Effectiveness of Treating Prenatal Depression to Reduce Postpartum Depression

描述（由申请人提供）：产后抑郁症（PPD）困扰约10-15%的孕妇。怀孕期间的抑郁症是PPD的最大风险因素。然而，目前，关于在怀孕期间治疗抑郁症是否可以降低PPD的风险存在很大的困惑。我们的初步研究表明，治疗产前抑郁症可能会降低PPD风险。为了进一步确定（1）产前抑郁本身是否会增加PPD的风险，因此应该进行治疗，（2）治疗是否有益，以及（3）哪种治疗对减少PPD最有效，我们建议在北方加州（KPNC）的Kaiser Permanente进行两阶段前瞻性队列研究。KPNC实施了一项独特的普遍围产期抑郁症筛查计划。所有孕妇（每年约33，000人）在怀孕期间和产后使用患者健康问卷（PHQ-9）进行两次抑郁症筛查。在研究期间，12万名接受抑郁症筛查的孕妇将被纳入围产期抑郁症筛查登记处。使用所有120，000名女性的抑郁状态和治疗选择信息（第一阶段样本），将形成五个队列：（A）“未治疗队列”：妊娠期间抑郁症筛查阳性但未接受治疗的那些;（B）“心理治疗队列”：筛查阳性且仅接受心理治疗;（C）“抗抑郁队列”：筛查阳性且仅使用抗抑郁药;（D）“组合治疗组群”：筛查阳性并且使用心理疗法和抗抑郁药两者;和（E）“对照组群”：筛查阴性抑郁并且不接受任何治疗。在第二阶段的子样本中，我们将从五个队列（共2，000名女性）中随机选择400名受试者，并亲自访问他们，以获得有关混杂因素和效应修正因素的详细信息，以便进行调整。队列A与队列E的比较将确定未经治疗的妊娠期抑郁症是否会增加PPD的风险。队列B、C和D分别与队列A的比较将确定抑郁症治疗的有效性。队列B、C和D之间的成对比较将确定各种治疗方案（包括心理治疗、抗抑郁药和联合治疗）的比较有效性。多元线性回归分析将用于检查从怀孕期间到怀孕后改善抑郁状态的治疗有效性，其中比较产前和产后期间PHQ-9评分的人内变化。将使用逻辑回归分析来检查降低PPD风险的治疗有效性，其中比较所有治疗组之间的PPD风险（二分变量）。这些发现将为迫切的临床问题提供答案，即是否应该治疗妊娠期抑郁症，如果是，哪种选择是减少PPD的最佳选择。选择一种有效的治疗方法可以减少PPD，这仍然是全球主要的公共卫生挑战。已建立的登记处可能是许多未来研究抑郁症对孕产妇健康和儿童发育的长期影响的宝贵资源。 公共卫生相关性：这项拟议的研究将确定在怀孕期间治疗抑郁症是否会降低产后抑郁症的风险或严重程度，如果是这样，哪种治疗方案（心理治疗或抗抑郁药）在减少产后抑郁症方面更有效。

DESCRIPTION (provided by applicant): Postpartum depression (PPD) afflicts about 10-15% of pregnant women. Depression during pregnancy is the strongest risk factor for PPD. However, currently, significant confusion exists about whether treating depression during pregnancy could reduce the risk of PPD. Our preliminary studies suggest that treating prenatal depression may reduce PPD risk. To further determine (1) if prenatal depression itself increases the risk of PPD, thus should be treated, (2) if treatment is beneficial, and (3) which treatment is most effective i reducing PPD, we propose to conduct a two-stage prospective cohort study in Kaiser Permanente Northern California (KPNC). KPNC has implemented a unique universal peripartum depression screening program. All pregnant women (about 33,000 annually) are screened for depression twice during pregnancy and once postpartum using the Patient Health Questionnaire (PHQ-9). During the study period, 120,000 pregnant women who are screened for depression will be included in a peripartum depression screening registry. Using the information on depression status and treatment choices from all 120,000 women (stage-one sample), five cohorts will be formed: (A) "Untreated cohort": those who screen positive for depression during pregnancy, but do not receive treatment; (B) " Psychotherapy cohort": screen positive and receive psychotherapy only; (C) "Antidepressant cohort": screen positive and use antidepressants only; (D) "Combination treatments cohort": screen positive and use both psychotherapy and antidepressants; and (E) "Control cohort": screen negative for depression and do not receive any treatments. For the stage-two sub-sample, we will randomly select 400 subjects from each of the five cohorts (a total of 2,000 women) and interview them in-person to obtain detailed information on confounders and effect modifiers for adjustment. Comparison of Cohort A versus Cohort E will determine if untreated depression in pregnancy increases the risk of PPD. Comparisons of Cohorts B, C, and D to Cohort A, respectively, will determine the effectiveness of depression treatment. Pair-wise comparisons among Cohorts B, C, and D will determine the comparative effectiveness of various treatment options including psychotherapy, anti-depressants, and combination therapies. Multiple linear regression analyses will be used to examine the treatment effectiveness in improving depression status from during to after pregnancy where within person change in PHQ-9 scores between prenatal and postpartum periods are compared. Logistic regression analyses will be used to examine the treatment effectiveness in reducing PPD risk where PPD risk (a dichotomized variable) is compared among all treatment groups. The findings will provide answers to pressing clinical questions of whether depression in pregnancy should be treated and, if so, which option is the best for reducing PPD. Selecting an effective treatment could lead to a reduction in PPD which remains a leading public health challenge worldwide. The established registry could be a valuable resource for many future studies of long-term effects of depression on maternal health and children's development. PUBLIC HEALTH RELEVANCE: The proposed study will determine whether treating depression during pregnancy would reduce the risk or severity of postparturm depression, and, if so, which treatment option (psychotherapy or antidepressants) is more effective in reducing postpartum depression.