Group cognitive behavioural therapy for postnatal depression: a systematic review of clinical effectiveness, cost effectiveness and value of information analyses

Impact of health problem

Variation in services and/or uncertainty about best practice

The NICE guidance states that the structure of services varies in different parts of the country because of local factors including the organisation of existing mental health services, the demographic profile of the population and geographical issues. Recommendations are made to ensure local needs are met and integrated care is delivered, by developing managed clinical networks involving linked groups of services in primary, secondary and tertiary care.

As services vary widely across the UK it is appropriate to provide details of how PND is managed in a particular NHS trust and how this may potentially contrast with the management of PND in other areas of the UK. Rotherham Primary Care Mental Health Service provides a service based in GP practices for common mental health problems, including PND. Women can be referred to the service by any practitioner, obstetrician, midwife, health visitor or other health professional during both the antenatal and postnatal periods, if it is felt necessary. Rotherham Primary Care Mental Health Service provides a service based in GP practices for common mental health problems, including PND. Women can be referred to the service by any practitioner, obstetrician, midwife, health visitor or other health professional during both the antenatal and postnatal periods, if it is felt necessary. The NICE clinical guidance for antenatal and postnatal mental health is used by practitioners where PND is suspected and they are aware of the primary care mental health service and how to refer into it (although it should be noted that this service is not specific to PND). The EPDS is not used. Once referred to the service, women may attend the GP practice or be visited at home for assessment; women may then be offered six to eight sessions of individual treatment in which CBT approaches and counselling are utilised by the primary care mental health service staff (J Hunter, Head of Service, Primary Care Mental Health Service, Rotherham Community Health Services, 2008, personal communication). This service may differ from other services provided in the UK in the following ways: health visitors in other services may routinely administer the EPDS, which was previously used in the Rotherham service and may be used again in the future; there may not be a dedicated GP-based service for common mental health disorders; and individual CBT may not be routinely administered. The applicability of the Rotherham model to other areas is also likely to be limited owing to the wide variation in health service provision amongst Primary Care Trusts (PCTs) with a reported range of whole time equivalent health visitors per child under 5 years old of 165 in County Durham PCT to 894 in Lambeth PCT. 35

As the section on current service provision indicates, psychological interventions to treat pregnant and breastfeeding women are preferable to the use of psychotropic medication because of the risks of harm to the fetus or child. However, in reality there is a significant mismatch between provision of psychological therapies and the recommendations for their provision. 34 Although undocumented it is widely held that conventional antidepressants are the usual first-line treatment prescribed by GPs for women with PND. However, women have been found to prefer psychological intervention, rather than antidepressants, during the postnatal period. 33,36 Furthermore, it is common to prescribe antidepressants and provide psychological therapies together, although a report suggests that there is no advantage in receiving both, and that cognitive behavioural counselling and a separate antidepressant are equally effective. 33

Previous attempts to improve services have had only limited success. A Royal College of Psychiatrists’ report suggests that, despite efforts to improve the recognition of and screening for PND in primary care, little has changed. 37 In a more recent report by the Healthcare Commission31 (now known as the Care Quality Commission) it is stated that the recording of mental health needs by maternity staff in trusts is inconsistent, making it problematic to assess the prevalence of mental health problems associated with child birth. It reported the number of women receiving a postnatal check-up of their own health and well-being at 6 weeks postpartum as ranging between 71% and 97%. Half of the trusts reported a rate of 89% or below, showing that many women may not be receiving postnatal checks with the GP.

The Healthcare Commission report in relation to mental health focuses on input from perinatal psychiatry and puerperal psychosis and suggests that PND can be treated with support from mainstream services and does not usually require specialist services. As women with a previous history of mental health problems and those with depression during pregnancy are reported as at higher risk of developing postnatal illnesses,15,21 the data reported by the Healthcare Commission may have some relevance to PND.

Data for the Healthcare Commission report31 were provided from 40 trusts, and of these the median trust reported that 8% of women were identified at booking as having personal or family history of mental illness (range 2–30% across trusts). Twenty-nine trusts provided data on referrals to mental health teams following booking; the median number of women referred by these trusts to a mental health team was 1.6% (range 0–7%). It was also reported that about a third of trusts had joint clinics with mental health teams for previous puerperal psychosis, and some had specialist midwives for women with previous puerperal psychosis (19%) or to support women with a psychiatric disorder (21%). Forty-two per cent of trusts had no access to a specialist perinatal mental health service. Midwives provided most antenatal and postnatal care but only 70% of trusts were able to refer women directly to mental health specialists, this was not possible for the remaining 30%. Ninety-five per cent of trusts had access to a mother and baby unit, it is assumed that the other 5% do not have any access to a mother and baby unit, although this is not detailed in the report.

The Healthcare Commission report concluded that there are inadequate provisions for mental health needs in many trusts’ maternity services, including booking, speciality training, streamlining referral pathways and access to specialist services. If services are lacking for those with severe postnatal illnesses, the likelihood is that this will be the case with those treated only in primary care for mild to moderate depression associated with pregnancy and the postpartum period, although this is not explicitly covered in the Healthcare Commission report.

There is also uncertainty around the number of women with PND who may be undiagnosed or unidentified. It is reported that women are often reluctant to pursue health care for PND for a variety of reasons. These include a lack knowledge about the condition meaning they are not aware they have it, thinking they could or were expected to cope with it without help, stigma and a fear of failure a fear of losing their baby if they admit to having PND, the fear of giving the family a bad name, and the fear of being labelled as mentally ill. 13,36 Cultural reasons have also been reported, these include the fact that the family may discourage women from obtaining help as it is seen as unacceptable to discuss such issues with people external to the family. Furthermore, it is reported that health professionals may limit the number of women who come forward for treatment for PND by making inappropriate assessments and having insufficient knowledge of PND to provide adequate care. It is also reported that women with PND feel health professionals have a tendency to normalise depressive symptoms making women less likely to pursue treatments. They also feel that they have limited time with health professionals and are not taken seriously. 36 These reports suggest that there may be a significant number of women with PND who remain undiagnosed and that a clearer referral process may help address this.

It is beneficial to improve the commissioning of effective antenatal and postnatal mental health services for a number of reasons outlined in the commissioning guide. These include improving the mother–child relationship, reducing inequalities and improving timely access to services in primary care, mental health and maternity services; reducing the risk of relapse; reducing the risk of women stopping medication in an unplanned way; reducing the number of inappropriate referrals and readmissions and the length of inpatient stays, and offering alternatives to admission; reducing the risk of self-harm and suicide; preventing avoidable separation of mother and baby; and improving performance and person-centred clinical care. 34

Current service cost

It is assumed that usual care (UC) for PND includes visits by midwives and health visitors, visits to the GP, prescriptions for medication, and other health contacts, such as community mental health contacts, clinical mental health contacts and social services contacts. Based on these contacts, Morrell et al. 13 report that costs at 6 months postpartum for women scoring 12 or above on the EPDS are £374 per patient. Health visitor costs per hour of client time were reported as £77 for UC, and £79 for those trained in using a cognitive behavioural or person-centred approach. Overall costs at 6 months were £339 for those receiving CBT or person-centred therapy. These prices were based on 2003–4 unit costs: prices using 2007–8 inflation indices38 would equate to health visitor costs of £86 for UC and £89 for those trained to deliver an intervention, and overall costs as £419 for UC and £380 for intervention care. The findings of Morrell et al. 13 provide some evidence that a psychological intervention delivered by health visitors is cost-effective compared to UC. The costs related to UC did not include any formal CBT treatment.

The current NICE guidance recommends psychological intervention such as CBT or IPT for women with PND. On occasions where formal CBT is provided it is assumed in current practice to be on an individual basis. If a course of individual CBT were offered this would most likely be delivered by a CBT therapist, and would consist of around 12 sessions, 90 minutes in duration. One or two follow-up sessions may be included and the therapist would be required to undertake clinical supervision for approximately 10–30 minutes per session; however, it should be noted that the current service provision of CBT may vary widely (P Slade, Professor of Clinical Psychology, University of Sheffield and J Curran, Consultant Cognitive Behavioural Psychotherapist, Sheffield Health and Social Care NHS Foundation Trust, 2008, personal communication). The cost of a CBT session has been estimated as £6238 (based on a 55-minute session), therefore we estimate the cost per hour to be £68. Assuming 25 hours of treatment and clinical supervision, the cost per patient would be £1700. An alternative method based on health visitor hourly rate provides a larger cost; the cost per hour of health visitor time was estimated at £89 (based on information from Morrell et al. 13 amended using inflation indices to represent current prices), which equates to an estimated cost of £2225 assuming a health visitor was required for 25 hours per patient, although it is unclear whether these resources would be used in reality and may be an overestimation.

Summary of intervention

Cognitive behavioural therapy is a psychotherapy commonly practised in the NHS. CBT refers to a combination of concepts and techniques from cognitive and behaviour therapies. Cognitive therapy is derived from cognitive theories and seeks to challenge negative automatic thoughts with an aim of changing maladaptive thoughts and beliefs. 39 Behavioural therapy refers to a therapy derived from learning theory and works on symptoms by changing behaviour and environmental factors that control behaviour. The patient works collaboratively with a therapist to identify the types and effects of thoughts, beliefs and interpretations on current symptoms, feelings states and/or problem areas. They develop skills to: identify, monitor and then counteract problematic thoughts, beliefs and interpretations related to the target symptoms/problems; learn a repertoire of coping skills appropriate to the target thoughts, beliefs and/or problem areas; and test out new behavioural patterns. 40

Cognitive behavioural therapy has an important role to play in helping people with mental health problems. There is evidence to support the use of CBT in the treatment of several mental health problems (e.g. depression, panic/agoraphobia, social phobia, generalised anxiety disorder, obsessive compulsive disorder, bulimia, etc.). 39 However, it has also been reported that psychological therapy is effective in the treatment of mild to moderate, non-childbirth related depression. 41 There is no evidence that CBT is more effective than other psychological therapies in the treatment of the same condition. Specific to PND, a systematic review has indicated that psychosocial and psychological interventions are effective treatments. 42 Furthermore, a recent trial has demonstrated that psychologically informed treatments delivered by trained health visitors are clinically effective at 6 and 12 months for women with PND compared with UC. 12

Cognitive behavioural therapy can be practised in an individual or group setting; the potential benefits of providing CBT in a group setting include increasing the availability of therapists, reducing waiting times and reducing costs. Group CBT differs from individual CBT only in the respect that participants are treated in small groups of around eight people, rather than in a one-to-one situation with their therapist. Group CBT treatment usually runs for 12 weeks, and is often preceded by one individual session of 2-hour duration with the purpose of assessing the patient and briefing the patient regarding group treatment, and one or two sessions follow-up the treatment. Thus, approximately 13 sessions are required for the group treatment, each typically of 2-hour duration. The group facilitators are likely to require 12 hours for preparation and supervision. Follow-ups may take place at 6 months and sometimes at 12 months, but may vary to a large extent. Group psycho-educational CBT is lower impact than normal group CBT and is usually delivered in a smaller number of sessions, four to six opposed to 10–12 (J Curran, personal communication).

There is little available evidence on the service provision of group CBT specifically for PND. For this reason we have provided details of service provision from two sources. The first from a UK study which has reported data on the efficacy of group CBT for PND,43 and the second based on the delivery methods deemed by the authors to be most likely were group CBT to become widely available.

The UK study43 indicates that it is likely that two health visitors trained to use a cognitive behavioural approach would normally deliver group CBT for PND. Clinical psychologists, mental health workers and nurses may also be involved in supervision or run groups, but this is less likely to occur. Although not reported in this study, group CBT for PND would usually take place at the health visitor base which is often the GP surgery. In some situations the setting could also be a health centre or another community-based facility. Minimal equipment would be required, but would include a flip chart, audio-visual equipment, and equipment to display powerpoint presentations (J Curran, personal communication). It is likely that services of this kind are very limited.

The resources required using the delivery methods deemed by the authors to be most likely were group CBT to become widely available would include two group facilitators, a recently qualified clinical psychologist and a health visitor.

The criteria used for entry to the treatment would normally include a diagnosis of DSM-IV depression, or an elevated score on a self-report measure such as the EPDS. However, those with subthreshold symptoms of PND or those with a history of depression may also be referred at the discretion of the GP (J Curran, personal communication).

Identification of important subgroups

From a clinical perspective, PND includes four subgroups of women whose management may differ: (1) those who develop depression only after childbirth; (2) those who have developed antenatal depression which continues into the postnatal period; (3) those with pre-existing chronic or relapsing depression; and (4) subthreshold groups. It was not possible to assess the efficacy of group CBT for these subgroups separately because of a lack of available data.

Anticipated costs associated with intervention

As detailed in the Summary of intervention section, because of the little available evidence on the service provision of group CBT specifically for PND, details of service provision have been provided both from a UK randomised controlled trial (RCT)43 and also based on the delivery methods deemed by the authors to be most likely were group CBT to become widely available.

Based on the UK RCT43 it is estimated that one programme of group CBT treatment would include eight sessions, occurring once per week for a duration of 2 hours. It is assumed that the group sessions would also be preceded by a 2-hour individual session for the initial assessment of each participant. The average number of participants for the treatment was reported as five. It is assumed that preparation time would be required for each session and this would equate to 1 hour per health visitor per session, and a further hour per session per health visitor would be required for travelling to and from the sessions. Based on these parameters the health visitor time required would be 74 hours, cost per hour of health visitor time was estimated at £89 (based on information from Morrell et al. 13 amended using inflation indices to represent 2007–8 prices). This equates to a total health visitor cost of £6586 and a total cost per participant of £1317.

The authors estimated that two group facilitators would be required, a recently qualified clinical psychologist and a health visitor. The programme would consist of 12 sessions occurring once per week for a duration of 2 hours. These would be preceded by a 2-hour individual session for the initial assessment. The average number of participants for the treatment was estimated as eight. Preparation time was estimated as 1 hour per health visitor per session, and a further hour per session per health visitor would be required for travelling to and from the sessions (G Parry, University of Sheffield, P Slade, University of Sheffield, J Hamilton, St John’s Hospital, West Lothian, Clinical experts, 2008, personal communication). Facilitator time required would be 112 hours, cost per hour of facilitator time was estimated at £89 (based on information from Morrell et al. 13 amended using inflation indices to represent current prices). This equates to a total facilitator cost of £9968 and a total cost per participant of £1246.

We assume the group facilitators would be undertaking their normal duties relating to UC during the rest of the week. The costs presented may be slightly underestimated as they do not include any set up costs or additional running costs, such as room hire and crèche facilities, which may be incurred (J Hamilton, Psychiatrist, personal communication).

Identification of studies

Inclusion and exclusion criteria

Quality assessment strategy

Deeks et al. 54 suggest that the Downs and Black55 checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health-care interventions is the most appropriate checklist to assess non-RCTs. As this checklist can be applied to both RCTs and non-RCTs, all included papers were assessed using this checklist. Qualitative studies were assessed using the qualitative version of the Critical Appraisal Skills Programme (CASP). 56 Key components of the quality appraisal are listed as part of the data extraction tables in Appendices 2 and 3.

Data extraction strategy

All full papers were read by two reviewers (AS and DS) who made independent decisions regarding inclusion or exclusion, and consensus, where possible, was obtained by meeting to compare decisions. In the event of disagreement, a third reviewer (EK) read the paper and made the decision. All data from included quantitative studies were extracted by one reviewer (AS) using a standardised data extraction form. All data from included qualitative studies were extracted by two reviewers (AS and AB) using a standardised data extraction form with disagreements resolved by discussion. Two different data extraction forms were used, one for the quantitative papers and a second for the qualitative papers.

Data synthesis

Quantitative papers

Quantity and quality of research available

For this review a total of six relevant quantitative studies of clinical effectiveness were identified, of which three were RCTs43,58,59 and three were non-randomised trials. 60–62 The evidence tables for these studies are presented in Appendix 2. The qualitative studies are considered later in this section with evidence tables in Appendix 3. Figure 1 shows the quality of reporting of meta-analyses (QUOROM) flowchart for the included quantitative studies.

FIGURE 1.

Summary of study selection and exclusion of quantitative papers.

Tables relating to those studies excluded at full paper sift with reasons for exclusion are presented in Appendix 4 (see Tables 47–50).

Randomised controlled trials

Of the six included studies three43,58,59 were RCTs. The method of randomisation was reported in all three RCTs, blinding of participants is not possible for psychological interventions owing to their nature; however, two studies reported blinded assessment,58,59 and two58,59 reported power calculations. All three RCTs reported numbers lost to follow-up, but none reported reasons for loss to follow-up.

Non-randomised controlled trials

The three non-randomised studies were Meager and Milgrom,62 Clark et al. 61 and Highet and Drummond. 60 Participants included in the Meager and Milgrom62 study were volunteers and were reported to be randomly assigned to either the group treatment or a waiting list group (WLG); however, the randomisation method was not detailed. The Highet and Drummond study60 was a retrospective study which examined patient records; therefore, no randomisation had taken place. In the Clark et al. 61 study, suitable participants were referred for the treatment by a health-care provider. Sequential assignment to group treatment or to the waiting list was performed on the basis of matching for sociodemographic variables. A third individual treatment group was added later. Owing to the retrospective nature of the Highet and Drummond60 study, no blinded assessment was performed. Meager and Milgrom62 and Clark et al. 61 did not report that the assessment had been blinded. None of the non-RCTs presented a power calculation. Meager and Milgrom62 detailed numbers and reasons for loss to follow-up, these included physical illness, need to support de facto husband who was on a methadone programme, difficulty in organising attendance and distance to travel. Clark et al. 61 gave numbers but not reasons for loss to follow-up. Highet and Drummond60 was a retrospective study therefore participants who had been lost to follow-up were not included in the study at all. Reasons were provided for loss to follow-up, these included not being contactable post treatment, not considered to have PND by their health-care provider, refusal to take part in the study and stopping treatment prior to completion.

Therapy details

Table 3 and Tables 22 and 23 in Appendix 2 describe the details of therapy for the three RCTs and three non-RCTs.

Study site, follow-up and inclusion/exclusion criteria

Tables 24 and 25 in Appendix 2 describe the details of study site, follow-up and inclusion/exclusion criteria for the three RCTs and three non-RCTs.

Patient characteristics

Tables 26 and 27 in Appendix 2 describe the details of patient characteristics for the three RCTs and three non-RCTs.

Outcomes and results

Tables 28 and 29 in Appendix 2 describe the details of the outcomes and results for the three RCTs and three non-RCTs.

Results for psychological symptoms

Qualitative papers

Quantity and quality of papers available

Figure 2 shows the QUOROM flowchart for the included qualitative studies. A table of excluded studies with reasons for exclusion is presented in Appendix 5 (see Tables 52 and 53), with the reference for these studies provided in Appendix 6.

FIGURE 2.

Summary of study selection and exclusion of qualitative papers.

Therapy details

Tables 38 and 39 in Appendix 3 describe the details of therapy for the six studies.

Study site, follow-up and inclusion/exclusion criteria

Tables 40 and 41 in Appendix 3 describe the details of study site, follow-up and inclusion/exclusion criteria for the studies.

Patient characteristics

Tables 42 and 43 in Appendix 3 describe the details of patient characteristics for the six studies.

Outcomes and results

Tables 5 and 6 below and Tables 44 and 45 in Appendix 3 summarise the findings with themes presented by findings related specifically to PND and those related to depression in general. These are followed by a narrative summary of the findings.

Diagrammatic representation of the synthesised findings

The supportive environment enabled a sense of community to be built with group facilitators being instrumental in this. This created an environment where social comparisons and prototyping could take place. Adverse effects could disrupt this flow. Practicalities and knowledge, and the improvement of practical issues via the resolution of partner difficulties, could be gained as a result of the social comparison and community. This is shown in Figure 3 as a diagrammatic representation.

FIGURE 3.

Diagrammatic representation of the synthesised findings.

Assessment of effectiveness

Identification of studies

To retrieve papers on cost-effectiveness the search terms for clinical effectiveness were rerun on MEDLINE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and EMBASE using an economics filter. The economics filters used are provided in Appendix 1. The literature retrieved in the searches on the NHS Economic Evaluation Database (NHS EED) and the Health Economic Evaluations Database (HEED) was also reviewed. The searches were undertaken in January 2008. Databases were searched from 1950 to 2008 with the actual date range for each of the databases searched depending on coverage of the individual database. The searches were not restricted by language.

Pertinent economic literature was planned to be assessed using the Drummond and Jefferson checklist. 70 However, no applicable publications were found.

Methods

Given the scarcity of the data identified within the clinical effectiveness section, a pragmatic approach was taken when constructing the mathematical model, with the intention to provide indicative estimations of likely cost-effectiveness ratios rather than a definitive answer.

A conceptual model was constructed which would investigate the benefits associated with group CBT for PND. The design of the conceptual model was influenced by the data that were available to populate the model, which were deemed to be only those data from the Honey RCT. 43 This RCT was selected as it was UK based, had a clear CBT component and reported data at baseline, at end of treatment and at a 6-month follow-up period.

Unfortunately this trial did not incorporate an individual CBT arm; therefore this comparison was not explicitly modelled. Only the cost-effectiveness of group CBT compared with RPC was evaluated.

When modelling the cost-effectiveness of group CBT it was assumed that benefit would be accrued only on initiation of the treatment. Once treatment had commenced it was assumed that there would be a linear increase in the benefit of group CBT compared with RPC, peaking at the end of treatment. Although the CIs were wide, data from the Honey RCT43 provided relatively strong evidence that any gain would persist throughout a 6-month follow-up period (Figures 4 and 5).

FIGURE 4.

Efficacy data at the end of treatment.

FIGURE 5.

Efficacy data at 6-month follow-up.

We assumed that any gain would be maintained over the 6-month period and would then be followed by a linear decline in the advantage of group CBT compared with RPC that was assumed to be reduced to zero 1 year after treatment. That is, a linear decline over a 14-week period. The duration of this decline was chosen as the authors understand that after 12 months PND would be reclassified as general depression. This may be conservative as the focus of CBT is on developing skills that may provide longer benefits; longer time periods are evaluated in sensitivity analyses. A linear decline was chosen as it appeared reasonable, other distributions may be applicable, however, given the large uncertainty in the model parameters, particularly length of comparative advantage associated with group CBT, it was believed that fitting other distributions would be introducing unnecessary complexity.

These assumptions would lead to a gain in EPDS scores associated with group CBT compared with RPC as depicted in Figure 6; the base-case values have been used in this figure. Because of the small time period of the model neither benefits nor costs were discounted.

FIGURE 6.

The conceptual model of the effects of group CBT on EPDS compared with RPC.

In the Figure 6, 8 weeks relates to the end of the treatment period, 26 weeks the assumed time at which maximum comparative advantage declines and 52 weeks the period at which there was assumed to be no comparative advantage of group CBT compared with RPC. The duration of comparative advantage was altered within sensitivity analyses.

The assumed effectiveness of group CBT compared with RPC

As previously noted, the CIs for the effects of group CBT compared with RPC at end of treatment and follow-up in the Honey RCT43 were large. In order to reduce the uncertainty and to provide an estimation of the constant benefit assumed from the end of treatment to 6 months thereafter all data points for Honey43 were pooled together to produce a single estimate. It is acknowledged that this will remove any correlation between the two time points, but this was deemed a worthwhile sacrifice. The assumed efficacy is depicted in Figure 7.

FIGURE 7.

The efficacy of group CBT used within the model.

Thus it was expected that a woman who received group CBT would have at the end of treatment and for the following 6-month period, on average, an EPDS score that was 3.98 lower than a similar woman who received only RPC. The 95% CI ranged from a reduction of 4.69 to a reduction of 3.27.

Mapping from changes in EPDS scores to changes in utility

In order that the cost-effectiveness ratios calculated can be compared with those estimated for other interventions in other disease areas NICE recommends that QALYs be used as the metric for health gain. 71 A methodology was thus needed to translate between changes in EPDS scores and changes in utility. This was achieved by using data from the PoNDER trial13 which had recorded both EPDS scores and utility scores [as measured using the Short Form questionnaire-6 Dimensions (SF-6D)] for women following childbirth at 6 weeks and 6 months. The SF-6D is a preference-based scoring system that provides a utility value for a patient. 72

Data were taken for those woman (n = 401), regardless of arm in the RCT, who had an EPDS score of 12 or greater at 6 weeks following childbirth and who had values for both EPDS and SF-6D at both 6 weeks and 6 months. The change in EPDS and SF-6D between 6 weeks and 6 months was recorded; these data are plotted in Figure 8.

FIGURE 8.

A regression of change in SF-6D against change in EPDS.

A moderate relationship was observed (r2 = 0.27) that indicated that as the EPDS score improved (i.e. became lower) the SF-6D score improved (i.e. became higher). It was also noted that regardless of any change in EPDS score, the utility of a woman was 0.0625 higher at 6 months than at 6 weeks. This result was not surprising given that the EPDS does not include a sleep component and it is likely that women would be achieving more hours of sleep at 6 months than at 6 weeks.

A plot of the residuals versus the fitted values is provided in Figure 9 and visually displays no marked bias within the fit.

FIGURE 9.

A plot of the residuals versus the fitted values from the change in SF-6D versus change in EPDS regression.

Tests for heteroskedasticity were conducted in stata version 9 (StataCorp LP, College Station, TX) using the Breusch–Pagan/Cook–Weisberg test. This showed that the variance was not constant (p = 0.008) and therefore robust standard errors were used when sampling from the regression equation.

The stata output is provided in Table 11.

TABLE 11 - stata output when regressing change in utility with change in EPDS score

SE, standard error.

12+	Coefficient	Robust			95% CI
		SE	t	p > (t)	Lower	Upper
EPDS change	–0.01134	0.000984	–11.52	0	–0.01327	–0.0094
Constant	0.062505	0.006818	9.17	0	0.049101	0.07591

In order that the correlation between the slope and constant of the regression was maintained the variance–covariance matrix was identified. Cholesky decomposition techniques73 were used, assuming that the coefficients for both the EPDS change and the constant were normally distributed, in order to preserve correlation. The variance–covariance matrix is provided in Table 12.

TABLE 12 - The variance–covariance matrix associated with the regression of change in utility with change in EPDS score

	EPDS change	Constant
EPDS change	9.68 × 10–7
Constant	4.11 × 10–6	4.65 × 10–5

Sampling parameters for the slope and constant of the regression equation and for the efficacy of group CBT

In order to estimate the overall utility gain associated with group CBT, PSA were conducted. 74 One thousand Monte Carlo estimations of the distribution of the efficacy of group CBT were sampled along with 1000 pairs of correlated slope and constant coefficients describing the linear relationship between change in EPDS and change in utility, thus forming 1000 parameter configurations. The gain in utility for each woman associated with each configuration was calculated algebraically using the assumptions depicted in Figure 6. The range of the 1000 utility estimates is provided in Figure 10.

FIGURE 10.

The distribution of sampled utility gains per woman receiving group CBT.

The mean value of the utility gain was 0.032 with a 95% CI, using a percentile method of 0.025 to 0.041.

Base-case results

The estimated cost per QALY result for the base case is provided in Table 15.

These results are displayed in Figure 11 with a CEAC. 45 The mean cost per QALY results were high when compared with recommended NICE thresholds of £20,000 and £30,000 per QALY,71 indicating that group CBT was unlikely to be cost-effective based on present assumptions.

FIGURE 11.

The CEAC for group CBT compared with RPC.

Exploration of the expected value of information within the decision problem

As discussed previously there was considerable uncertainty within the decision problem. This uncertainty was initially explored using sensitivity analyses assuming remaining parameters in the base case remained constant. Such analyses showed that there were plausible scenarios where group CBT would be deemed cost-effective compared with RPC.

Further analyses were undertaken using formal expected value of perfect information (EVPI) techniques, which indicate the most that a decision-maker would pay to remove all uncertainty from the decision problem. 46,47 This analysis required that distributions were assigned to variables subject to uncertainty. The uncertainty in the efficacy had previously been estimated; however, the uncertainties in the costs of group CBT per woman and the duration of comparable advantage had not addressed using scenario analyses rather than a distribution. It was deemed that a triangular distribution for costs ranging from £750 to £2000 with a mode of £1500 was not unreasonable considering potential economies of scale and also that a triangular distribution for duration of comparative advantage ranging from 1 to 2 years with a mode of 1 year was also not unreasonable. The authors recognised that these distributions were arbitrary but believed that the exploratory results provided from this analysis would provide an indication of the likely value of information. It was also commented that these values did not match identically those in the deterministic base case, as the mean cost was £1418 compared with £1500 and the duration of comparative advantage was 16 months compared with 12 months. The mean of the probabilistic values were not surprising given that it was commented that the comparative advantage in the base case was likely to be conservative, and that were group CBT to become more widespread the cost per participant would be likely to fall.

The estimated cost per QALY result having fitted distributions to data on comparative advantage and cost of group CBT per woman is provided in Table 17 with a CEAC presented in Figure 12.

FIGURE 12.

The CEAC for group CBT compared with RPC having fitted statistical distributions to uncertain parameters.

It was seen that the cost per QALY value had fallen to £36,062, but this value still fell outside the recommended cost-effectiveness threshold. However, some scenarios fell below a value of £30,000 per QALY,71 which may be deemed a more appropriate threshold than £20,000 as only utility gains relating to the woman (neither the partner or baby) were considered, indicating that there was uncertainty in the correct decision.

The EVPI methodology evaluates in monetary terms the cost of potentially making the wrong decision using a net benefit approach. 75 Given our chosen parameter distributions, the EVPI per woman receiving group CBT was calculated to be £53.50.

The number of births in 2003 in the UK was 695,500;76 assuming that 17.3% of women had an EPDS score of 12 or over13 this equates to an estimated 120,000 women suffering from PND per annum. It was assumed that CBT may be the most appropriate treatment for the forthcoming 10 years. If the birth rate and the prevalence of PND stay constant this would equal 1,200,000 women with an incident case of PND over the next 10 years. For simplicity, we have assumed that each case of PND represents a new episode. Therefore, 1,200,000 women were estimated to benefit from increased knowledge regarding the efficacy, cost and duration of comparative advantage of group CBT compared with RPC. Combining the number of women who could benefit and the EVPI per woman would mean that decision-makers would be willing to pay a maximum of £64M to remove all uncertainty in the decision problem. This amount appeared more than sufficient to adequately fund an RCT to assess the value of the uncertain parameters as well as to explicitly incorporate individual CBT within the RCT.

Furthermore, the expected value of partial perfect information (EVPPI)48 was used to estimate the benefit of removing all uncertainty from one of four variables: the assumed efficacy of group CBT in increasing EPDS values; the assumed cost per woman treated of group CBT; the assumed duration of comparative advantage of group CBT; and the assumed gradient in the relationship between EPDS values and the SF-6D. Figure 13 depicts the EVPI and the EVPPI of the four selected variables.

FIGURE 13.

The value of perfect information associated with parameters in the model.

It was seen that variables with the biggest influence on the cost-effectiveness of group CBT were the cost of treating a woman and the assumed relationship between EPDS values and the SF-6D. By contrast, there was less to be gained by researching the increase in EPDS associated with group CBT and the length of comparative benefit. However, even the variable with the lowest EVPPI value per woman (the efficacy in terms of EPDS) when multiplied by the number of women affected would still equate to an estimated maximum cost of £500,000 to remove all uncertainty in this variable.

Discussion

The current work provides the first published estimate of the cost-effectiveness of group CBT for PND in the UK. The base-case cost per QALY is relatively high (£46,462) compared with currently used thresholds,71 although there is considerable uncertainty in the model parameters. The sensitivity analyses have shown that relatively small QALY gains compared with the base case bring the cost per QALY into values that would potentially be considered cost-effective. The costs of treating a woman with group CBT also markedly affect the cost per QALY ratio. Were the costs estimated here to be larger than those that would arise if group CBT were widely implemented then the cost per QALY value of £46,462 would be an overestimate. It is further noted that any health benefits that are achieved in addition to women with postnatal depression, such as partners and children as previously reported,26,27,29,30 have not been included, which may also overestimate the cost-effectiveness ratio. There is enough uncertainty in the parameters that we cannot provide more than an exploratory indication of the likely cost-effectiveness of group CBT for PND; when ‘reasonable’ distributions were fitted to the costs of treatment and the duration of comparative advantage, the cost per QALY fell to £36,062.

Expected value of perfect information analyses were undertaken to provide an indication of the maximum value that would be placed on removing all uncertainty in the decision problem, this value was > £64M and would appear sufficient to fund the further research required to provide more accurate data on input parameters and to produce more robust estimates of cost-effectiveness. EVPPI analyses show that the variables that have the largest influence on uncertainty are the cost per woman treated and the assumed relationship between EPDS values and the SF-6D.

The results reported are for the UK, as studies in other countries (such as Chile) have been excluded because of the differences in delivering CBT between countries. As such, generalising our results to other countries may not be possible.

A strength of our analyses is that an indicative cost-effectiveness ratio for group CBT for PND has been reported, although it is cautioned that this is subject to uncertainty due to gaps within the current knowledge base. An additional strength has been the relationship between changes in EPDS scores and changes in SF-6D; such a relationship has not previously been reported. Our analyses indicate that the SF-6D value typically increases between 6 weeks and 6 months even though the EPDS remains constant, which could be explained by the lack of a sleep component in the SF-6D. Furthermore, the exploratory analyses have indicated those parameters to which the cost-effectiveness ratio is most sensitive, allowing future research to be more targeted.

The primary limitation of our analysis is caused by the uncertainty in key model inputs. Whilst some, such as the efficacy of group CBT could be tested using PSA, others, such as the residual benefit of group CBT or the costs of group CBT per woman, could not be analysed using PSA, and only selected combinations were tested. Furthermore, utility measurements were not recorded in the appropriate RCT, thus relying on a regression of EPDS to SF-6D, which introduces further uncertainty. The sensitivity analyses undertaken indicate that the cost per QALY can change markedly with plausible combinations of values, which means that a definitive answer on whether group CBT is likely to be cost-effective cannot be provided given current data.

Clinical effectiveness

In total 12 studies were identified in the clinical effectiveness review. Six of these studies were included in the quantitative review43,58–62 and six in the qualitative review. 52,53,65–68 The six studies in the quantitative review comprised three RCTs43,58,59 and three non-randomised trials. 60–62 The studies were found to be unsuitable for meta-analysis, and a narrative analysis of the findings was undertaken. The findings were inconsistent across the studies but three studies, two RCTs43,58 and one non-RCT62 did provide an indication that groups incorporating CBT principles and ranging from intervention to purely psycho-education were more effective than RPC in reducing depression in women with PND. Data were too limited to provide an assessment of group CBT against any other comparator.

The six studies in the qualitative review included two studies52,53 investigating a group treatment with a specified CBT component, and four studies65–68 investigating a group treatment without a specific theoretical basis. These four studies were used as a collective comparator against the two group CBT studies. Women in the CBT groups reported that the group environment allowed women to develop better relationships with their baby, to understand that their feelings as a result of PND were normal, and to assess their role as a wife and mother. More generally they appreciated the caring and supportive environment, the development of a community and practical aspects of the group. Negative aspects included difficulty in applying CBT techniques and difficulty in talking openly in a group setting. In terms of the comparison of CBT groups against the non-theoretically-based groups, other than comments specifically relating to practical issues around the use of CBT techniques, the user perspective did not appear to differ.

Cost-effectiveness

An indicative cost per QALY of group CBT for PND has been provided. The base-case value was relatively high (£46,462); however, this value changes markedly with changes in other parameters such as assumed cost of CBT per woman and the duration of any residual benefit. An analysis using plausible, but favourable, assumptions to group CBT for PND produced a cost per QALY value that would generally be considered cost-effective. The analysis excluded any benefits or cost implications associated with partners and children, which may mean that the cost per QALY ratio has been overestimated. These uncertainties mean that a definitive assessment of the cost-effectiveness could not be provided. However, EVPI analyses indicate that the monetary cost of potentially making the wrong decision is large (our estimate is > £64M). This value should be sufficient to fund an RCT to provide robust data on the variables that are currently uncertain. In the interim, EVPPI analyses show that the uncertainty in the cost of treating a woman with group CBT and the gradient of the relationship between EPDS values and SF-6D values have a large influence on potentially making an incorrect decision regarding the cost-effectiveness of group CBT.

Clinical effectiveness

One strength is the presented summary of both quantitative and qualitative evidence for group CBT in PND. However, any conclusions drawn from this summary will be subject to limitations which have been detailed in the section below, Uncertainties.

Cost-effectiveness

A further strength of our analyses is that a mathematical model has been constructed and an indicative cost-effectiveness ratio for group CBT for PND has been reported, although it is cautioned that this is subject to uncertainty due to gaps within the current knowledge base. An additional strength includes an analysis of the relationship between changes in EPDS scores and changes in SF-6D; such a relationship has not previously been reported. Finally, the value of information analyses guide the development of future research agendas.

The primary limitation of our analyses is caused by the uncertainty in key model inputs. Whilst some inputs, such as the efficacy of group CBT, could be tested using PSA, others, such as the residual benefit of group CBT or the costs of group CBT per woman, could not be analysed using PSA, and only selected combinations were tested. Furthermore, utility measurements were not recorded in the appropriate RCT, thus relying on a regression of EPDS to SF-6D which introduces further uncertainty. The sensitivity analyses undertaken show that the cost per QALY can change markedly with plausible combinations of values, which means that a definitive answer on whether group CBT is likely to be cost-effective cannot currently be provided. EVPPI analyses have indicated where further research should initially be focused.

Clinical effectiveness

There was little quantitative or qualitative RCT evidence to assess the effectiveness of group CBT for PND. The evidence that was available was of low quality in the main because of poor reporting of the results. Furthermore, little information was reported on concurrent treatment used in the studies, which was controlled for in only two of the studies. 43,62

The evidence from the clinical effectiveness review provides inconsistent and low-quality information on which to base any interpretations for service provision. Although three of the included studies43,58,62 provide some indication that group psycho-education incorporating CBT is effective compared with RPC, there is enough doubt in the quality, the level of CBT implemented in the group programmes, and the applicability to a PND population to significantly limit any interpretations. Some studies lacked important detail of the intervention, making it difficult to assess whether the treatment did genuinely reflect group CBT. Further, the time postpartum of the participants varied to a great extent across the studies, making generalisations to a PND population problematic. Furthermore, the potentially small number of health visitors involved in delivering the group CBT in the RCT assumed applicable to the UK setting may provide severe limitations in generalising the results to other health visitors. User perspectives assessed in the qualitative review may have been biased toward positive comments, although this was difficult to ascertain because of the limited detail provided on the methods incorporated.

Although NICE guidelines for antenatal and postnatal care exist,5 these provide little detail on the referral process and the content of treatment programmes. Therefore, it was also difficult to ascertain whether group treatments and the comparators reflect current practice in the UK. Only two of the studies43,52 assessed in the review had a UK setting and both were pilot investigations.

Impacts on the family and child have been highlighted as important outcomes in the treatment of PND. However, they could not be assessed here because of limited available data.

Based on the evidence presented here it is unclear whether drop-out and withdrawal rates have implications for group interventions. Although reasons for loss to follow-up are presented in some cases, it is unclear whether patient acceptability of group treatment is a causal factor in the drop-out rates reported.

It has been reported that variability in therapist effectiveness can account for variance in treatment outcomes, and is independent of both the therapists’ professional background and patient factors at the start of treatment. 69 Given the small number of participants, and therefore the small number of therapists involved in facilitating the interventions reported here, it is possible that a particularly good or poor therapist could have markedly affected the results. As such there may be severe limitations in generalising the results observed in the RCTs to other settings.

Cost-effectiveness

The cost per QALY ratio for group CBT in PND is uncertain because of gaps in the evidence base. Research is urgently needed to populate key parameters in the model including the effectiveness of group CBT compared with both RPC and individual CBT in terms of a utility measure rather than EPDS, the costs of conducting CBT courses and the duration of residual benefit associated with CBT treatment. The cost-effectiveness ratio reported should be treated with caution until more robust data become available.

A list of the electronic bibliographic databases searched

1. MEDLINE

2. MEDLINE In-Process & Other Non-Indexed Citations

3. CINAHL

4. Cochrane Database of Systematic Reviews (CDSR)

5. Cochrane Central Register of Controlled Trials (CENTRAL)

6. EMBASE

7. Database of Abstracts of Reviews of Effects (DARE)

8. NHS EED

9. NHS Health Technology Assessment (HTA)

10. PsycINFO

11. Science Citation Indexes

12. Social Sciences Citation Indexes

13. Applied Social Sciences Index and Abstracts (ASSIA)

14. BIOSIS

15. British Nursing Index

16. Social Care Online

17. Office of Health Economics Economic Evaluations database.

A list of additional sources

1. National Research Register (NRR)

2. Research Findings Register (ReFeR)

3. Current Controlled Trials and its links

4. Health Services Research Projects in Progress (HSRProj) and index to theses

5. health service research and guideline producing bodies (e.g. Scottish Intercollegiate Guidelines Network, NICE, National Guidelines Clearinghouse, etc.) have been consulted via the internet and other key organisations (e.g. Association for Postnatal Illness, Postnatal illness-Support & Help Association) have been contacted

6. grey literature has been identified from searches of databases including dissertation abstracts.

Copies of the search strategies used in the major databases

Economics filters used to retrieve cost-effectiveness literature

References for Table 48

1. Counseling to prevent postnatal emotional problems. Nurses Drug Alert 2007;31:40.

2. Groups don’t help postnatal blues. Aust Nurs J 1996;3:16.

3. Psychological intervention for postpartum depression. Nurses Drug Alert 2006;30:39.

4. Abramov L, Zohar AH. A controlled community-based family study of major depression with postpartum onset. Am J Med Genet 1998;81:455–6.

5. Ammerman R, Bodley A, Putnam F, Lopez W, Holleb L, Stevens J, et al. In-home cognitive behavior therapy for a depressed mother in a home visitation program. Clin Case Stud 2007;6:161–80.

6. Appleby L, Warner R, Whitton AF, Faragher B. A controlled study of fluxetine and cognitive-behavioral counselling in the treatment of postnatal depression. BMJ 1997;314:932–6.

7. Appleby L. Fluoxetine vs counselling for postnatal depression. N Z Med J 1997;110:221.

8. Appleby L, Hirst E, Marshall S, Keeling F, Brind J, Butterworth T, et al. The treatment of postnatal depression by health visitors: impact of brief training on skills and clinical practice. J Affect Disord 2003;77:261–6.

9. Austin MP, Frilingos M, Lumley J, Hadzi P, Roncolato W, Acland S, et al. Brief antenatal cognitive behaviour therapy group intervention for the prevention of postnatal depression and anxiety: A randomised controlled trial. J Affect Disord 2008;105:35–44.

10. Ayers S, Kenzie-McHarg K, Eagle A. Cognitive behaviour therapy for postnatal post-traumatic stress disorder: case studies. J Psychosom Obstet Gynaecol 2007;28:177–84.

11. Berchtold N, Burrough M. Reaching out: depression after delivery support group network. NAACOGS Clin Issu Perinat Womens Health Nurs 1990;1:385–94.

12. Bledsoe S, Grote N. Treating Depression During Pregnancy and the Postpartum: A Preliminary Meta-Analysis. Res Soc Work Pract 2006;16:109–20.

13. Boath E, Cox J, Lewis M, Jones P, Pryce A. When the cradle falls: The treatment of postnatal depression in a psychiatric day hospital compared with routine primary care. J Affect Disord 1999;53:143–51.

14. Boath E, Henshaw C. The treatment of postnatal depression: A comprehensive literature review. J Reprod Infant Psychol 2001;19:215–48.

15. Boath E, Major K, Cox J. When the cradle falls II: The cost-effectiveness of treating postnatal depression in a psychiatric day hospital compared with routine primary care. J Affect Disord 2003;74:159–66.

16. Brugha T, Sharp HM, Cooper SA, Weisender C, Britto D, Shinkwin R, et al. The Leicester 500 Project. Social support systems and the development of postnatal depressive symptoms, a prospective cohort survey. Psychol Med 1998;28:63–79.

17. Brugha TSW. Pragmatic randomized trial of antenatal intervention to prevent post-natal depression by reducing psychosocial risk factors. Psychol Med 2000;30:1273–81.

18. Buist A, Westley D, Hill C. Antenatal prevention of postnatal depression. Arch Womens Ment Health 1999;1:167–73.

19. Buist A, Speelman C, Hayes B, Reay R, Milgrom J, Meyer D, et al. Impact of education on women with perinatal depression. J Psychosom Obstet Gynaecol 2007;28:49–54.

20. Camdeviren HA, Yazici AC, Akkus Z, Bugdayci R, Sungur MA. Comparison of logistic regression model and classification tree: An application to postpartum depression data. Expert Syst Appl 2007;32:987–94.

21. Carroll J, Reid A, Biringer A, Midmer D, Glazier R, Wilson L, et al. Effectiveness of the Antenatal Psychosocial Health Assessment (ALPHA) form in detecting psychosocial concerns: A randomized controlled trial. Can Med Assoc J 2005;173:253–9.

22. Casiano ME. Outpatient medical management of postpartum psychiatric disorders. NAACOGS Clin Issu Perinat Womens Health Nurs 1990;1:395–401.

23. Chung P, Yue X. Postpartum depression and social support: A comparative study in Hong Kong. Psychologia 1999;42:111–21.

24. Chun L-Q, Bo X, Wen J-X. A controlled clinical trial of citalopram and citalopram combined with psychotherapy in the treatment of postpartum depression. Chinese Mental Health Journal 2005;19:847–8.

25. Cooper P, Murray L. The impact of psychological treatments of postpartum depression on maternal mood and infant development. New York, NY: Guilford Press; 1997. pp. 201–20.

26. Cooper PJ, Murray L, Wilson A, Romaniuk H. Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression. I. Impact on maternal mood. Br J Psychiatry 2003;182:412–19.

27. Corral M, Wardrop AA, Zhang H, Grewal AK, Patton S. Morning light therapy for postpartum depression. Arch Womens Ment Health 2007;10:221–4.

28. Creedy D. Postnatal depression: improving the experience of country women through professional and community awareness. Aust J Rural Health 1993;1:43–9.

29. Cuijpers P, Brannmark JG, Van SA. Psychological treatment of postpartum depression: a meta-analysis. J Clin Psychol 2008;64:103–18.

30. Currie J, Boxer E, Devlin E. Pramwalking as postnatal exercise and support: an evaluation of the Stroll Your Way To Well-Being program and supporting resources in terms of individual participation rates and community group formation. Aust J Midwifery 2001;14:21–5. [Erratum published in Aust J Midwifery 2001;14:5.]

31. Dennis CL. The effect of peer support on postpartum depression: a pilot randomized controlled trial. Can J Psychiatry 2003;48:115–24.

32. Dennis CL. Preventing postpartum depression part I: a review of biological interventions. Can J Psychiatry 2004;49:467–75.

33. Dennis C. Counselling and cognitive behavioural therapy reduce anxiety and depression in women with postnatal depression. Evid Based Ment Health 2006;9:50.

34. Elliott S, Sanjack M, Leverton T. Parents groups in pregnancy: A preventive intervention for postnatal depression? In Gottlieb B, editor. Marshalling social support: formats, processes and effects. London: Sage; 1988. pp. 86–110.

35. Elliott S, Leverton T, Sanjack M, Turner H, Cowmeadow P, Hopkins J, et al. Promoting mental health after childbirth: A controlled trial of primary prevention of postnatal depression. Br J Clin Psychol 2000;39:223–41.

36. Escobar GJ, Braveman PA, Ackerson L, Odouli R, Coleman-Phox K, Capra AM, et al. A randomized comparison of home visits and hospital-based group follow-up visits after early postpartum discharge. Pediatrics 2001;108:719–27.

37. Fairchild M. Women with postpartum psychiatric illness: A professionally facilitated support group. Soc Work Groups 1995;18:41–53.

38. Field T, Grizzle N, Scafidi F, Schanberg S. Massage and relaxation therapies’ effects on depressed adolescent mothers. Adolescence 1996;31:903–11.

39. Flynn H, Mahen H, Massey L, Marcus S. The impact of a brief obstetrics clinic-based intervention on treatment use for perinatal depression. J Womens Health 2006;15:1195–204.

40. Fones C. A postpartum support group. Birth 1984;11:244.

41. Free ML, Oei TPS, Sanders MR. Treatment outcome of a group cognitive therapy program for depression. Int J Group Psychother 1991;41:533–47.

42. Gjerdingen D, Katon W, Rich DE. Stepped care treatment of postpartum depression a primary care-based management model. Womens Health Issues 2008;18:44–52.

43. Grote N, Bledsoe S, Swartz H, Frank E. Feasibility of providing culturally relevant, brief interpersonal psychotherapy for antenatal depression in an obstetrics clinic: A pilot study. Res Soc Work Pract 2004;14:397–407.

44. Grote N, Bledsoe S, Swartz H, Frank E. Culturally relevant psychotherapy for perinatal depression in low-income ob/gyn patients. Clin Soc Work J 2004;32:327–47.

45. Gruen D. A group psychotherapy approach to postpartum depression. Int J Group Psychother 1993;43:191–203.

46. Gutteridge K. Postnatal depression -- an integrative psychotherapeutic group approach. MIDIRS Midwifery Digest 2002;12:85–8.

47. Hagan RE. Preventing postnatal depression in mothers of very preterm infants: A randomised controlled trial. BJOG 2004;111:641–7.

48. Halonen J, Passman R. Relaxation training and expectation in the treatment of postpartum distress. J Consult Clin Psychol 1985;53:839–45.

49. Hayes B, Muller R, Bradley B. Perinatal depression: A randomized controlled trial of an antenatal education intervention for primiparas. Birth 2001;28:28–35.

50. Hayes B, Muller R. Prenatal depression: A randomized controlled trial in the emotional health of primiparous women. Res Theory Nurs Pract 2004;18:165–83.

51. Heh SS, Fu YY. Effectiveness of informational support in reducing the severity of postnatal depression in Taiwan. J Adv Nurs 2003;42:30–6.

52. Holden JMS. Counselling in a general practice setting: Controlled study of heath visitor intervention in treatment of postnatal depression. BMJ 1989;298:223–6.

53. Honikman J. Role of self-help techniques for postpartum mood disorders. Washington, DC, US: American Psychiatric Association; 1999. pp. 195–215.

54. Horowitz JA, Cousins A. Postpartum depression treatment rates for at-risk women. Nurs Res 2006;55(Suppl. 2):S23–S27.

55. Hynd S, Khan S. Identity and the experience of postnatal depression: The use of Video Interaction Guidance. J Psychiatr Ment Health Nurs 2004;11:738–41.

56. Johnston D, Tough S, Siever J. The Community Perinatal Care Study: home visiting and nursing support for pregnant women. Zero Three 2006;27:11–17.

57. Jung V, Short R, Letourneau N, Andrews D. Interventions with depressed mothers and their infants: Modifying interactive behaviours. J Affect Disord 2007;98:199–205.

58. Kersting A, Kuschel S, Reutemann M, Ohrmann P, Arolt V. Outpatient psychotherapy for mothers--first empirical results. Psychiatry 2003;66:335–45.

59. Klier CM, Muzik M, Rosenblum K, Lenz G. Interpersonal psychotherapy adapted for the group setting in the treatment of postpartum depression: A pilot study. Infant Ment Health J 2000;21:381.

60. Kopelman R, Stuart S. Psychological treatments for postpartum depression. Psychiatr Ann 2005;35:556–66.

61. Lane B, Roufeil L, Williams S, Tweedie R. It’s just different in the country: Postnatal depression and group therapy in a rural setting. Soc Work Health Care 2001;34:333–48.

62. Lau Y. Establishing an interpersonal group therapy program for Chinese women with postnatal depression in Hong Kong. Hong Kong Nurs J 2005;41:7–17.

63. Lee D. Partner support reduced depressive symptoms in postpartum depression. Evid Based Ment Health 2001;4:51.

64. Lembke A. A psychosocial approach to postpartum depression. Psychiatr Times 2002;19:(6).

65. Lockhart K. Karitane mothers’ post partum support group. Lamp 1988;45:11–12.

66. Loendersloot EWH. Management of post-partum depression (PPD) in a special PPD clinic. J Psychosom Obstet Gynaecol 1983;2:53–6.

67. Magalhaes PV, Pinheiro RT, Faria AD, Osorio CM, da Silva RA, Botella L. Impact of defense style on brief psychotherapy of postpartum depression. J Nerv Ment Dis 2007;195:870–3.

68. Maley B. Focusing on you: professional & personal direction. Out of the blue: creating a postpartum depression support group. AWHONN Lifelines 2002;6:62–5.

69. Markou P. Psychotherapeutic support group for the partners of women with post natal depression. Aust NZ J Psychiatry 1999;33:A19.

70. Matthey S. Calculating clinically significant change in postnatal depression studies using the Edinburgh Postnatal Depression Scale. J Affect Disord 2004;78:269–72.

71. McClendon JM. Reexamining paroxetine and cognitive-behavioral therapy in postpartum depression and anxiety. J Clin Psychiatry 2005;66:1494–5.

72. Milgrom J, Negri L, Meager I. Group treatment for post-partum depression. Int J Psychol 1996;31:1203.

73. Milgrom J, Martin PR, Negri LM. A randomized trial of psychological treatments for postnatal depression in Australia objective. J Psychosom Res 2003;55:119–20.

74. Milgrom J, Negri L, McNeil M, Martin P. A randomized trial of psychological treatments for postnatal depression. Int J Psychol 2004;39:509.

75. Miller P, Chilvers C, Dewey M, Fielding K, Gretton V, Palmer B, et al. Counseling versus antidepressant therapy for the treatment of mild to moderate depression in primary care: economic analysis. Int J Technol Assess Health Care 2003;19:80–90.

76. Misri S, Kostaras X, Fox D, Kostaras D. The impact of partner support in the treatment of postpartum depression. Can J Psychiatry 2000;45:554–8.

77. Misri S, Reebye P, Corral M, Milis L. The use of paroxetine and cognitive-behavioral therapy in postpartum depression and anxiety: a randomized controlled trial. J Clin Psychiatry 2004;65:1236–41.

78. Misri S, Reebye P, Milis L, Shah S. The Impact of treatment intervention on parenting stress in postpartum depressed mothers: A prospective study. Am J Orthopsychiatry 2006;76:115–19.

79. Morrell CJ, Spiby H, Stewart P, Walters S, Morgan A. Costs and effectiveness of community postnatal support workers: randomised controlled trial. BMJ 2000;321:593–8.

80. Morris JB. Group psychotherapy for prolonged postnatal depression. Br J Med Psychol 1987;60:279–81.

81. Murray L, Cooper PJ, Wilson A, Romaniuk H. Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression: 2. Impact on the mother–child relationship and child outcome. Br J Psychiatry 2003;182:420–7.

82. O’Brien LM, Boath E, Hodgson R, Cox JL. The long-term follow-up of women treated for postnatal depression at a specialist day hospital compared to routine primary care. Int J Psychiatry Clin Pract 2002;6:199–203.

83. O’Hara MW, Rehm LP, Campbell SB. Predicting depressive symptomatology: cognitive-behavioral models and postpartum depression. J Abnorm Psychol 1982;91:457–61.

84. O’Hara MW. Interpersonal psychotherapy for postpartum depression. Womens Health Issues 1995;5:75–6.

85. O’Hara MWS. Efficacy of interpersonal psychotherapy for postpartum depression. Arch Gen Psychiatry 2000;57:1039–45.

86. Olson MR, Cutler LA, Legault F. Bittersweet: a postpartum depression support group. Can J Public Health 1991;82:135–6.

87. Pedrina F, Scmid T. Group therapy with mothers and babies in postpartum crises: preliminary evaluation of a pilot project. Group Analysis 2004;37:137–51.

88. Prendergast J, Austin M. Early childhood nurse-delivered cognitive behavioural counselling for post-natal depression. Australas Psychiatry 2001;9:255–9.

89. Reay R, Robertson M, Owen C. Interpersonal psychotherapy for postnatal depression: A quality improvement approach. Australas Psychiatry 2002;10:211–13.

90. Rees BL. Effect of relaxation with guided imagery on anxiety, depression, and self-esteem in primiparas. J Holist Nurs 1995;13:255–67.

91. Reid M, Glazener C, Connery L, Mackenzie J, Ismail D, Prigg A, et al. Two interventions for postnatal support. Br J Midwifery 2003;11:294–8.

92. Reid MG. A two-centred pragmatic randomised controlled trial of two interventions of postnatal support. BJOG 2002;109:1164–70.

93. Ryding E, Wirén E, Johansson G, Ceder B, Dahlström A. Group counseling for mothers after emergency cesarean section: A randomized controlled trial of intervention. Birth 2004;31:247–53.

94. Saltzberg M. A year’s experiences with a postpartum depression group. Group 2003;27:21–9.

95. Spinelli M. Interpersonal psychotherapy for depressed antepartum women: A pilot study. Am J Psychiatry 1997;154:1028–30.

96. Spinelli M. Interpersonal psychotherapy for antepartum depressed women. New York, NY, US: Oxford University Press; 2001. pp. 105–21.

97. Spinelli M, Endicott J. Controlled clinical trial of interpersonal psychotherapy versus parenting education program for depressed pregnant women. Am J Psychiatry 2003;160:555–62.

98. Stamp GE, Williams AS, Crowther CA. Evaluation of antenatal and postnatal support to overcome postnatal depression: a randomised controlled trial. Birth 1995;22:138–43.

99. Steinberg SI, Bellavance F. Characteristics and treatment of women with antenatal and postpartum depression. Int J Psychiatry Med 1999;29:209–33.

100. Stuart S, Ohara MW. Treatment of postpartum depression with interpersonal psychotherapy. Arch Gen Psychiatry 1995;52:75–6.

101. Stuart S, O’Hara M. Interpersonal psychotherapy for postpartum depression: A treatment program. J Psychother Pract Res 1995;4:18–29.

102. Stuart S, O’Hara M. The efficacy of psychotherapy for perinatal depression. Econ Neurosci 2001;3:46–51.

103. Tam WHL. A randomised controlled trial of educational counselling on the management of women who have suffered suboptimal outcomes in pregnancy. BJOG 2003;110:853–9.

104. Tam WH, Lee D-T, Chiu H-F, Ma KC, Lee A, Chung T-K, et al. Educational counselling did not improve psychological wellbeing in women with suboptimal childbirth outcomes. Evid Base Obstet Gynecol 2004;6:173–4.

105. Tezel A, Gözüm S. Comparison of effects of nursing care to problem solving training on levels of depressive symptoms in post partum women. Patient Educ Couns 2006;63:64–73.

106. Thoppil J, Riutcel TL, Nalesnik SW. Early intervention for perinatal depression. Am J Obstet Gynecol 2005;192:1446–8.

107. Ugarriza D. Group therapy and its barriers for women suffering from postpartum depression. Arch Psychiatr Nurs 2004;18:39–48.

108. Ugarriza DN, Schmidt L. Telecare for women with postpartum depression. J Psychosoc Nurs Ment Health Serv 2006;44:37–45.

109. Webster J, Linnane J, Roberts J, Starrenburg S, Hinson J, Dibley L. IDentify, Educate and Alert (IDEA) trial: an intervention to reduce postnatal depression. BJOG 2003;110:842–6.

110. Wickberg B, Hwang CP. Counselling of postnatal depression: a controlled study on a population based Swedish sample. J Affect Disord 1996;39:209–16.

111. Wiggins MO. Postnatal support for mothers living in disadvantaged inner city areas: A randomised controlled trial. J Epidemiol Community Health 2005;59:288–95.

112. Wilkinson J, Phillips S, Jackson J, Walker K. “Mad for fitness”: an exercise group to combat a high incidence of postnatal depression. J Fam Health Care 2003;13:44–8.

113. Wheatley SL, Brugha TS, Shapiro DA, Berryman JC. PATA PATA: midwives’ experiences of facilitating a psychological intervention to identify and treat mild to moderate antenatal and postnatal depression… Positive Attitude Towards Antenatal and Postnatal Adjustment, Training for All. MIDIRS Midwifery Digest 2003;13:523–30.

114. Zayas L, McKee M, Jankowski K. Adapting psychosocial intervention research to urban primary care environments: A case example. Ann Fam Med 2004;2:504–8.

115. Zlotnick C, Johnson SL, Miller IW, Pearlstein T, Howard M. Postpartum depression in women receiving public assistance: pilot study of an interpersonal-therapy-oriented group intervention. Am J Psychiatry 2001;158:638–40.

116. Zlotnick C, Miller I, Pearlstein T, Howard M, Sweeney P. A preventive intervention for pregnant women on public assistance at risk for postpartum depression. Am J Psychiatry 2006;163:1443–5.

References for Table 50

1. Alder E, Truman J. Counselling for postnatal depression in the voluntary sector. Psychology and Psychotherapy: Theory 2002;75:207–20.

2. Armstrong K, Edwards H. The effectiveness of a pram-walking exercise programme in reducing depressive symptomatology for postnatal women. Int J Nurs Pract 2004;10:177–94.

3. Armstrong K, Edwards H. The effects of exercise and social support on mothers reporting depressive symptoms: A pilot randomized controlled trial. Int J Ment Health Nurs 2003;12:130–8.

4. Chen C, Tseng Y, Chou F, Wang S. Effects of support group intervention in postnatally distressed women: A controlled study in Taiwan. J Psychosom Res 2000;49:395–9.

5. Davies S, Jasper M. A first-stage evaluation of a group programme for PND. Community Pract 2004;77:426–33.

6. Eastwood P. Group work 1. Promoting peer group support with postnatally depressed women. Health Visit 1995;68:148–50.

7. Fleming AS, Klein E, Corter C. The effects of a social support group on depression, maternal attitudes and behavior in new mothers. J Child Psychol Psychiatry 1992;33:685–98.

8. Harner KT. Effectiveness of professionally led postpartum support groups among depressed postpartum women. Fresno, CA: Alliant International University; 2004.

9. Klier C, Muzik M, Rosenblum K, Lenz G. Interpersonal psychotherapy adapted for the group setting in the treatment of postpartum depression. J Psychother Pract Res 2001;10:124–31.

10. Kurzweil S. Relational-developmental therapy group for postnatal depression. Int J Group Psychother 2008;58:17–34.

11. MacInnes A. Findings of a community-based group for women with PND. Community Pract 2000;73:754–6.

12. May A. Group work 2. Using exercise to tackle postnatal depression. Health Visit 1995;68:146–7.

13. Morgan M, Matthey S, Barnett B, Richardson C. A group programme for postnatally distressed women and their partners. J Adv Nurs 1997;26:913–20.

14. Okano T, Nomura J, Kumar R, Kaneko E, Tamaki R, Hanafusa I, et al. An epidemiological and clinical investigation of postpartum psychiatric illness in Japanese mothers. J Affect Disord 1998;48:233–40.

15. Onozawa K, Kumar RC, Adams D, Doré C, Glover V. High EPDS scores in women from ethnic minorities living in London. Arch Womens Ment Health 2003;6(Suppl. 2):s51–s55.

16. Pitts F. Professional. Health visiting: the Monday group: postnatal depression revisited. Community Pract 1999;72:327–9.

17. Reay R, Fisher Y, Robertson M, Adams E, Owen C. Group interpersonal psychotherapy for postnatal depression: A pilot study. Arch Womens Ment Health 2006;9:31–9.

References for Table 52

1. Ahmad T, Suleiman R, Shougah D. Mixed anxiety depression in pregnancy: (The influence of misconceptions). Arab Journal of Psychiatry 1994;5:103–13.

2. Albertsson-Karlgren U, Graff M, Nettelbladt P. Mental disease postpartum and parent–infant interaction – Evaluation of videotaped sessions. Child Abuse Review 2001;10:5–17.

3. Amankwaa L. Enduring: A grounded theory investigation of postpartum depression among African-American women. Dissertation Abstracts International: Section B: The Sciences and Engineering 2000;61:1317.

4. Amankwaa L. Postpartum depression among African-American women. Issues Ment Health Nurs 2003;24:297–316.

5. Andajani-Sutjahjo, Manderson L, Astbury J. Complex emotions, complex problems: Understanding the experiences of perinatal depression among new mothers in urban Indonesia. Culture 2007;31:101–22.

6. Arborelius EU, Bremberg SG. Supportive and nonsupportive qualities of child health nurses’ contacts with strained infant mothers. Scand J Caring Sci 2003;17:169–75.

7. Bågedahl-Strindlund. Parapartum mental illness: An interview follow-up study. Acta Psychiatr Scand 1997;95:389–95.

8. Baker S, Choi P, Henshaw C, Tree J. ‘I Felt as though I’d been in Jail’: Women’s experiences of maternity care during labour, delivery and the immediate postpartum. Fem Psychol 2005;15:315–42.

9. Beck C. The lived experience of postpartum depression: A phenomenological study. Nurs Res 1992;41:166–70.

10. Beck CT. Perceptions of nurses’ caring by mothers experiencing postpartum depression. J Obstet Gynecol Neonatal Nurs 1995;24:819–25.

11. Beck CT. Postpartum onset of panic disorder. Image J Nurs Sch 1998;30:131–5.

12. Bennett D, Slade P. Infants born at risk: Consequences for maternal post-partum adjustment. Br J Med Psychol 1991;64:159–72.

13. Benoit C, Westfall R, Treloar A, Phillips R, Jansson SM. Social factors linked to postpartum depression: A mixed-methods longitudinal study. J Ment Health 2007;16:710–30.

14. Benvenuti P, Valoriani V, Degl I, Favini I, Hipwell A, Pazzagli A. Postnatal depression and the impact on infant-carer attachment strategies: A case report. Arch Womens Ment Health 2001;3:155–64.

15. Berggren C. Out of the darkness and into the light: Women’s experiences with depression after childbirth. Can J Commun Ment Health 1998;17:103–20.

16. Brown W, Shereshefsky P. Seven women: A prospective study of postpartum psychiatric disorders. Psychiatry 1972;35:139–59.

17. Buchwald J, Unterman R. Precursors and predictors of postpartum depression: A retrospective study. J Prev Psychiatry 1982;1:293–308.

18. Buultjens M, Liamputtong P. When giving life starts to take the life out of you: women’s experiences of depression after childbirth. Midwifery 2007;23:77–91.

19. Campbell SB, Cohn JF, Meyers T. Depression in first-time mothers – mother-infant interaction and depression chronicity. Dev Psychol 1995;31:349–57.

20. Campbell S, Cohn J. The timing and chronicity of postpartum depression: Implications for infant development. In: Murray L, Cooper P, editors. Postpartum depression and child development. New York, NY: Guildford; 1997. pp. 165–97.

21. Chan SW, Levy V, Chung TK, Lee D. A qualitative study of the experiences of a group of Hong Kong Chinese women diagnosed with postnatal depression. J Adv Nurs 2002;39:571–9.

22. Chen CH, Wu HY, Tseng YF, Chou FH, Wang SY. Psychosocial aspects of Taiwanese postpartum depression phenomenological approach: a preliminary report. Kaohsiung J Med Sci 1999;15:44–51.

23. Chen C, Wang S, Chung U, Tseng Y, Chou F. Being reborn: the recovery process of postpartum depression in Taiwanese women. Jan J Adv Nurs 2006;54:450–6.

24. Clemmens DA. Adolescent mothers’ depression after the birth of their babies: weathering the storm. Adolescence 2002;37:551–65.

25. Creedy D. Postnatal depression and post traumatic stress disorder: what are the links? Birth Issues 1999;8:125–30.

26. Cubison J, Munro J. Acceptability of Using the EPDS as a Screening Tool for Postnatal Depression. Psychology: Professional & Research Language. London: Jessica Kingsley Publishers; 2005. pp. 152–161.

27. Edge D, Baker D, Rogers A. Perinatal depression among black Caribbean women. Health Soc Care Community 2004;12:430–8.

28. Edge D. Perinatal depression: its absence among Black Caribbean women. Br J Midwifery 2006;14:646–50, 652.

29. Edwards E, Timmons S. A qualitative study of stigma among women suffering postnatal illness. J Ment Health 2005;14:471–81.

30. Engqvist I, Nilsson A, Nilsson K, Sjostrom B. Strategies in caring for women with postpartum psychosis--an interview study with psychiatric nurses. J Clin Nurs 2007;16:1333–42.

31. Everingham CR, Heading G, Connor L. Couples’ experiences of postnatal depression: a framing analysis of cultural identity, gender and communication. Soc Sci Med 2006;62:1745–56.

32. Field T, Hernandez R, Feijo L. Breastfeeding in depressed mother-infant dyads. Early Child Dev Care 2002;172:539–45.

33. Fisher J, Astbury J, Smith A. Adverse psychological impact of operative obstetric interventions: a prospective longitudinal study. Aust N Z J Psychiatry 1997;31:728–38.

34. Fisher JR, Morrow MM, Ngoc NT, Anh LT. Prevalence, nature, severity and correlates of postpartum depressive symptoms in Vietnam. BJOG 2004;111:1353–60.

35. Fooladi MM. Therapeutic tears and postpartum blues. Holist Nurs Pract 2006;20:204–11.

36. Gaff-Smith M. The relationship between self-esteem, social support and postnatal depression in adolescent mothers in rural New South Wales. Birth Issues 2003;12:69–75.

37. Garel M, Dardennes M, Blondel B. Mothers’ psychological distress 1 year after very preterm childbirth. Results of the epipage qualitative study. Child Care Health Dev 2007;33:137–43.

38. Giovannini M. The relevance of gender in postpartum emotional disorders. 1992:209–31.

39. Hall P. Mothers’ experiences of postnatal depression: an interpretative phenomenological analysis. Community Pract 2006;79:256–60.

40. Hanley J, Long B. A study of Welsh mothers’ experiences of postnatal depression. Midwifery 2006;22:147–57.

41. Hanley J. The emotional wellbeing of Bangladeshi mothers during the postnatal period. Community Pract 2007;80:34–7.

42. Holopainen D. The experience of seeking help for postnatal depression. Aus J Adv Nurs 2002;19:39–44.

43. Horowitz JA, Chang SS, Das S, Hayes B. Women’s perceptions of postpartum depressive symptoms from an international perspective. International Nursing Perspectives 2001;1:5–14.

44. Kane H. Emotion work, labeling, and gender in post-partum and post-adoptive depression. Dissertation Abstracts International Section A: Humanities and Social Sciences 2006;67:3996.

45. Kazi A, Fatmi Z, Hatcher J, Kadir MM, Niaz U, Wasserman GA. Social environment and depression among pregnant women in urban areas of Pakistan: Importance of social relations. Soc Sci Med 2006;63:1466–76.

46. Ketler S. Separating mothering and motherhood: Women’s changing maternity experiences and the normalization of postpartum depression in Cagliari, Italy, 1943–1994. Dissertation Abstracts International Section A: Humanities and Social Sciences 1997;58:4327.

47. Kim H, Bracha Y, Tipnis A. Automated depression screening in disadvantaged pregnant women in an urban obstetric clinic. Arch Womens Ment Health 2007;10:163–9.

48. Lauer W. Postpartum depression: A phenomenological exploration of the woman’s experience. Dissertation Abstracts International: Section B: The Sciences and Engineering 2001;62:2064.

49. Lawler D, Sinclair M. Grieving for my former self: a phenomenological hermeneutical study of women’s lived experience of postnatal depression. Evidence Based Midwifery 2003;1:36–41.

50. Lesser J. From childhood maltreatment to motherhood: An exploration of the triad of childhood abuse, depression, and maternal role attainment in adolescent mothers. Dissertation Abstracts International: Section B: The Sciences and Engineering 1997;58:5329.

51. Letourneau N, Duffett-Leger L, Stewart M, Hegadoren K, Dennis CL, Rinaldi CM, et al. Canadian mothers’ perceived support needs during postpartum depression. J Obstet Gynecol Neonatal Nurs 2007;36:441–9.

52. Leung E. Family support and postnatal emotional adjustment. Bulletin of the Hong Kong Psychological Society 1985;14:32–46.

53. Leung S, Arthur DG, Martinson I. Stress in women with postpartum depression: a phenomenological study. J Adv Nurs 2005;51:353–60.

54. Lewis S, Nicolson P. Talking about early motherhood: Recognizing loss and reconstructing depression. J Reprod Infant Psychol 1998;16:177–97.

55. Luepker E. Joint admission and evaluation of postpartum psychiatric patients and their infants. Hosp Community Psychiatry 1972;23:284–7.

56. Maloney DM. Postnatal depression: a study of mothers in the metropolitan area of Perth, Western Australia. Aust Coll Midwives Inc J 1998;11:18–23.

57. Mauthner NS. Postnatal depression – the significance of social contacts between mothers. Womens Stud Int Forum 1995;18:311–23.

58. Mauthner NS. Postnatal depression: how can midwives help? Midwifery 1997;13:163–71.

59. Mauthner N. “Feeling low and feeling really bad about feeling low”: Women’s experiences of motherhood and postpartum depression. Can Psychol 1999;40:143–61.

60. Mauthner N. “It’s a woman’s cry for help”: A relational perspective on postnatal depression. Fem Psychol 1998;8:325–55.

61. Mauthner N. Re-assessing the importance and role of the marital relationship in postnatal depression: Methodological and theoretical implications. J Reprod Infant Psychol 1998;16:157–75.

62. Mauthner N, Doucet A. Reflections on a voice-centred relational method: analysing maternal and domestic voices. In Ribbens J, Edwards R, editors. Feminist dilemas in qualitative research: private lives and public texts. London: Sage; 1998. pp. 119–44.

63. Mauthner N. Towards a feminist understanding of “postnatal depression”: I. Fem Psychol 1993;3:350–5.

64. Mayes L, Leckman J. Parental representations and subclinical changes in postpartum mood. Infant Ment Health J 2007;28:281–95.

65. Nahas V, Amasheh N. Culture care meanings and experiences of postpartum depression among Jordanian Australian women: a transcultural study. J Transcult Nurs 1999;10:37–45.

66. Nahas VL, Hillege S, Amasheh N. Postpartum depression. The lived experiences of Middle Eastern migrant women in Australia. J Nurse Midwifery 1999;44:65–74.

67. Nicolson P. Counselling women with post natal depression: Implications from recent qualitative research. Couns Psychol Q 1989;2:123–32.

68. Nicolson P. Loss, happiness and postpartum depression: The ultimate paradox. Can Psychol 1999;40:162–78.

69. O’Hara MW, Rehm LP, Campbell SB. Postpartum depression. A role for social network and life stress variables. J Nerv Ment Dis 1983;171:336–41.

70. Oates MR, Cox JL, Neema S, Asten P, Glangeaud F, Figueiredo B, et al. Postnatal depression across countries and cultures: A qualitative study. Br J Psychiatry 2004;184:s10–s16.

71. Olshansky E. A theoretical explanation for previously infertile mothers’ vulnerability to depression. J Nurs Scholarsh 2003;35:263–8.

72. Parvin A, Jones CE, Hull SA. Experiences and understandings of social and emotional distress in the postnatal period among Bangladeshi women living in Tower Hamlets. Fam Pract 2004;21:254–60.

73. Phillips L. Behavior analysis in a case of “post-partum depression”. J Behav Ther Exp Psychiatry 1986;17:101–4.

74. Poole H, Mason L, Osborn T. Women’s views of being screened for postnatal depression. Community Pract 2006;79:363–7.

75. Regev M. The experience of postpartum depression: A grounded theory study. Dissertation Abstracts International Section A: Humanities and Social Sciences 2003;63:2801.

76. Regmi S, Sligl W, Carter D, Grut W, Seear M. A controlled study of postpartum depression among Nepalese women: validation of the Edinburgh Postpartum Depression Scale in Kathmandu. Trop Med Int Health 2002;7:378–82.

77. Rodrigues M, Patel V, Jaswal S, de Souza N. Listening to mothers: Qualitative studies on motherhood and depression from Goa, India. Soc Sci Med 2003;57:1797–806.

78. Ross LE, Steele L, Sapiro B. Perceptions of predisposing and protective factors for perinatal depression in same-sex parents. J Midwifery Womens Health 2005;50:e65–e70.

79. Roux G, Anderson C, Roan C. Postpartum depression, marital dysfunction, and infant outcome: a longitudinal study. J Perinat Educ 2002;11:25–36.

80. Scott D. Early identification of maternal depression as a strategy in the prevention of child abuse. Child Abuse Negl 1992;16:345–58.

81. Scrandis D. Normalizing postpartum depressive symptoms with social support. J Am Psychiatr Nurses Assoc 2005;11:223–30.

82. Setse R, Grogan R, Cooper LA, Strobino D, Powe NR, Nicholson W. Weight loss programs for urban-based, postpartum African-American women: perceived barriers and preferred components. Matern Child Health J 2008;12:119–27.

83. Shakespeare J. Health visitor screening for PND using the EPDS: a process study. Community Pract 2002;75:381–4.

84. Shakespeare J, Blake F, Garcia J. A qualitative study of the acceptability of routine screening of postnatal women using the Edinburgh Postnatal Depression Scale. Br J Gen Pract 2003;53:614–19.

85. Shakespeare J, Blake F, Garcia J. Breast-feeding difficulties experienced by women taking part in a qualitative interview study of postnatal depression. Midwifery 2004;20:251–60.

86. Shakespeare J, Blake F, Garcia J. How do women with postnatal depression experience listening visits in primary care? A qualitative interview study. J Reprod Infant Psychol 2006;24:149–62.

87. Shanok AF, Miller L. Depression and treatment with inner city pregnant and parenting teens. Arch Womens Ment Health 2007;10:199–210.

88. Sleath B, West S, Tudor G, Perreira K, King V, Morrissey J. Ethnicity and prenatal depression: women’s experiences and perspectives on communicating about their emotions and feelings during pregnancy. Patient Educ Couns 2005;58:35–40.

89. Small R, Johnston V, Orr A. Depression after childbirth: the views of medical students and women compared. Birth 1997;24:109–15.

90. Steinfeld G. Brief therapy with a postpartum depressive: Integrating cognitive behavior and thought field therapies within a spiritual framework. J Psychother Integr 1999;9:337–63.

91. Stewart S, Jambunathan J. Hmong women and postpartum depression. Health Care Women Int 1996;17:319–30.

92. Tammentie T, Paavilainen E, stedt-Kurki P, Tarkka MT. Family dynamics of postnatally depressed mothers – discrepancy between expectations and reality. J Clin Nurs 2004;13:65–74.

93. Templeton L, Velleman R, Persaud A, Milner P. The experiences of postnatal depression in women from black and minority ethnic communities in Wiltshire, UK. Ethn Health 2003;8:207–21.

94. Thomas H. Women’s postnatal experience following a medically complicated pregnancy. Health Care Women Int 2004;25:76–87.

95. Thurtle V. First time mothers’ perceptions of motherhood and PND. Community Pract 2003;76:261–5.

96. Uddenberg N, Englesson I. Prognosis of post partum mental disturbance: A prospective study of primiparous women and their 4-year-old children. Acta Psychiatr Scand 1978;58:201–12.

97. Ugarriza DN, Brown SE, Chang-Martinez C. Anglo-American mothers and the prevention of postpartum depression. Issues Ment Health Nurs 2007;28:781–98.

98. Ward C. Migrant mothers and the role of social support when child rearing. Contemp Nurse 2003;16:74–82.

99. Wheatley SL, Brugha TS. ‘Just because I like it doesn’t mean it has to work’: personal experiences of an antenatal psychosocial intervention designed to prevent postnatal depression. International J Ment Health Promotion 1999;1:26–31.

100. White P. Heat, balance, humors, and ghosts: Postpartum in Cambodia. Health Care Women Int 2004;25:179–94.

101. Williamson V, McCutcheon H. Postnatal blues. Singapore Nursing Journal 2002;29:32–6.

102. Woollett A, Parr M. Psychological tasks for women and men in the post-partum. J Reprod Infant Psychol 1997;15:159–83.