Untreated depression in pregnancy may result in adverse health outcomes to both the mother and her unborn child. Pharmacotherapy with antidepressants is the most common treatment option for depression; however, the decision to treat with medication becomes complicated by pregnancy. Risk benefit assessments are critical tools to guide the treatment decision. Factors that should be included in these analyses include the pharmacokinetics and pharmacodynamics of antidepressants in pregnancy and their maternal and fetal safety. The economic cost of untreated maternal depression is also important to keep in mind. When the pharmacokinetics of the antidepressants venlafaxine and bupropion were studied in pregnancy it was found that the apparent oral clearance rate of bupropion was increased in late pregnancy when compared to early pregnancy (p = 0.03). There was a trend for lower area under the curve for these medications when the third trimester was compared to the first trimester. When the metabolism of antidepressants was investigated using hair analysis it was found that there was increased metabolism in pregnancy when compared to the postpartum period for citalopram (p = 0.02) but not venlafaxine (p = 0.77). Follow up of depressive symptoms throughout pregnancy identified that depression scores were highest in the first trimester of pregnancy, which may be due to concurrent nausea and vomiting of pregnancy. A meta-analysis of paroxetine use in early pregnancy demonstrated that there was no increased risk for cardiac malformations; case-control studies had an odds ratio of 1.18 (CI95: 0.88 – 1.59) while a weighted average difference of 0.3% was found in case-control studies (CI95: -0.1 – 0.7%, p = 0.19) The direct medical costs incurred by the Ontario government due to discontinuation of antidepressant medications in pregnancy was estimated to exceed $20,000,000 CAD. The management of depression in pregnancy with pharmacotherapy is an important and complex issue. My study documents the advantages of conducting risk benefit assessments for vulnerable populations such as pregnant women with depression.

Untreated depression in pregnancy may result in adverse health outcomes to both the mother and her unborn child. Pharmacotherapy with antidepressants is the most common treatment option for depression; however, the decision to treat with medication becomes complicated by pregnancy. Risk benefit assessments are critical tools to guide the treatment decision. Factors that should be included in these analyses include the pharmacokinetics and pharmacodynamics of antidepressants in pregnancy and their maternal and fetal safety. The economic cost of untreated maternal depression is also important to keep in mind. When the pharmacokinetics of the antidepressants venlafaxine and bupropion were studied in pregnancy it was found that the apparent oral clearance rate of bupropion was increased in late pregnancy when compared to early pregnancy (p = 0.03). There was a trend for lower area under the curve for these medications when the third trimester was compared to the first trimester. When the metabolism of antidepressants was investigated using hair analysis it was found that there was increased metabolism in pregnancy when compared to the postpartum period for citalopram (p = 0.02) but not venlafaxine (p = 0.77). Follow up of depressive symptoms throughout pregnancy identified that depression scores were highest in the first trimester of pregnancy, which may be due to concurrent nausea and vomiting of pregnancy. A meta-analysis of paroxetine use in early pregnancy demonstrated that there was no increased risk for cardiac malformations; case-control studies had an odds ratio of 1.18 (CI95: 0.88 – 1.59) while a weighted average difference of 0.3% was found in case-control studies (CI95: -0.1 – 0.7%, p = 0.19) The direct medical costs incurred by the Ontario government due to discontinuation of antidepressant medications in pregnancy was estimated to exceed $20,000,000 CAD. The management of depression in pregnancy with pharmacotherapy is an important and complex issue. My study documents the advantages of conducting risk benefit assessments for vulnerable populations such as pregnant women with depression.

Depression occurs in approximately 20% of pregnant women, and up to 25% of them experience anxiety. Several pregnancy complications and labour and delivery outcomes have been associated with antenatal depression and anxiety, such as higher rates of nausea and vomiting, bleeding, psychosomatic complaints, preterm labour and delivery complications. Neonatal outcomes include lower Apgar scores, shorter gestation, smaller head circumference, and increased admissions to the neonatal intensive care unit. Research Questions: 1. To examine the prevalence of pregnancy complications and neonatal outcomes in this study sample. 2. To examine whether there is a difference in the association between observed pregnancy complications and neonatal outcomes and major depression, when depression is episodic compared to when the depression is continuous. 3. To examine whether there is a difference in the association between observed pregnancy complications and neonatal outcomes and mild depression, when the mild depression is episodic compared to when it is continuous. 4. To examine whether there is a difference in the association between observed pregnancy complications and neonatal outcomes and anxiety, when anxiety is episodic compared to when it is continuous. Methods: The data for this study was collected for the Feelings in Pregnancy and Motherhood Study (FIP). This population-based study interviewed 649 participants three times: in the second trimester, the third trimester, and in the early postpartum. Participants were screened for depression and anxiety with the Edinburgh Postnatal Depression Scale (EPDS), using the validated cut-off scores of >12 and >4 respectively. Sociodemographic data as well as detailed risk behaviours, and sources of stress and coping, were explored. Finally, pregnancy, labour and delivery and neonatal complications were collected. Descriptive and multivariate logistic regression analyses were completed. Results: Major depression in the second trimester was significantly associated with gestational diabetes (OR: 3.518; 95% CI 1.56, 7.93) and swelling/edema (OR: 2.099; 95% CI 1.13, 3.89). Major depression that occurred continuously throughout pregnancy was significantly associated with induced labour (2.417; 95% CI 0.99, 5.92) and antenatal bleeding/abruption (OR: 2.099; 95% CI 1.13, 3.89). Anxiety in the second trimester was significantly associated with caesarean birth (OR: 0.522; 95% CI 0.29, 0.95). Anxiety occurring continuously throughout pregnancy was significantly associated with swelling/edema (OR: 1.816; 95% CI 1.19, 2.77) and there was a significant interaction between age and anxiety that predicted epidural use during pregnancy: while age decreased in the participants who had anxiety in both trimesters, the likelihood of using an epidural increased. Finally, mild depression in the second trimester was significantly associated with antenatal bleeding/abruption (OR: 2.124; 95% CI 1.09, 4.14) and PROM (OR: 2.504; 95% CI 1.04, 6.05). Mild depression in the third trimester was associated with caesarean birth (OR: 0.298; 95% CI 0.10, 0.86). Mild depression that occurred continuously throughout pregnancy was significantly associated with the use of vacuum/forceps in delivery or an operative delivery (OR: 4.820; 95% CI 1.10, 21.16). Conclusions: These results show that episodic depression and anxiety can have a more profound impact on pregnancy complications and labour and delivery outcomes than continuous depression and anxiety. Furthermore, the results demonstrate that even mild depression can have a significant negative impact on pregnancy complications and labour and delivery outcomes. These results further highlight the imperative need for women to be screened and treated for depression and anxiety during pregnancy.

Introduction Maternal mental health during pregnancy and its effects on offspring outcomes have received increased attention as a public health concern. Recent policies have highlighted the need for better universal perinatal services and to routinely incorporate attention to mental health into antenatal care. This thesis aimed to examine and evaluate current research into the effects of maternal antenatal depression on child psychological, development and developmental psychopathology. A research study was carried out with the aim of understanding the subjective experiences of women with antenatal depression during pregnancy and their transition to motherhood. Method Quantitative studies, exploring the relationship between antenatal depression and early child development were reviewed systematically. The empirical study employed Interpretative Phenomenological Analysis to investigate the experience of antenatal depression in pregnant women. Semi-structured interviews were conducted with six participants who were pregnant and recruited from a perinatal mental health service. Results The small number of papers considered suitable for this review highlights the lack of good quality research in this field. Twelve studies met inclusion criteria for the systematic review, demonstrating mixed results regarding whether antenatal depression effects early child development. Studies were predominantly of poor methodological quality, with inconsistent results and limited by the use of differing antenatal depression and infant development outcomes, making cross study comparisons difficult and weakening any conclusions that could be drawn. In the empirical study one super-ordinate theme, ‘The Lost Self’, and four main themes emerged. Conclusions Findings were inconsistent and of poor quality, and so we cannot say for sure whether antenatal depression itself is associated with adverse outcomes for young children. Further rigorous research on antenatal depression and adverse early child outcomes is needed in order to try and disentangle the effects of both antenatal and postnatal depression on each other and on child development. The findings from the empirical study contribute to an increased understanding of the experiences and challenges faced by women experiencing depression during pregnancy. The study highlights the need for improved awareness of depression during pregnancy to improve understanding of this disorder during the antenatal period.

SAMMANFATTNING  Bakgrund  Depression är vanligt bland unga kvinnor i fertil ålder vilket innebär att barnafödande infaller under en del av livet då många kvinnor är psykisk sårbara. Cirka 10 till 20 procent av alla gravida kvinnor drabbas av depression av varierande grad under den antenatala perioden. Depression ökar risken för tillväxthämning hos fostret, prematur förlossning och postpartum-depression samt försvårar anknytningen mellan mor och barn. Den rådande uppfattningen är att kvinnor som medicinerat med antidepressiva läkemedel innan graviditet bör fortsätta medicinera samt att insättning bör göras när behov finns. Många kvinnor vill dock inte använda antidepressiva läkemedel under graviditet av rädsla för negativ påverkan på fostret och för dessa kvinnor behövs alternativ. I barnmorskans arbete ingår att stödja och vårda kvinnor under graviditet varför kunskap om behandlingsalternativ är vikt för yrkesgruppen.  Syfte Syftet med detta examensarbete var att undersöka vilka icke-farmakologiska behandlingar som finns för depression under graviditet samt dess för- och nackdelar. Metod  En systematisk litteraturstudie har gjorts där 28 artiklar inkluderades av totalt 659 granskade titlar, 110 granskade abstracts och 44 artiklar granskade i sin helhet. De inkluderade artiklarna analyserades med kvalitativ innehållsanalys och kvalitetsgranskades i enlighet med Willman, Stoltz och Bahtsevani, (2016). Resultat  Analysen av studiernas resultat visade attmånga former av ickefarmakologisk behandling kan ha mildrande eller botande effekt vid depression under graviditet. Det framkommer att behandling med yoga, behandling med mind-body terapi, behandling given till par, behandling given digitalt, behandling given i grupp samt behandling med psykoterapi eller samtalsstöd har positiv effekt om än i olika grad.Resultatet ger stöd för att komplement till basprogrammet vid sedvanlig mödrahälsovård är eftersträvansvärt och hjälper kvinnor med antenatal depression och att den positiva effekten ofta kvarstår efter förlossningen. Slutsats  Detta examensarbete visade att många icke-farmakologiska behandlingsmetoder kan hjälpa kvinnor med antenatal depression. Tilltron till behandlingsmetoderna var oftast hög och få negativa effekter framkom. Kvinnor kan utifrån detta informeras om att forskning visat att utöver antidepressiv medicinering finns icke-farmakologiska behandlingsmetoder med god effekt på depression under graviditet. Vidare forskning får visa om behandlingsformerna skulle kunna erbjudas inom ramen för mödrahälsovårdens basprogram, samt om det är möjligt att genom dessa alternativa terapier minska graviditetskomplikationer orsakade av depression. NYCKELORD  Antenatal depression, behandling, depression, graviditet, moderskap, perinatal terapi / ABSTRACT  Background  Depression is common among young women of childbearing age, which means that childbirth occurs during a part of life when many women are mentally vulnerable. About 10 to 20 percent of all pregnant women suffer from depression of varying degree during the antenatal period. Depression increases the risk of growth retardation in the fetus, premature birth and postpartum depression and complicates the bonding between mother and child. The current perception is that women who are taking antidepressants before pregnancy should continue to medicate and that insertation should be made when needed. However, many women do not want to use antidepressant drugs during pregnancy out of fear of adverse affects on the fetus, and for these women more options are needed. Midwifery includes supporting and nursing women during pregnancy, why knowledge about treatment options is important to the occupational group. Purpose  The purpose of this thesis was to investigate the non-pharmacological treatments available in pregnancy depression and their advantages and disadvantages. Method  A systematic review has been made where 28 articles were included in a total of 659 reviewed titles, 110 reviewed abstracts and 44 articles reviewed in full text. The included articles were analyzed with qualitative content analysis and quality assayed according to Willman, Stoltz and Bahtsevani, (2016). Results  The analysis of the results showed that many forms of non-pharmacological treatments may have mitigating or curing effects in the event of depression during pregnancy. It appears that treatment with yoga, treatment with mind-body therapy, treatment given to couples, treatment given digitally, treatment given in a group and treatment with psychotherapy or counseling  has a positive effect, albeit to a different extent. The result provides support for complementing the basic program of customized maternity care, which is desirable and helps women with antenatal depression and that the positive effect often persists after childbirth. Conclusion  This degree project showed that many non-pharmacological treatment methods can help women with antenatal depression. Access to treatment methods was usually high and few negative effects were observed. Women can from this be informed that research has shown that in addition to antidepressant medication there are non-pharmacological treatment methods that have a good effect on depression during pregnancy. Further research can show whether treatment options could be offered within the framework of maternal health care programs, and whether it is possible to reduce pregnancy complications caused by depression through these alternative therapies. KEYWORDS Antenatal depression, depression, maternity, perinatal depression, pregnancy, therapy, treatment

Depression i samband med graviditet förekommer hos ungefär 10% av gravida och medför risker för den gravida och barnet. Många erhåller inte behandling. IKBT kan öka behandlingstillgängligheten och har visat sig effektivt jämfört med sedvanlig mödravård. Utvärderingens syfte var att undersöka skillnader i depressionssymtom före och efter fyra veckor i en IKBT-behandling mot antenatal depression och att jämföra skillnaderna med en tidigare RCT på en snarlik behandling. Huvudfrågeställningen var huruvida depressionssymtom minskar hos patienter med antenatal depression efter fyra veckor i en IKBT-behandling. 26 personer deltog i behandlingen. Förmätning jämfördes med senast kända mätningen efter fyra veckor. Dessa och de veckovisa mätningarna fram till vecka fyra, jämfördes med två icke-randomiserade kontrollgrupper. Skillnad mellan förmätning och senaste mätningen avseende grad av depressionssymtom var signifikant i genomfört t-test och symtomreduktionen tycks vara i nivå med resultat från den tidigare RCT-studien. IKBT skulle således kunna utgöra ett behandlingsalternativ för gravida med depression. Slutsatser bör dras med försiktighet. Framtida forskning inom fältet är av vikt för att validera resultat och för att ge underlag till utvecklingen av behandling vid antenatal depression. / Pregnancy related depression exists in approximately 10% of pregnant people and adds risks for the pregnant individual and the baby. Many are not treated. ICBT may increase the treatment availability and appears to be more effective than conventional maternal health care. The purpose of this evaluation was to examine differences in symptoms of depression before and after four weeks of ICBT-treatment for antenatal depression and to compare the differences with a prior RCT of a similar treatment. The main research question was whether symptom of depression decreases in patients with antenatal depression after four weeks when being treated with an ICBT-treatment. 26 persons participated in the treatment. Pre-measures was compared to the most recent measurement after four weeks. These, and the weekly done measurements up to week four, was compared with two non-randomized control groups. The difference between pre-measures and the most recent measurement regarding degree of depressive symptoms was significant in completed t-test and the reduction of symptoms appears to be on a par with results from the prior RCT. ICBT could be a treatment alternative for pregnant people with depression. Conclusions should be done with caution. Further studies in this field are of importance for validating results and to provide knowledge for the development of treatment for antenatal depression.

Background: Antenatal depression is relatively a new area of study compared to postnatal depression and the depth and sophistication of this research is yet developing. For instance, very little is reported on the specific role of the risk factors as moderators and mediators to explain the variability in the magnitude of exposure and the causal pathway for depression during pregnancy. Moderators are those variables that are not modifiable (e.g., ethnicity, and gender), or have qualitative character or nominal in nature, and could also often be antecedent to other independent variables (e.g., behavioural and psychosocial) and depression. Mediators are those variables that may be better able to describe the pathway that connects a predictor to an outcome and intervention can be designed targeting mediators as they are causally related to the outcome. This thesis will address this gap in research and provide empirical evidence to increase the understanding of the role of each identified risk factors that could potentially influence maternal mental health interventions. Methods: In this thesis, I have used the Feelings in Pregnancy and Motherhood (FIP) study. This was a longitudinal study and 649 pregnant women participated in the study. Women were interviewed three times over the course of their pregnancy and the immediate postpartum. Depression status was assessed by the Edinburgh Postnatal Depression Scale (EPDS); sociodemographic characteristics, psychosocial and behavioural information were collected at each time point. Depression status in late pregnancy and postpartum were the two outcomes of interest. Non-modifiable sociodemographic risk factors were considered as moderators. Behavioural and psychosocial variables were considered as mediators. Moderators and mediators were tested through series of regression analysis. Results: In modeling moderating effects in late pregnancy, low income women who were in poor marital relationships (β=1.54; p<0.05) and partnered women (married or common law) who reported having used recreational drugs (β= -1.62; p<0.05) were more likely to be depressed. Young mothers with low social support (β= 1.04; p=0.15) and Aboriginal mothers with low social support (β= 1.12; p=0.17) were also almost significantly noted to have depression symptoms in late pregnancy. In mediating analysis for late pregnancy, psychosocial mediators such as stress, social support, and marital satisfaction, and behavioural factors, such as smoking and recreational drug use exerted partial or full mediating effect for depressive symptoms in women in late pregnancy. In moderating analysis for postpartum, Aboriginal women who had never exercised in late pregnancy were found to be depressed at postpartum compared with non Aboriginal mothers who did not exercise. In looking at mediating effects in postpartum, smoking at late pregnancy exerted full mediating effects for ethnicity and marital satisfaction pathways, and partial mediating effects for age, education, and stress pathways in predicting depression in postpartum period among mothers. Conclusion: Depression, particularly during pregnancy and in postpartum, is a top priority for women themselves, their families, care providers, and society in general. This study found that characteristics of women or their psychosocial or behavioural experiences could have specific effects such as either a mitigating or exacerbating role, or a mediating role, in depression in late pregnancy or in postpartum. This information could be strategically used by clinicians or by health promotion professionals to either target or provide tailored programs to women who might experience depression during pregnancy and postpartum.

Magister Public Health - MPH / Common perinatal mental disorders (CPMDs) are increasingly being recognised as an important public health issue including depression and anxiety. In low and middle income countries such as Rwanda, CPMDs are prevalent among women in perinatal period. In Africa, the estimated prevalence rates of depression are 11.3% and 18.3% during ante-postnatal respectively, while ante-postnatal anxiety rates are 14.8% and 14% respectively. However, in Rwanda there is limited literature on CPMDs. This study was aimed at determining the occurrence of CPMDs in a selected district hospital of the Eastern Province in Rwanda as well as the factors associated with CPMDs in the selected study area. A descriptive quantitative cross-sectional survey was conducted with a sample of one hundred and sixty five mothers in perinatal period, who were selected systematically. Demographic data and factors associated with CPMDs were determined using structured questionnaire and combined screening tools such as Zungu Self-rating anxiety scale (SAS) and Edinburgh Postnatal Depression Scale (EPDS). The Cronbach alpha values were 0.87 and 0.89 for SAS and EPDS respectively. SPSS Version 21 was utilized to analyse data. Univariate, bivariate correlational and multivariate analyses were performed. Most of the respondents (38.2%) were aged 25-29 years; Protestants (77.6%); married (44.8%); unemployed (77%) and had a primary school level of education (60.6%). With respect to participants in antenatal period (51.5%); 14.5% had a clinical level of anxiety and 19.4% had depression. In terms of participants in postnatal period (46.7%); 22.5% had a clinical level of anxiety and 29.7% had depression. However, participants in both periods (1.8%) all had a normal level of anxiety and 1.2% had depression.

Antenatal depression (depression under graviditeten) drabbar 10–20% av gravida och innebär risker för både den gravida och barnet. Forskning visar att internetbaserad kognitiv beteendeterapi (IKBT) tycks vara effektivt jämfört med sedvanlig mödravård. Uppsatsen var en sambands- och prediktionsstudie som genomfördes inom den randomiserade DANA-studien för IKBT vid antenatal depression. En inomgruppsdesign med upprepade mätningar tillämpades där 40 kvinnor med antenatal depression deltog. Syftet var att undersöka (a) patientnöjdhet med bedömningssamtalet i relation till behandlingsföljsamhet, avhopp och minskning av depressionssymtom under IKBTbehandlingen, samt (b) jämföra förändring i depressionssymtom mot två tidigare studier. Resultatet visade att en högre patientnöjdhet med bedömningssamtalet signifikant predicerade en mindre minskning av depressionssymtom mellan screening och förmätning. Inga signifikanta samband hittades mellan patientnöjdhet med bedömningssamtalet och behandlingsföljsamhet eller avhopp. Slutsatser bör dras med stor försiktighet utifrån metodologiska begränsningar. Resultatet visade även att depressionssymtom jämfört med förmätningen signifikant minskade från andra veckomätningen i behandlingen till och med eftermätningen vecka tio. Detta bekräftade tidigare studiers resultat. Framtida randomiserade prövningar kan ge underlag till utvecklingen av bedömningssamtal och IKBT mot antenatal depression. / Antenatal depression (depression during pregnancy) affects 10–20% of pregnant women and involves risks for both the pregnant woman and the child. Research shows that internet-based cognitive behavioral therapy (ICBT) seems to be effective compared to conventional maternity care. The thesis was a correlational predictive study that was conducted within the randomized DANAstudy for ICBT during antenatal depression. An in-group design with repeated measurements was applied in which 40 women with antenatal depression participated. The purpose was to examine (a) patient-satisfaction with the assessment interview in relation to adherence, dropouts and remissionof depressive symptoms during ICBT treatment, and (b) compare changes in depressive symptoms against two previous studies. The result showed that a higher patient-satisfaction with the assessment interview significantly predicted a lesser reduction of depressive symptoms between screening and pre-measurement. No significant correlations were found between patient-satisfaction with the assessment interview and treatment adherence or dropouts. Conclusions should be drawn with great caution based on methodological limitations. The result also showed that depressive symptoms compared with the pre-measurement decreased significantly from the second weekly measurement in the treatment until the post-measurement week ten. This confirmed the results of previous studies. Future randomized trials may provide a basis for the development of assessment interviews and ICBT for antenatal depression.

I Sverige drabbas ca 10 - 20% av kvinnor av depression under graviditeten eller efter förlossningen. Då tidigare forskning har gett indikationer på att depression kan ha en negativ inverkan på prenatal anknytning och mamma-barn bindning, är syftet med uppsatsen att undersöka detta hos mammor som genomgått internetbaserad kognitiv beteendeterapi (IKBT) för antenatal depression.  Denna uppsats skrevs i samarbete med den randomiserade DANA-studien om IKBT för gravida med depression. Uppsatsen var en prediktions- och sambandsstudie som tillämpar en inomgruppsdesign med tre mättillfällen; före och efter IKBT behandling samt postpartum.  Syftet med uppsatsen var bland annat att undersöka vilka faktorer som förutsäger mamma-barn bindning 8–10 veckor postpartum, samband mellan prenatal anknytning och behandlingsutfall samt samband mellan förändring i depression och förändring i prenatal anknytning under behandlingen. Resultatet indikerar att tidigare missfall samt prenatal anknytning före och efter behandlingen, kunde förutsäga mamma-barn bindning 8-10 veckor postpartum. Prenatal anknytning var inte en signifikant prediktor för förändring i depressionsnivå. Slutligen indikerar resultatet ett signifikant samband mellan förändring i prenatal anknytning samt förändring i depression före och efter behandlingen. / In Sweden, about 10-20% of women suffer from depression during pregnancy or after childbirth. As previous research has given indications that depression can have a negative impact on prenatal attachment and mother-infant bonding, the aim of the essay is to investigate this in mothers who underwent internet-based cognitive behavioral therapy (ICBT) for antenatal depression. This paper was written in collaboration with the DANA randomized trial of ICBT for pregnant women with depression. The design was a prediction and correlation study that applies a within-group design with three measurement occasions: before and after ICBT treatment and 8-10 weeks after childbirth. The purpose of the essay was, among other things, to investigate which factors predict mother-infant bonding 8–10 weeks postpartum, the relationship between prenatal attachment and treatment outcome, and the relationship between change in depression and change in prenatal attachment during treatment. The results indicate that previous miscarriages and prenatal attachment before and after treatment could predict mother-child bonding 8-10 weeks postpartum. Prenatal attachment was not a significant predictor of change in depression level. Finally, the results indicate a significant relationship between change in prenatal attachment and change in depression before and after treatment.