Effectiveness of Treating Prenatal Depression to Reduce Postpartum Depression

描述(申请人提供)：产后抑郁症(PPD)困扰着大约10%-15%的孕妇。妊娠期抑郁是产后抑郁的最大危险因素。然而，目前，对于妊娠期抑郁症的治疗是否可以降低PPD的风险，存在着重大的困惑。我们的初步研究表明，治疗产前抑郁可能会降低产后抑郁的风险。为了进一步确定(1)产前抑郁本身是否增加了产后抑郁的风险，因此应该进行治疗，(2)治疗是否有益，以及(3)哪种治疗方法最有效地减少产后抑郁，我们建议在北加州凯撒永久医院(KPNC)进行一项分两个阶段的前瞻性队列研究。KPNC实施了一项独特的普及性围产期抑郁筛查计划。所有孕妇(每年约33,000人)在孕期接受两次抑郁症筛查，产后使用患者健康问卷(PHQ-9)进行一次筛查。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。利用所有120,000名妇女关于抑郁状况和治疗选择的信息(第一阶段样本)，将形成五个队列：(A)“未治疗队列”：那些在怀孕期间筛查抑郁症阳性，但没有接受治疗的人；(B)“心理治疗队列”：筛查阳性，只接受心理治疗；(C)“抗抑郁剂队列”：筛查阳性，只使用抗抑郁药；(D)“联合治疗队列”：筛查阳性，同时使用心理治疗和抗抑郁药物；以及(E)“对照队列”：筛查阴性抑郁症，不接受任何治疗。对于第二阶段的子样本，我们将从五个队列(总共2,000名女性)中随机选择400名受试者，并亲自采访他们，以获得关于混杂因素和影响因素的详细信息，以便进行调整。A组和E组的比较将确定怀孕期间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。队列B、C和D之间的配对比较将确定包括心理治疗、抗抑郁药物和联合治疗在内的各种治疗方案的比较有效性。多元线性回归分析将被用来检验从怀孕期间到怀孕后改善抑郁状态的治疗效果，其中将比较产前和产后期间人内PHQ-9得分的变化。Logistic回归分析将被用来检验降低产后抑郁风险的治疗效果，其中产后抑郁风险(一个二分法变量)在所有治疗组中进行比较。这些发现将为紧迫的临床问题提供答案，这些问题包括是否应该治疗妊娠期抑郁症，如果应该的话，哪种选择是减少产后抑郁的最佳选择。选择一种有效的治疗方法可能会导致产后抑郁的减少，而产后抑郁仍然是全球公共卫生面临的主要挑战。建立的登记可以成为未来许多关于抑郁症对产妇健康和儿童发育的长期影响的研究的宝贵资源。 公共卫生相关性：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的风险或严重程度，如果是的话，哪种治疗方案(心理治疗或抗抑郁药)在减少产后抑郁方面更有效。

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.