Effectiveness of Treating Prenatal Depression to Reduce Postpartum Depression

描述（由申请人提供）：产后抑郁症（PPD）困扰着约10-15%的孕妇。怀孕期间的抑郁是PPD的最大危险因素。然而，目前对于在怀孕期间治疗抑郁症是否能降低产后抑郁症的风险存在很大的困惑。我们的初步研究表明，治疗产前抑郁可能会降低产后抑郁症的风险。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；(3)哪种治疗对减少PPD最有效，我们建议在Kaiser Permanente Northern California （KPNC）进行一项两阶段的前瞻性队列研究。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3.3万名）在怀孕期间和产后都要通过患者健康问卷（PHQ-9）进行两次抑郁症筛查。在研究期间，12万接受抑郁症筛查的孕妇将被纳入围产期抑郁症筛查登记。利用来自所有120,000名妇女（第一阶段样本）的抑郁症状况和治疗选择信息，将形成五个队列：(A)“未治疗队列”：在怀孕期间抑郁症筛查呈阳性但未接受治疗的人群；(B)“心理治疗组”：筛检阳性，只接受心理治疗；(C)“抗抑郁队列”：筛查呈阳性，仅使用抗抑郁药物；(D)“联合治疗队列”：筛检呈阳性，同时使用心理治疗和抗抑郁药；(E)“对照组”：抑郁症筛查呈阴性，未接受任何治疗。对于第二阶段的子样本，我们将从五个队列（共2000名女性）中随机选择400名受试者，并亲自采访他们，以获得有关混杂因素和效果修饰因子的详细信息以进行调整。队列A与队列E的比较将确定妊娠期未经治疗的抑郁症是否会增加PPD的风险。将B组、C组和D组分别与A组进行比较，将确定抑郁症治疗的有效性。B、C和D组的两两比较将确定各种治疗方案的比较效果，包括心理治疗、抗抑郁药和联合治疗。多元线性回归分析将用于检查治疗效果，改善抑郁状态，从怀孕期间和怀孕后，PHQ-9评分的个人变化产前和产后期间进行比较。逻辑回归分析将用于检查治疗在降低PPD风险方面的有效性，其中PPD风险（二分类变量）在所有治疗组之间进行比较。这一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，如果应该治疗，哪种选择对减少产后抑郁症最好。选择一种有效的治疗方法可能导致PPD的减少，这仍然是世界范围内主要的公共卫生挑战。建立的登记可以成为未来许多关于抑郁症对孕产妇健康和儿童发展的长期影响的研究的宝贵资源。

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.