围产期抑郁症及其他——对研究设计和临床管理的影响 | JAMA子刊

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The 2 newly published studies, Smythe et al1 and Sultan et al,2 are systematic reviews (Smythe et al1 also comprises a meta-analysis) dealing with the topic of perinatal mental health (ie, mental health during the time of pregnancy up to 1 year after birth). Smythe et al1 estimated prevalence rates of perinatal depression and anxiety in parental dyads and associated factors. The pooled prevalence of depression was 1.72% (antenatally), 2.37% (0-12 weeks post partum), and 3.18% (3-12 months post partum). Given the paucity of dyadic studies, no prevalence estimate for anxiety could be determined. Sultan et al2 examined the psychometric properties of 10 existing patient-reported outcome measures for assessing maternal postpartum depression. Although all included patient-reported outcome measures demonstrated adequate content validity, only the Edinburgh Postnatal Depression Scale received a class A recommendation (recommended for use). All other patient-reported outcome measures received a class B recommendation (further psychometric evaluation required before recommendation). The authors concluded that the Edinburgh Postnatal Depression Scale is currently the best available patient-reported screening measure for maternal postpartum depression.

Perinatal mental health problems are very common: according to the World Health Organization,3 approximately 10% of women in high income countries and approximately 30% in low- or middle-income countries are affected. The most common perinatal mental health problems are depression, anxiety disorders, and posttraumatic stress disorder (PTSD).4 In the UK, the health care costs associated with maternal mental health problems are estimated at £8.1 billion, of which 72% are associated with health care costs related to the child.5 Indeed, maternal depression, anxiety, or PTSD symptoms may negatively impact birth and breastfeeding outcomes and increase the risk for emotional or behavioral problems, symptoms of attention deficit hyperactivity disorder, or impaired cognitive development in the child.6,7

Despite the large body of research on maternal perinatal mental health, most studies are conducted in samples of White, highly educated women, of middle to high socioeconomic background, and with planned or wanted singleton pregnancy. Hence, more studies on more diverse samples including teenage pregnancy, single motherhood, multiple pregnancies, adoption, and so forth, are needed. Moreover, paternal perinatal mental health has so far received fairly little attention from researchers and clinicians. A recent article8 called for an inclusion of fathers’ mental health in perinatal research. With the increasing involvement of fathers (or coparents) in family life in western societies, their mental health is also ever more important for maternal mental health, family relationships, and child development.9 Similar to (expectant) mothers, (expectant) fathers also have an elevated risk of depression and anxiety disorders and PTSD during the perinatal period. Indeed, perinatal depression is reported by approximately 8% to 10% of fathers and is the most studied paternal mental health disorder so far.10 Paternal depression symptoms have been shown to increase the risk of child emotional and behavioral problems and psychopathology.11 Of critical importance is that partner depression is a factor associated with risk for one’s own depression, thus making it a cumulative family factor associated with risk for both parent and child outcomes.12

There is still inequality in perinatal depression management across countries, and evidence-based practical guidelines for the management of perinatal depression and other mental health problems are quite sparse. Various treatment options are available, with psychopharmacological treatment most often recommended for severe symptoms (except in the case of PTSD), and psychotherapy for moderate to severe symptoms, with cognitive-behavior therapy achieving the best outcomes.13 However, there are disparities in the availability of the treatment across countries. Nevertheless, even when the treatment is available, mothers are reluctant to seek help because of lack of knowledge about symptoms, fear of stigma, and feelings of guilt and shame. Therefore, universal screening for perinatal mental health disorders might be beneficial for women and their families in order to detect problems at early stages. However, more studies are needed to examine its cost-effectiveness and ethical aspects, especially if no systematic referral is offered following the screening.

To implement screening, valid and reliable assessment tools are a prerequisite. However, most assessment tools continue to focus only on depression symptoms, and there is a lack of assessment tools specifically designed for perinatal mental health problems other than depression. Moreover, measures designed for (expectant) fathers are scarce. Perinatal mental health problems in (expectant) fathers may be underestimated because they may express their distress differently from mothers, ie, with mood alterations and anxiety, and more hostility and aggression. What is concerning is that cultural conceptions of masculinity and stigma may prevent them from seeking professional help.8 However, paternal depression should not be left unrecognized and untreated because it can be associated with parent-infant bonding difficulties and other infant-related outcomes.11,14

Although studies including (expectant) fathers/coparents or even both (expectant) mothers and fathers/coparents are slowly emerging, data are still analyzed mainly at the individual level and not dyadically, even though most (expectant) parents have a committed relationship during the perinatal period.15 However, such scientific approaches neglect the interdependence within the family, as both (expectant) parents share common experiences and events, such as the birth of the same child or coparenting.12 Indeed, parenting can be a source of dyadic stress, and because the stress experiences and resulting reactions of (expectant) parents may influence each other, this dyadic stress may be associated with perinatal mental health problems.12,15 On the other hand, dyadic coping (ie, jointly dealing with daily stressors) may provide a buffer against perinatal mental health problems. Hence, (expectant) parents can draw on each other's resources when their own resources are depleted. In addition, the fact that both experience the same stress may also be perceived as comforting and may thus be protective.1,15

To conclude, perinatal mental health disorders, such as postpartum depression, are highly prevalent, as also highlighted in the systematic review and meta-analysis by Smythe et al.1 They affect not only (expectant) mothers, but also (expectant) fathers/coparents and may have a long-lasting negative impact on the child. The personal distress and associated health care costs are high and strategies for prevention, early detection and treatment of such difficulties are called for.4,5,13 According to the findings of Sultan et al2 based on their systematic review, the Edinburgh Postnatal Depression Scale should be used to screen for and assess postpartum depression symptoms in mothers. Future research needs to focus on validating self-report measures for (expectant) fathers/coparents. The rather frequent contacts with health care professionals during the perinatal period provide ideal opportunities for the screening of (expectant) parents. Moreover, further studies of perinatal mental health problems should focus on the inclusion of couples in different constellations and, in general, on the inclusion of more diverse populations.12 Finally, interdependence within the family system should be considered. Thus, using dyadic research designs, future research should examine the coexistence of perinatal mental health problems in (expectant) parents as well as associated outcomes.1 Such dyadic approaches could even be extended to 3 or 4 family members by including siblings or grandparents to further unravel and investigate the complex family relationships and their implications for family mental health.15

全文翻译（仅供参考）

有 2 项新发表的研究，Smythe 等人1和 Sultan 等人2是系统评价（Smythe 等人1还包括一项荟萃分析），涉及围产期心理健康（即怀孕期间的心理健康）至出生后 1 年）。Smythe 等人1估计了父母二元组中围产期抑郁和焦虑的患病率及相关因素。抑郁症的综合患病率为 1.72%（产前）、2.37%（产后 0-12 周）和 3.18%（产后 3-12 个月）。鉴于缺乏二元研究，无法确定焦虑的患病率估计值。苏丹等人2检查了 10 种现有的用于评估产妇产后抑郁症的患者报告结果测量的心理测量特性。尽管所有纳入的患者报告的结果测量都显示出足够的内容有效性，但只有爱丁堡产后抑郁量表获得了 A 级推荐（推荐使用）。所有其他患者报告的结果测量均获得 B 级推荐（推荐前需要进一步的心理测量评估）。作者得出的结论是，爱丁堡产后抑郁量表是目前针对产妇产后抑郁症的最佳患者报告筛查措施。

围产期心理健康问题非常普遍：根据世界卫生组织的数据，3高收入国家约 10% 的女性和低收入或中等收入国家约 30% 的女性受到影响。最常见的围产期心理健康问题是抑郁症、焦虑症和创伤后应激障碍 (PTSD)。4在英国，与孕产妇心理健康问题相关的医疗保健费用估计为 81 亿英镑，其中 72% 与儿童相关的医疗保健费用有关。5事实上，母亲的抑郁、焦虑或 PTSD 症状可能会对分娩和母乳喂养结果产生负面影响，并增加儿童出现情绪或行为问题、注意力缺陷多动障碍症状或认知发育受损的风险。6 , 7

尽管有大量关于孕产妇围产期心理健康的研究，但大多数研究都是在白人、受过高等教育、社会经济背景中等到高、计划或想要单胎怀孕的女性样本中进行的。因此，需要对更多样化的样本进行更多的研究，包括少女怀孕、单亲母亲、多胎妊娠、收养等。此外，迄今为止，父亲围产期心理健康很少受到研究人员和临床医生的关注。最近的一篇文章8呼吁将父亲的心理健康纳入围产期研究。随着父亲（或共同父母）越来越多地参与西方社会的家庭生活，他们的心理健康对于孕产妇心理健康、家庭关系和儿童发展也越来越重要。9与（准）母亲类似，（准）父亲在围产期患抑郁症和焦虑症以及 PTSD 的风险也较高。事实上，大约 8% 到 10% 的父亲报告了围产期抑郁症，并且是迄今为止研究最多的父亲精神健康障碍。10父亲抑郁症状已被证明会增加儿童情绪和行为问题以及精神病理学的风险。11至关重要的是，伴侣抑郁症是与自己抑郁症风险相关的一个因素，因此使其成为与父母和孩子结局风险相关的累积家庭因素。12

各国在围产期抑郁症管理方面仍然存在不平等，针对围产期抑郁症和其他心理健康问题管理的循证实用指南相当稀少。有多种治疗方案可供选择，最常推荐用于严重症状（PTSD 除外）的精神药理学治疗，以及用于中度至重度症状的心理治疗，认知行为疗法可达到最佳效果。13然而，各国治疗的可及性存在差异。然而，即使有治疗方法，母亲也不愿意寻求帮助，因为缺乏对症状的了解、害怕耻辱感以及内疚和羞耻感。因此，围产期心理健康障碍的普遍筛查可能对妇女及其家人有益，以便在早期发现问题。然而，需要更多的研究来检查其成本效益和伦理方面，特别是如果在筛选后没有提供系统转诊。

要实施筛查，有效和可靠的评估工具是先决条件。然而，大多数评估工具仍然只关注抑郁症状，并且缺乏专门针对抑郁症以外的围产期心理健康问题设计的评估工具。此外，为（准）父亲设计的措施很少。（准）父亲的围产期心理健康问题可能被低估了，因为他们表达的痛苦可能与母亲不同，即情绪变化和焦虑，以及更多的敌意和攻击性。令人担忧的是，阳刚之气和污名的文化观念可能会阻止他们寻求专业帮助。8然而，不应忽视和治疗父亲抑郁症，因为它可能与亲子联系困难和其他与婴儿相关的结果有关。11 , 14

尽管包括（准）父亲/共同父母或什至（准）母亲和父亲/共同父母的研究正在缓慢出现，但数据仍然主要在个人层面进行分析，而不是二元分析，即使大多数（准）父母在围产期。15然而，这种科学方法忽略了家庭内部的相互依赖，因为（预期的）父母双方都有共同的经历和事件，例如同一个孩子的出生或共同抚养。12事实上，养育子女可能是二元压力的来源，并且由于（预期）父母的压力经历和由此产生的反应可能相互影响，这种二元压力可能与围产期心理健康问题有关。12 , 15另一方面，二元应对（即共同应对日常压力源）可以为围产期心理健康问题提供缓冲。因此，（预期的）父母可以在自己的资源耗尽时利用彼此的资源。此外，两者都经历相同压力的事实也可能被认为是安慰，因此可能是保护性的。1 , 15

总而言之，围产期精神健康障碍，如产后抑郁症，非常普遍，Smythe 等人的系统评价和荟萃分析也强调了这一点。1它们不仅影响（准）母亲，还影响（准）父亲/共同父母，并可能对孩子产生长期的负面影响。个人痛苦和相关的医疗保健费用很高，因此需要采取预防、早期发现和治疗这些困难的策略。4 , 5 , 13根据 Sultan 等人的研究结果2根据他们的系统评价，爱丁堡产后抑郁量表应用于筛查和评估母亲的产后抑郁症状。未来的研究需要侧重于验证（准）父亲/共同父母的自我报告措施。围产期与医疗保健专业人员的频繁接触为筛查（准）父母提供了理想的机会。此外，围产期心理健康问题的进一步研究应侧重于纳入不同星座的夫妇，一般来说，应侧重于纳入更多样化的人群。12最后，应考虑家庭系统内的相互依存关系。因此，使用二元研究设计，未来的研究应该检查（预期）父母中围产期心理健康问题的共存以及相关结果。1这种二元方法甚至可以扩展到 3 或 4 个家庭成员，包括兄弟姐妹或祖父母，以进一步解开和调查复杂的家庭关系及其对家庭心理健康的影响。15

原文链接：

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2793557

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