With prevalence rates of postnatal depression (PND) as high as at least 7%, there was a need for early detection and intervention of postpartum mental illness amongst Singaporean mothers. This is a report on the first year results of our country's first PND Intervention Programme. The programme consists of two phases: (1) postpartum women were screened with the Edinburgh Postnatal Depression Scale and provided appropriate care plans; (2) individualized clinical intervention using a case management multidisciplinary team model. Screening for PND was generally acceptable, as 64% eligible women participated voluntarily. Nine percent (126) were identified as probable cases from 1369 women. Forty-one women accepted intervention and achieved 78% reduction in the EPDS symptom scores to below the cutoff of 13, 76% had improvement in GAF functioning scores, and 68% had improved health quality scores. Preliminary results are promising, and this intervention model can be replicated.
The prevalence of perinatal depression in Singapore is about 12% for antepartum depression and about 7% for postpartum depression [
In the USA, a number of comprehensive and integrated services have been established to cater maternal mental health [
The programme, funded by the health ministry, ran at the Kendang Kerbau Women’s and Children’s Hospital (KKH), which handles some 12,000 deliveries annually, representing about a third of the national births. The psychiatric service was established in 2006 to provide liaison consultative and outpatient psychiatric services, and referral had largely relied on the interests and the limited resources of the frontline obstetric professionals who were understandably more focused on obstetric issues. An integrated service was needed to provide accessible screening and early intervention for postpartum depression. Whilst intervening antenatally is ideal as antepartum depression is an important risk factor for postpartum depression [ screening and early detection of postpartum depression and severe postpartum mental illness, managing postpartum depression early using a case management multidisciplinary model to improve the outcomes.
We report here the results of the first year of the programme.
This is a prospective cohort study of postpartum women, conducted at KKH between 1 April 2008 to 31 March 2009, approved by the KKH Institutional Review Board, and funded by the Ministry of Health and the KKH Research Small Grant.
Participants were recruited from two obstetric outpatient clinics handling about 2000 postpartum women annually, at 2 weeks to 6 months postdelivery. Excluded were (i) adolescent mothers (<18 yrs), as they were already cared for on an established medical social work programme, which included emotional support, (ii) women with stillbirth or early neonatal loss, (iii) those already receiving psychiatric treatment and close monitoring since the antepartum.
Participants were interviewed by the perinatal mental health case managers, using the Edinburgh Postnatal Depression Scale (EPDS) [
The high scorers (EPDS > 12), or those who answered yes to any of the three additional questions, were offered a psychiatric consultation, thus entering the intervention phase.
Those scoring borderline (EPDS 10–12) were mostly found to have minor problems or difficulties related to adjustment to motherhood, not amounting to clinical depression, and they were provided counselling and offered follow-up phone review and/or counselling by the assigned case manager. The case manager would then advise if there was a need to see the psychiatrist, if the difficulties worsened or continued, or be directed to community resources as was appropriate. For high scorers that declined to the intervention, the assigned case managers would conduct phone followup to check on their progress. The process flow of the programme is detailed in Figure
Process flow of the Postnatal Depression Intervention Programme.
Early intervention for the high scorers included full psychiatric assessments, with supportive counseling, psychoeducation, and problem-solving focused counseling incorporating the principles of interpersonal and cognitive behavioural therapy (Table
Supportive Therapy and Counselling In Perinatal Depression.
(I) Individual care |
Early phase |
(i) |
Establishing rapport |
Developing therapeutic alliance |
(ii) |
Encouraging expression of emotion and thought |
Clarify thinking |
Empathic mirroring and validation |
Support, reassurance, encouragement |
(iii) |
Exploring problems, possible solutions |
(iv) |
Advise about illness and possible causative factors |
Counselling about treatment options |
Counselling about expected progress |
Mid phase |
(v) |
(a) addressing the mother’s self-percept, |
for example, dealing with negative self-view |
(borrowing from CBT), |
(b) Addressing role changes (borrowing from |
interpersonal therapy), |
(c) Issues related to unwanted pregnancy, past trauma, |
precious pregnancy, and so forth. |
Recovery Phase |
(vi) |
Advise about future risks |
Counselling regarding long-term treatment (maintenance |
options discussed, if needed) |
(vii) |
Enhancing strengths, positive encouragement |
Instilling hope, empowering woman as mother |
(II) Care engaging husband/partner |
(i) |
Advise about illness, treatment options |
Advise about risks to self/fetus or infant |
(ii) |
Addressing areas of need |
Facilitating the understanding of illness |
Encouraging support |
(iii) |
Brief exploration of husband’s/partner’s coping |
Brief exploration of needs and counselling on resources |
available |
Measures were taken at (a) baseline, when women first engaged into clinical intervention with the psychiatrist and then (b) repeated at 6 months or at discharge, whichever was earlier. These included the EPDS (described earlier), the Global Assessment of Functioning Scale (GAF) [ The GAF is a 100-point scale that measures overall level of psychological, social, and occupational functioning on a hypothetical continuum and is particularly useful for managed care-driven diagnostic evaluations to determine the eligibility for treatment and disability benefits and to delineate the level of care required for patients. The EuroQol health index, EQ5D, is a generic measure of health-related quality of life that consists of a self-classifier and a visual analogue scale and can be used in the clinical and economic evaluation of health care and in population health surveys. The self-classifier consists of 5 items assessing health in 5 dimensions of mobility, self-care, usual activities, pain/discomfort, and anxiety/depression on a 3-point Likert scale. The visual analog scale is a vertical, graduated thermometer from 0 (worst imaginable health state) to 100 (best imaginable health state). We also administered a patient satisfaction survey at discharge: a 5-point Likert scale we developed to ask participants three questions, whether they were satisfied with medical care, counselling support, and psychoeducation provided about postpartum depression. Satisfaction was determined by a response ranging from “very dissatisfied” to “very satisfied”.
Data in numbers, percentages, means, and standard deviations were presented as descriptives. For the scale/interval ratio variables, independent
2148 postpartum women presented at the selected clinics, and 64% (1367) participated in screening and received educational information about postnatal depression.
Two-thirds (71%) of the women who participated in the screening programme were aged 25 to 34 years, with mean age 30.52 years (SD = 5.00), range from 18 to 44 years old. Half of the participating women were Chinese (52.1%), with Malays (19.2%) and Indians (14.2%) forming one-third of the sample, whilst 14.5% were of other races. 56.5% were Singapore-born, whilst 43.5% were foreign-born. The majority of women (94%) lived in public housing, whilst 6% lived in private housing.
Of the 1367 women screened, the majority (85%) scored below 10 on the EPDS, with 6% (80) having borderline scores of 10–12 (see Figure
Pearson’s chi-square tests compared the EPDS scores category between Singaporean and foreign-born migrant women (Table
Comparison of EPDS scores between Singaporean and non-Singaporean women.
Nationality | EDPS ≥ 13 | EPDS < 13 | |
---|---|---|---|
Singaporeans | 11%** | 89% | 773 |
Non-Singaporeans | 7% | 93% | 594 |
**Pearson’s Chi-square statistical significance at
Looking at the comparison across races (Table
Comparison of EPDS scores category between races.
Chinese | Malays | Indians | Others | ||
---|---|---|---|---|---|
EPDS score < 13 | 91 | 93 | 85 | 96 | 1247 |
EPDS score ≥ 13 | 9 | 7 | 15** | 4 | 120 |
**Kruskal-Wallis test statistical significance at
There was no difference in terms of EPDS scores when comparing between those who lived in private housing with those who lived in public housing.
Only 32.5% (41) of the 126 women with high EPDS scores accepted clinical intervention. The others declined referral due to various reasons, such as no time, cost concerns, stigma of receiving psychiatric disorder, no insight, and other reasons. 2 foreign-born women left Singapore.
The characteristics of the 41 women who entered intervention are summarized in Table
Descriptives of women entering intervention.
Number | Percentage (%) | |
---|---|---|
Maternal age at birth | ||
18–24 years | 4 | 10 |
25–34 years | 29 | 71 |
35–40 years | 7 | 17 |
>41 years | 1 | 2 |
Race | ||
Chinese | 24 | 59 |
Malay | 8 | 20 |
Indian | 8 | 20 |
Others | 1 | 2 |
Marital status | ||
Married | 39 | 95 |
Single | 1 | 2 |
Divorced | 0 | 0 |
Separated | 0 | 0 |
Cohabiting | 1 | 2 |
Educational qualification at enrolment | ||
Primary | 1 | 2 |
Vocational | 6 | 15 |
Secondary | 9 | 22 |
Tertiary | 14 | 34 |
Degree | 11 | 27 |
Occupation | ||
Professional executive/senior | 8 | 20 |
3 | 7 | |
General administrative/supervisory | 5 | 12 |
Service line | 7 | 17 |
Self-employed/business owner | 0 | 0 |
Home maker/unemployed | 18 | 44 |
Pregnancy details | ||
Planned pregnancy | 14 | 34 |
Unplanned pregnancy | 27 | 66 |
Breast feeding | 24 | 59 |
Had no other child | 25 | 61 |
Had other children under 5 years old | 41 | 100 |
Had termination(s) before | 7 | 17 |
Had miscarriage(s) before | 6 | 15 |
Sixty percent (24) were Chinese, 95% (39) married, with 83% (34) having at least secondary-level or high-school-equivalent education, and 66% (23) were working. Interestingly, two-thirds (22) had not planned their pregnancy, and this was the first pregnancy for almost two-thirds of the women (25). One-third (14) had other children below the age of 5. Thirty-nine percent (16) had no available help whilst the others had help from live-in domestic help, relatives, or nursery.
Of the 41 women who engaged in clinical intervention, diagnosis was made based on DSM-IV criteria [
Of these 41 under clinical intervention, Seventy-eight percent (32) experiencing a reduction of scores to below the cut-off score of 13. 2 patients had increased scores, and 1 had no change (Figure
Change in EPDS scores with intervention.
Change in GAF and EQ5D scores with intervention.
Together with the 67% (84) of high scorers who rejected intervention, 80 women with borderline EPDS scores (10–12) were provided supportive counselling by the case managers. Repeating EPDS showed that 74% (62) of high scorers and 56% (45) of borderline scorers benefited from this, with reduction in the EPDS scores (Figures
Change in EPDS scores amongst women who scored borderline (EPDS 10–12).
Change in EPDS scores amongst women who scored high (EPDS ≥ 13).
Those who accepted clinical intervention presented significantly later in the postpartum period, compared to those who declined (8 weeks versus 4.3 weeks) (
Those who declined clinical care had lower mean baseline EPDS score compared to the high scorers who accepted intervention (15.8 versus 19.1), with this difference being statistically significant (
In terms of improvement in the EPDS symptom scores, the mean difference between those who entered intervention was 12.9, compared with 10.7 for those who declined clinical care, and this was statistically significant (
More than 95% of the women who participated in the screening programme were either satisfied or very satisfied with the counselling support and psychoeducation. Whilst 71% of those who entered clinical intervention were either satisfied or very satisfied with the medical care, and the rest felt neutral, whilst none were dissatisfied.
9% of our cohort of 1369 postpartum scored above the cutoff on the EPDS, indicative of possible caseness, reflecting worldwide prevalence rates of postpartum depression [
Notably, 66% of high scorers declined psychiatric intervention even with the well-trained case manager engaging and reassuring them about seeking help. The stigma of a psychiatric disorder can be significant, especially in the context of motherhood. Indeed, it is well established that one of the most challenging barriers related to help seeking for mental-health-related problems is stigma [
Additionally, it is likely that women who declined intervention experienced less symptoms, as reflected by lower mean baselines EPDS scores and were thus less distressed. Results also demonstrated that those who accepted intervention presented later, possibly reflecting a longer duration of distress although the onset of symptoms was not studied.
The main limitation of this research is that it is non-randomized and observational; hence, the groups are not directly comparable and results not generalizable.
The results demonstrate that the majority (three-quarters) of the depressed mothers who accepted treatment responded well to the intervention. Social risk factors, particularly marital conflicts and lack of social support, were seen in the women who experienced no improvement or worsening outcomes. Indeed, depressed patients with greater dyadic (marital) discord have been found to have a lower likelihood of remission of their depression during medication treatment [
Both the screening and intervention programme were well accepted, with more than 95% and 71% patient satisfaction, respectively.
With no previous existing screening programme in Singapore, we believe that many women have struggled or presented late when the impact of the illness would have set in. With this programme, we now have the means to address the maternal mental health needs of our women. Indeed, with a foreign-born population representing almost half of our cohort, with nationalities or races from many countries, this model can be applicable to a wider global community.
Postpartum depression is a significant public health problem, but with a right-tier approach integrated on-site into obstetric setting, outcomes can be improved, and this model of care can be replicated.
The authors declare that there is no conflict of interests.
I have had thoughts of harming my baby.
□ Yes □ No I have heard voices when no one was around.
□ Yes □ No I have felt people around me wish to harm me, or have bad intentions.
□ Yes □ No
Financial support for the Postnatal Depression Intervention Programme was provided by Grant RF07-MW01H from the Ministry of Health, Singapore, and research Grant RAU/2008/141 from the KKH Small Grant. The authors would like to thank Lim Bee Moy for her valuable contribution to the database management, Drs Choo Chih Huei, Loretta Ang, and Chua Tze Ern for their contribution, and Fu Sheng for his editorial support.