health care professionals. This study aimed at verifying the prevalence of postpartum depression in women receiving care at basic health units.

METHODS: Cross-sectional study including 292 women in the postpartum period (from day 31 to 180) who answered the EPDS questionnaire. Cut-off point < 12 for EPDS depression was used.

RESULTS: A total of 115 women (39.4%) had scores < 12 in EPDS, classified as depressive; 177 (60.6%) had scores < 12 and were not considered depressive. Women with lower education, higher number of pregnancies, higher parity, higher number of live children and shortest relationship time had more depression.

CONCLUSION: High frequency of postpartum depression is associated with social factors, which shows the importance of health care professionals in early detection of depression, with the aid of instruments such as EPDS, due to its efficacy and practicability.

Keywords: Postpartum depression, epidemiology, Edinburgh postnatal depression scale.

Introduction

Depression in Brazil is considered a serious public health problem, reaching 2-5% of the general population,^1,2 with prevalence in the female gender, often preceded by remarkable vital events, such as pregnancy, delivery and postpartum period. However, their importance to establish depression has not been completely explained.

In the postpartum period, depressive symptoms are not qualitatively different from those occurring in other stages of life,³ and can be properly diagnosed and treated at a primary health care level. Nevertheless, less than 25% of puerperal women have access to treatment,⁴ and only 50% of postpartum depression cases are diagnosed in daily clinical practice.^5,6

Brazilian studies report prevalence of postpartum depression ranging between 12-19%.^7-10 These data are compatible with the international literature, which reports a rate of 10-20%.^11,12

The medical literature describes the following psychic manifestations in the postpartum period as being the most common: maternal blues or sadness, postpartum depression and psychosis.^13-17 Relationship and potential overlapping between these conditions have not been clearly defined.¹⁶

Maternal sadness is a self-limited disorder, starting during the first 2 postpartum weeks, with a 50-80% incidence, being considered risk factor for depression in the first year after delivery. On the contrary, postpartum psychosis is relatively rare, with 0.1-0.2% incidence, and it typically occurs over the first 4 weeks after delivery, representing medical emergence.¹⁶ Susman reports that, when maternal sadness persists or is worsened, the patient can be developing depression, whose clinical diagnostic criteria are the same found in the Diagnostic and Statistical Manual of Mental Disorders (DMS-IV) for major depression, which consider event duration in at least 2 weeks with five or more of the following symptoms: depressed mood, anhedonia, significant changes in weight or appetite, insomnia or hypersomnia, agitation or psychomotor retardation, fatigue, feelings of uselessness or guilt, reduced ability for thinking and concentrating, indecision, recurrent thoughts of death.¹⁸ Symptom onset over the first 4 weeks is only specifying.¹⁹

Although there are no physiological parameters to assess clinical manifestations of depression, assessment scales are used to measure and characterize symptoms, even if they cannot be used as diagnostic criteria.²⁰

Among existing self-reporting scales, the Edinburgh Postnatal Depression Scale (EPDS) is the most widely used to screen depressive symptoms that are manifested after delivery.²¹ It has been translated into 24 languages, with validation studies in most countries.²² This instrument offers easy application and interpretation, with wide acceptability and simplicity in its incorporation to clinical routine,^23,24 and can be applied by professionals of basic health areas.^5,25-29 EPDS is a self-reporting instrument composed of 10 statements, whose options are scored (0 to 3) according to symptom presence or intensity.

Its items cover psychic symptoms, such as depressive mood (feeling of sadness, self-devaluation and guilt, ideas of death and suicide), loss of pleasure in activities previously considered pleasant, fatigue, reduced ability of thinking, concentrating and making decisions, besides physiological symptoms (insomnia or hypersomnia) and behavioral changes (crying episodes). Total points account for a score of 30. Scores ≥ 12 are considered depressive symptoms, as defined in the scale validity in a Brazilian sample.⁸

In this context, obstetricians play a major role in the identification and management of maternal depressive symptoms in the postpartum period, minimizing their impacts on the mother, infant and family. Therefore, we developed this study with the aim of identifying prevalence of depressive symptoms after delivery, according to EPDS, applied to women who were between 31 and 180 days after delivery.

Methods

A cross-sectional, descriptive, observational study was conducted including postpartum women receiving care at the obstetrics and gynecological clinics at the Basic Health Unit of Maruípe, a district belonging to the municipality of Vitória, and at the Regional Health Unit of Feu Rosa, in the municipality of Serra, part of the metropolitan region of Greater Vitória, located in the State of Espírito Santo.

Sample calculation was based on a higher prevalence of expected postpartum depression, which is 20%, considering aimed accuracy of 5% and 95% confidence level.

For this study, 292 women who attended the aforementioned clinics from June 2004 to May 3006 were eligible, as long as they met the following inclusion criteria: postpartum time between 31 and 180 days; pregnancy whose resolution occurred between 34 and 42 weeks; maternal age between 15 and 45 years. Exclusion criteria were stillborn or neonatal death in current pregnancy; gestational age lower than 34 weeks; neonatal complications in current pregnancy; history of use of psychoactive drugs or previous psychiatric treatment.

To identify the profile of the population under investigation, we developed a semi-structured, standardized interview applied by the researcher at a private environment, containing sociodemographic data, factors associated to behavior and life habits and clinical obstetrician and neonatal data, defined as follows: age (measured in complete years); marital status (single, married, divorced, according to legal certificate); ethnic group; schooling level (maximum education level, considering: any education level, incomplete or complete elementary school, incomplete or complete high school, higher education); mean family income (sum of number of minimum wages earned by working members of the family); time of current relationship (total number of relationship months, i.e., couple that shares the same home when interview was performed, regardless of marital status); use of psychoactive drugs (drugs prescribed by clinicians or psychiatrists with the aim of treating psychiatric conditions, especially depression); illicit drugs (use of cannabis, cocaine, crack); number of pregnancies; parity; number of live children; type of delivery (vaginal or cesarean); breastfeeding; postpartum time (time between delivery date and interview); aid at home (effective participation of the father or other relatives in infant care).

EPDS was used to screen depressive symptoms (Appendix 1), adopting a cut-off point of 12.

Edinburgh Postnatal Depression Scale

Over the past 7 days

1) I have been able to laugh and see the funny side of things:

( ) As much as I always could.

( ) Not quite so much now.

( ) Definitely not so much now.

( ) Not at all.

2) I have looked forward with enjoyment to things:

( ) As much as I ever did.

( ) Rather less than I used to.

( ) Definitely less than I used to.

( ) Hardly at all.

3) I have blamed myself unnecessarily when things went wrong:

( ) Yes, most of the time.

( ) Yes, some of the time.

( ) Not very often.

( ) No, never.

4) I have been anxious or worried for no good reason:

( ) No, not at all.

( ) Hardly ever.

( ) Yes, sometimes.

( ) Yes, very often.

5) I have felt scared or panicky for no very good reason:

( ) Yes, quite a lot.

( ) Yes, sometimes.

( ) No, not much.

( ) No, not at all.

6) Things have been getting on top of me:

( ) Yes, most of the time I haven't been able to cope at all.

( ) Yes, sometimes I haven't been coping as well as usual.

( ) No, most of the time I have coped quite well.

( ) No, I have been coping as well as ever.

7) I have been so unhappy that I have had difficulty sleeping:

( ) Yes, most of the time.

( ) Yes, sometimes.

( ) Not very often.

( ) No, not at all.

8) I have felt sad or miserable:

( ) Yes, most of the time.

( ) Yes, quite often.

( ) Not very often.

( ) No, not at all.

9) I have been so unhappy that I have been crying:

( ) Yes, most of the time.

( ) Yes, quite often.

( ) Only occasionally.

( ) No, never.

10) The thought of harming myself has occurred to me:

( ) Yes, quite often.

( ) Sometimes.

( ) Hardly ever.

( ) Never.

Scoring:

For questions 1, 2 and 4, scoring for the sequence of alternatives is: 0, 1, 2 and 3.

For the other questions, scoring for the sequence of alternatives is: 3, 2, 1 and 0.

1 - Comparison between means of pregnancy number in depressed and non-depressed women - Pregnancy: number of pregnancy.

2 - Comparison between means of parity in depressed and non-depressed women - Parity: number of deliveries.

3 - Comparison between means of number of live children in depressed and non-depressed women - Number of live children.

4 - Comparison between means of relationship time in depressed and non-depressed women - Relationship time (in months).

5 - Sociodemographic data and habits of puerperal women and their partners - Schooling level: ignored, none, incomplete elementary school, complete elementary school, incomplete high school, complete high school, higher education. Race: Caucasian, black, mulatto, indigenous. Smoking: yes, no. Alcoholism: yes, no. Drugs: yes, no.

6 - Postpartum depression according to sociodemographic and obstetric characteristics and habits of maternal life - Schooling level, race, income (in minimum wages), drugs, number of deliveries, type of delivery, breastfeeding, infant gender, events (during pregnancy, delivery and after delivery), aid at home.

7 - Relationship between postpartum depression and form of EPDS application - Oral: scale applied by interviewer. Self-report: patient reads, interprets and answers the scale.

EPDS is a self-reporting scale and was answered at a private place. When the participants were unable to read, the questionnaire was applied by the researcher, as suggested by Cox et al. ²¹ In our population, we compared frequency of postpartum depression found in questionnaires answered by interviewees and that obtained in cases in which the questionnaire was applied by the researcher.

Techniques of descriptive analysis were applied to collected data to characterize studied sample. Associations between variable and patient's status as to postpartum depression were submitted to chi-square and Lèvene tests. For quantitative variables, when compared to disease status, tests to compare two means were used (Student's t test). Significance level was set at 5%.

The research project and the consent term were previously approved by the Research Ethics Committee of Universidade Federal de São Paulo, number 0941/04.

Results

In a population of 292 women, 115 (39.4%) had EPDS scores ≥ 12 (mean score = 16.37; standard deviation - SD = 0.360), which characterize presence of depressive symptoms; 177 (60.6%), had scores lower than 12 and were considered non-depressive (mean score = 6.23; SD = 3.048). Losses reached 1%, due to patients who did not answer the EPDS completely.

Mean age of participants and their partners was, respectively, 24.7 years (SD = 6.054) and 28.9 years (SD = 7.223). Regardless of marital status, most (281, 95.9%) had a stable relationship (mean relationship time was 5 years). In 15.8%, family income was lower than one minimum wage; in 36%, between one and two minimum wages; in 31.5%, between two and five minimum wages; in 15.8%, higher than five minimum wages; and 1% did not know. Sociodemographic profile and life habits of the participants and their partners are described in Table 1.

When relationship between qualitative maternal variables (sociodemographic, life habits, obstetric) and postpartum depression were evaluated, there was only significant association between postpartum depression and mother's schooling level (p = 0.0363). The lower the mother's schooling level, the higher the prevalence of postpartum depression (Table 2).

Table 2- Click to enlarge

As to association between maternal depression and paternal variables, there were no significant indexes.

We found statistically significant results in relation to number of pregnancies, number of deliveries, number of live children, relationship time (maternal quantitative variables) and occurrence of postpartum depression. Women with higher number of pregnancies, higher parity, higher number of live children and shortest relationship time had index suggesting depression (Figures 1 to 4).

In 277 women (94.9%), the scale was read, interpreted and answered by the patient, and only 15 patients (5.1%) needed to have the questionnaires orally applied by the researcher. Of these, 14 had incomplete elementary school, and one had complete elementary school as schooling level.

Association between depression and form of questionnaire application did not show statistical significance, as can be seen in Table 3.

Table 3- Click to enlarge

Discussion

Our sample included 292 women who were between 31 and 180 days after delivery (mean = 2.7 months), with sociodemographic profile predominantly formed by youths (mean age = 24.7 years), Caucasians, housewives, with stable partners. The most frequent schooling level for couples was complete high school, but with low family income. Low family income can be explained by lower participation of these women in the work market and because we did not include users of the private health system, but only users of the Brazilian Unified Health System.

Postpartum depression evaluated by EPDS was present in 39.4% of the women included in our study. Even being high, such prevalence is compatible with some Brazilian studies, such as those by Silva,⁷ Skasufka³⁰ and Cruz.³¹

Other Brazilian publications show lower prevalence rates of postpartum depression, ranging between 13-19%. In the study by Santos,⁸ the sample was predominantly composed of women with family income and schooling level higher than those in our sample. Cury⁹ analyzed women only on the 10th day after delivery, a period in which maternal sadness is prevalent, and not postpartum depression, using Beck Depression Inventory, whose sensitivity and specificity are lower than those of EPDS.³² Moraes used Hamilton scale, which focuses on cognitive and somatic symptoms.¹⁰

Also in the international context, methodological, social, cultural and economic differences in surveyed populations justify the wide variation in prevalence rates (0-60%), as concluded by a recent meta-analysis of studies from 40 countries, including Brazil.³³

EPDS was chosen as a screening method of depressive symptoms for this study because it is a self-reporting instrument specific for the postpartum, with sensitivity and specificity higher than those of other available methods, such as Beck Depression Inventory, Montgomery-Asberg Scale and Raskin Scale, as reported by Harris³² in a comparative study.

Application of EPDS corroborated the fact that it is simple and fast concerning data collection, not requiring more than 10 minutes, which makes it ideal for use in clinical routine by non-specialized practitioners in mental health, with the aim of screening mothers who have depressive symptoms, avoiding overload of specialized services.

Even considering use of EPDS as a limitation of this study, and not clinical depression criteria recommended by the DSM-IV, we believe it is important to know that screening of depressive symptoms in the postpartum period can be established through a questionnaire applied by trained professionals, since Brazil is a country where many women are illiterate or have difficulties reading and understanding texts. It should be stressed that such women are more likely to have this disease, since it is difficult for them to find the proper means to help them search for information. Other factors associated with likely depression is higher number of pregnancies, deliveries, live children and shorter relationship time with partner, which are determining factors of physical and mental burnout and maternal emotional instability, facilitators of depression.

We only had to apply EPDS orally in 15 women, who had low schooling level in common. Although there is an association between depression and mother's lower schooling level, this finding was not related to form of questionnaire application. This confirms the possibility of applying this questionnaire orally, since there is no influence of the interviewer on the interviewee; however, we stress the need of performing further studies about this topic.

Cut-off point is varied in many validation studies of EPDS worldwide, which is justified by social, economic and cultural influence in each country. Cox²¹ warns that adoption of lower cut-off points reduces risk of failure in screening of depressive symptoms, but it increases possibility of false-positive diagnoses. Zelkowitz et al. ³⁴ observed 3.4% of postpartum depression, considering a cut-off point of 12, a prevalence that doubled (6.2%) when EPDS cut-off point was reduced to 10. In this study, we adopted a cut-off point ≥ 12, because it has higher predictive values (positive predictive value = 78%; negative predictive value = 85%) when compared to other scores, as demonstrated by Santos⁹ in a Brazilian study.

We can conclude that many epidemiologic studies on postpartum depression confirm the complexity of this theme by showing divergence in prevalence rates, multiplicity of risk factors and suggested etiologies. The large number of women with depressive symptoms in our sample corroborates that depression is a serious public health problem, which justifies habilitation for professionals to an early recognition of postpartum depression, using instruments such as EPDS, due to its efficacy and practicability.

References

Received September 11, 2007.

Accepted November 6, 2007.

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Correspondence:

Gustavo Enrico Cabral Ruschi

Av. Rio Branco, 1239/902, Praia do Canto

CEP 29055-643, Vitória, ES, Brazil

Publication Dates

• Publication in this collection
  31 Mar 2008
• Date of issue
  Dec 2007

History

• Accepted
  06 Nov 2007
• Received
  11 Sept 2007