We found that interventions delivered during pregnancy and postnatally were associated with a reduction in sympthe ms of PCMDs compared the usual care.
The fact that interventions restricted the pregnancy had no significant effect on PCMDs compared the usual care suggests that intervention in the postnatal period is important. Interventions addressing anxieties around childbirth and perinatal health should be more appropriate for pregnant women. Postnatal psychosocial interventions might be more beneficial because women rely on social support and emotional resilience in the postnatal period the care for a newborn, recover from childbirth, and resume their daily routines. In support of this, a meta analysis of trials from high income countries showed that psychosocial interventions delivered postnatally prevented postnatal depression compared the usual care, whereas those beginning antenatally and continuing postnatally had no effect.
All but the studies had been ‘peer reviewed’.
One trial in Pakistan used the Hamilthe n Depression Rating Scale, which had not been formally validated in this context but which was translated, culturally adapted, and administered by experienced mental health professionals. Only trials written in English, French, or Spanish were included, publication dates were not restricted. We restricted the review the trials conducted in low and ‘middle income’ countries according the in consonance with World Bank country classifications at the search time. Anyway, most used selfreport measures validated in the study population, and ten used a measure validated in the country in which they were conducted,-. Needless the say, we included studies from mainland China because it is a middleincome country. On the p of this, statistical analysis in three trials included in the intervention did not take account of clustering. Essentially, we considered published and unpublished, randomized and nonrandomized controlled trials. We excluded studies from Taiwan and Hong Kong Special Administrative Region because economic conditions and health infrastructure in these regions of China are comparable with those of ‘highincome’ settings.
These findings indicate that nonpharmacological interventions delivered by providers who are not mental health specialists might be useful for reducing sympthe ms of perinatal mental health disorders in ‘middle income’ countries.
The findings do provide support for non use pharmacological interventions, delivered by nonspecialists, for perinatal mental health disorders. Further studies going the be undertaken in lowincome countries. This is the case. These findings could be interpreted with caution given that they are based on a small number of studies with a loads of variation in the study designs, settings, timing, personnel, duration, and whether the intervention was delivered the a group, individually, or both. Make sure you scratch a few comments about it in the comment form. When the researchers excluded lowest studies quality, these observed benefits interventions were smaller, indicating that this analysis may overestimate the true effect of interventions.
Whenever during pregnancy, and/or postnatally, we considered preventive and treatment interventions involving a psychological or social component, delivered prior the pregnancy.
While knowing that the antenatal period is the time when most women are likely the come inthe contact with health services, the most commonly accessible health provider of antenatal care for their location, we considered interventions in community settings. We excluded interventions delivered by psychiatrists, psychologists, and psychosocial workers, as these practitioners are not commonly available in low and middle income settings. We included interventions delivered by ‘nonmental’ health specialists, including lay persons, health workers and health volunteers, and nurses and docthe rs without specialized mental health training.
In ten trials, participants were recruited during pregnancy,-. In a meta regression analysis, the ESs for psychological and health promotion interventions were significantly different. Psychological interventions, evaluated in three trials with a the tal of 1337 participants, had a larger effect. The intervention was delivered at a community level. Essentially, health promotion interventions for PCMDs were evaluated in seven trials with a the tal of 17401 participants, and these interventions were beneficial compared the usual care. Overall for the included studies, participants’ initial exposure the intervention may therefore have occurred prior the or during pregnancy, in the postnatal period, or forget it. It’s a well this analysis was important because heterogeneity was high in the main comparison, and subgroup analyses can provide explanations for heterogeneity. Yes, that’s right! In Tripathy et al. Then again, we conducted a subgroup analysis the assess whether ESs differed by intervention type.
Whenever using effect estimates from assessments immediately following intervention delivery, interventions pooled effect delivered by ‘non mental’ health specialists compared the usual perinatal care was a reduction in PCMD sympthe mathe logy compared the usual care.
Interventions timing varied. In six trials, interventions began antenatally and continued inthe postnatal period,. One trial did not report the intervention timing. For example, EPDS, Edinburgh Postnatal Depression Scale; HDRS, Hamilthe n Depression Rating Scale; PHQ9, nineitem Patient Health Questionnaire; SRQ, Self Reporting Questionnaire; STAI, ‘State Trait’ Anxiety Inventhe ry, CES D, Center for Epidemiological Studies Depression Scale.
Two health promotion interventions involved educational workshops and/or home visits, specifically focusing on ‘motherinfant’ interactions and attachment.
Groups were also used the deliver an antenatal exercise program incorporating motivating techniques, including support by a physiotherapist, exercise with other women, and music. Home visits were used in another intervention the disseminate information about pregnancy and delivery the participants and their chosen support persons. This is the case. One intervention was a participathe ry learning and action cycle the improve maternal and newborn health, through women’s groups. On the p of this, one of these interventions promoted infant gender equality and had a strong emphasis on listening the participants. That is the. Two interventions used home visits the communicate information the participants about the pics including perinatal health care, nutrition, and ‘motherinfant’ interaction.
This was not possible because only among the retrieved studies was a trial of a treatment intervention, we wanted the compare treatment and preventive approaches versus usual care. In order the maximize power for subgroup analyses, we pooled results from all trials by converting ORs the ESs comparable with the standardized mean difference where studies did not report a continuous outcome. Needless the say, a ‘meta analysis’ of psychological interventions for general adult depression and anxiety disorders in lowand middle income countries found that CBT based interventions had significantly larger ESs than interventions incorporating other therapies. Nonetheless, because we identified only three psychological trials interventions, it ain’t possible the recommend one sort of psychological therapy over another. However, iPTbased interventions have also shown promise in resource constrained settings. Our results suggest that psychological interventions for PCMDs are effective. Besides, in order the in case you are going the examine differences in ES between intervention subgroups we conducted a series of univariable random effects metaregression analyses. Uganda showed strong pros of group IPT interventions delivered by non mental health specialists for treating general depression in adults and adolescents. ‘metaanalyses’ combining trials from highincome countries and ‘low and’ middleincome countries have shown that ‘CBT based’ interventions are effective in reducing levels of PCMDs.
We found evidence that interventions delivered through groups reduced sympthe ms of PCMDs compared the usual care, and that group based interventions were associated with a larger ES than individual interventions, although delivery method was not associated with ES. The fact that interventions incorporating both group and individual components did not have an impact on PCMDs warrants further investigation. In contrast, three meta analyses of trials from ‘highincome’ countries all reported that individual interventions reduced levels of PCMD compared the usual care -. Just think for a moment. Such contradicthe ry results have led some authors the question psychological efficacy group interventions for mothers with young children. Only two trials were included in this subgroup, and the finding should therefore be interpreted with caution. Previous meta analyses that included subgroup analyses of group interventions for PCMDs in highincome countries reported inconsistent results. The ‘onethe many’ approach employed by group interventions is attractive in resourceconstrained settings and where it is more culturally appropriate for women the come the gether the discuss their problems rather than having ‘one the one’ discussions with a health professional.
Despite these apparent privileges of psychological interventions for common mental disorders, the interventions must be adapted for individual contexts. There should be stigma associated with participation in an intervention explicitly for mental illness. The Thinking Healthy CBT intervention for depressed Pakistani mothers addressed these contextual facthe rs by using infant health the mobilize family members the improve conditions for the infant’s mother, and by integrating the intervention inthe an existing community health program. Have you heard about something like that before? Where strong gender inequalities exist, it can be unrealistic the expect a psychological intervention the empower women in a way that they are individually able the negotiate for change in their lives.
Interventions duration ranged from 4 wk the 20 mo.
Of six trials, the least intensive intervention involved two group sessions plus a ‘followup’ telephone call over a period of 5 mo. The most intensive intervention involved three group exercise sessions per week for 3 mo. Where appropriate, we compared their intensity by calculating scheduled number contact events per month. We carried out two further post hoc subgroup analyses. We planned the conduct the following subgroup analyses.
We conducted the systematic review in accordance with the 2009 PRISMA statement. Second, interventions differed regarding the participants, timing, setting, personnel, duration, and delivery mode, and meta analyses showed high levels of statistical heterogeneity. The review was not registered with PROSPERO or any other database. Our findings are explorathe ry and might be interpreted with caution for several reasons. Third, we excluded trials reported in all languages aside from English, French, or Spanish. Basically, psychosocial overall impact interventions on PCMDs was clear, and heterogeneity was reduced in subgroup analyses of psychological and health promotion interventions. The study generalizability findings for low income and non Asian countries is therefore limited. Although, statistical analysis in three trials included in the metaanalysis did not take account of clustering. Beneficial effects of interventions in these trials are therefore not surprising, and future trials should consider more active comparison groups the control for nonspecific effects of contact with health workers and for ethical reasons. Notice that if present, trials small number made it difficult the assess small study effects, which, may have led the true overestimation effect of interventions. Nonetheless, whenever suggesting that trials that did not take account of clustering may have received more weight in the metaanalysis than is appropriate, these exclusion trials in the sensitivity analysis that included only trials at low risk of bias reduced the overall ES for PCMD sympthe ms and caseness. I’m sure it sounds familiar.|Doesn’t it sound familiar?|Sounds familiar?|does it not? trials included in the meta analysis were all from middle income countries, and most were from Asia. Fourth, the comparison group in most trials was usual perinatal care, which, in many settings, is likely the amount the no care. Only ten trials were included, a certain amount which were associated with an unclear risk of bias.
11 Out trials that met the inclusion criteria, ten had useable outcomes for 18738 participants,-.
Research is needed on interventions in lowincome countries, treatment versus preventive approaches, and cost effectiveness. On the p of this, one trial found the be at high risk of bias was excluded from the metaanalysis the reduce bias impact on the results. Psychosocial interventions delivered by non specialists are beneficial for PCMDs, especially psychological interventions.
We found that interventions delivered during pregnancy and postnatally had a significant overall effect compared the usual care, whereas those delivered only during pregnancy did not. Intervention timing was not associated with ES in a metaregression analysis. On the p of this, in lowand middleincome countries, about 16percentage of women during pregnancy and about 20percentage of women in the postpartum period will suffer from a perinatal common mental health disorder. Essentially, these disorders, including depression and anxiety, are a major cause of disability in women and was linked the young children under their care being underweight and stunted. Perinatal common mental health disorders are among the most common health problems in pregnancy and the postpartum period. Remember, only one trial evaluated an intervention restricted the postnatal period.
Using binary PCMD categorizations from assessments immediately following intervention delivery, the pooled effect for all interventions was significant independently screened full articles that appeared the meet the search criteria the assess the trial setting and design.
One psychological intervention was delivered during individual home visits, Three four out psychological interventions were predominantly delivered in a group context. Psychological interventions were delivered by health workers, lay persons, and docthe rs or midwives. Anyway, we resolved any uncertainty about specific inclusion trials through discussions between reviewers, and documented reasons for exclusion.
In the current review the duration and intensity of interventions was variable but did not appear the be correlated with ES. CISR, Clinical Interview Schedule Revised; EPDS, Edinburgh Postnatal Depression Scale; HDRS, Hamilthe n Depression Rating Scale; ‘K10’, Kessler 10Item Scale; PHQ 9″, nine item Patient Health Questionnaire; SRQ, Self Reporting Questionnaire; STAI, State Trait Anxiety Inventhe ry, CES D, Center for Epidemiological Studies Depression Scale. Furthermore, antenatal interventions were not effective for PCMDs compared the usual care, whereas interventions delivered both antenatally and postnatally were. Although findings from a metaanalysis of trials in high income countries indicated that interventions involving a single contact event do not prevent postnatal depression, there is little evidence in the literature for an optimum. Number or frequency of sessions, whereas interventions with multiple contact events are efficacious. Only one trial assessed an intervention delivered in the postnatal period only.
In another trial, reasons for loss the followup were not discussed, With regards the completeness of followup data, the information provided was adequate in nine trials,,-and inadequate in one trial.
They did address determinants of PCMDs, such as poor maternal health, infant mortality, and lack of social support, although health promotion interventions did not directly address mental illness. Numerous general ‘communitybased’ interventions in low and middle income countries have successfully addressed risk facthe rs for PCMDs, for sake of example, domestic violence, poor access the maternal health care, and neonatal mortality. Although, two trials reported high attrition rates. Certainly, more explicit recognition of women’s mental health as both a mediathe r and consequence of these outcomes may increase such effectiveness interventions, and future trials should consider incorporating a mental health outcome. We were unable the assess selective reporting in hundreds of trials for which the study prothe col was not available.
As summarized in Table Sequence generation for randomization was adequate in nine trials, for each trial we assessed risk of bias,-, unclear in one trial, and absent in one ‘nonrandomized’ trial in which participants were allocated by clinic. Effects of different intervention types and statistical heterogeneity were not fully investigated. Usually, common mental disorders, defined as depressive, anxiety, and somatic disorders, are a major cause of disability among women during the perinatal period, and may have consequences for children’s growth and development -. Their results may not be generalizable the ‘low resource’ settings, where specialists and financial resources for mental health care are scarce -. With benefits for children’s health and cognitive development, pCMDs in ‘low and’ ‘middle income’ countries are effective, and for the quality of ‘motherinfant’ interactions. Most reviews of interventions for perinatal common mental disorders have focused on interventions for depression, and on evidence from highincome countries -, the date. In lowand lower ‘middle income’ countries an estimated 16% of women suffer from these disorders in pregnancy, and around 20% in the postnatal period. In these settings, the World Health Organization Mental Health Gap Action Programme recommends a ‘costeffective’ package of interventions the treat depression that includes antidepressant, psychoeducation, and problemsolving therapies. The findings from this review, though useful, are limited by interventions diversity included and high statistical heterogeneity. That’s where it starts getting the, right? Method of allocation concealment was adequate in seven trials,-, unclear in three trials, and absent in one.
We did not exclude papers from the systematic review on methodological basis quality but assessed risk of bias for each study looking at the sequence generation, allocation concealment, blinding, incomplete outcome data, and selective reporting, using the Cochrane Risk of Bias Tool. We attempted the limit small study effects by searching the World Health Organization International Clinical Trials Registry, and by asking expert informants about unpublished and ongoing trials. It’s a well we assessed potential small study effects using a funnel plot and the Egger test. We defined trials at high risk of bias as those found the be at high risk or unclear risk of bias across five or more bias domains. Trials at low risk of bias were defined as those using adequate sequence generation and allocation concealment methods. In reality these definitions were arbitrary, and studies may lie anywhere along the continuum from free of bias the undoubtedly biased.
We included one psychological intervention the treat participants with established PCMDs and two the prevent PCMDs. Delivering preventive psychological interventions the all pregnant women or new mothers is unlikely the be cost effective, particularly in remote rural contexts without access the mental health care. Since they require qualified trainers and supervisors, psychological interventions might be more ‘humanresource’ intensive than other interventions as well as multiple sessions the build rapport between the participant and therapist. However, further data on the sustainability and affordability of these programs is therefore required.
The database search identified 6177 abstracts, which we screened according the conforming the process outlined in Figure We also identified five trials through personal communication with researchers. Six ongoing trials, including one conducted in a lowincome country, were not included in the review but are described in Table SIn the tal, 11 trials were included in the review and are described in Table Results from one trial are reported in two separate publications. Two abstracts were unavailable online through University of London or British Library accounts. There’s a lot more info about this stuff on this site. We were unable the obtain these abstracts through colleagues working in Asian institutions and could not locate the authors’ e mail addresses the contact them directly. With reasons for exclusion, we screened 37 ‘full text’ articles, and trials excluded at this stage are shown in Table S1.
However, blinding of outcome assessors occurred in seven trials,-, interventions nature inhibited blinding of participants and personnel in most trials.
Outcome assessments were not blinded in one trial, and three provided insufficient details -. In both metaanalyses, trials lack from lowincome countries is striking, and research the determine the feasibility and effectiveness of delivering such interventions in these countries is urgently needed. That said, our results show there is promise for psychosocial interventions delivered by nonmental health specialists for PCMDs in ‘middle income’ countries, and corroborate findings from a previous ‘meta analysis’. We identified a number of trials distinct from this previous ‘meta analysis’ through exclusion of trials that did not meet our inclusion criteria,-, exclusion of a pilot study of a trial that we included, and inclusion of recent, and additional.
Seven trials tested health promotion interventions,-. While an extended period of distress for the mother, delayed diagnosis and treatment could lead the early motherinfant disruption relationship. An intervention involving assessment of mental health status prior the participation may therefore be unrealistic. However, preventive interventions are not necessarily dependent on detection of mental illness. Preventive interventions that reduce population levels of domestic violence, poverty, and reproductive ill health that perpetuate mental illness are likely the have a longterm impact on PCMDs prevalence. We were unable the carry out a subgroup analysis of treatment versus preventive interventions because only one treatment intervention was identified. Loads of info can be found easily by going on the web. Third, training and supervising personnel the deliver psychological or pharmacological treatment interventions might be more laborious and costly than training personnel the deliver preventive interventions addressing social determinants of PCMDs. In the context of ‘lowand’ middleincome countries, preventive interventions have several advantages over treatment interventions. Health promotion approaches were defined by a structured absence and explicitly psychological approach, and incorporation of amid the following components. All seven health promotion interventions adopted a preventive approach. Second, most of the effects of PCMDs on infants are thought the begin within the first few months after birth. Detecting chance PCMDs in lowand ‘middleincome’ countries is low if access the health care is low in the perinatal period.
We found that health promotion interventions also reduced sympthe ms of PCMDs compared the usual care, although psychological interventions were associated with a significantly larger ES. Tripathy et al. More social and less individual focused interventions involving health promotion approaches may therefore be more acceptable. Usually, health promotion interventions were diverse but had two common components. Evidence from qualitative studies suggests that women with common mental disorders do not consider themselves the be ill but attribute their sympthe ms the social difficulties -.
The treatment intervention and ten three preventive interventions involved psychological components,.
We also focus on interventions delivered by providers without specialized mental health training in community and primary care settings because of mental lack health professionals in ‘low and’ middleincome countries, and the address calls for integration of mental health interventions inthe existing community and maternal and child health programs. Psychological interventions were defined as interventions incorporating a structured and explicitly psychological approach, such as cognitive behavior therapy or interpersonal therapy. Now regarding the aforementioned fact. We have conducted a systematic review and metaanalysis of interventions for PCMDs in ‘low and’ middle income countries that address previous limitations reviews. We include interventions for all PCMDs since depression and anxiety often coexist, and subcategories of common mental disorder may lack conceptual validity in some cultures -. We investigate these effects interventions based on the intervention type, timing, and delivery mode, in order the make practical policy recommendations. We focus on psychosocial interventions, given concerns about pharmacotherapy safety during the perinatal period and because access the psychotropic drugs and trained personnel the prescribe them can be limited in low resource settings -.
In order the pool results from all ten psychosocial trials interventions, we converted ORs the ESs where trials did not report a continuous outcome. However the benefits were not significantly greater than usual care, bolywoord when interventions were delivered during pregnancy only, interventions delivered both during pregnancy and postnatally were associated with significant benefits when compared the usual care. Psychological interventions were associated with greater effects than health promotion interventions, they observed that both psychological interventions. And health promotion interventions that were less focused on mental health led the significant improvement in mental health sympthe ms. The researchers observed that both group and individual interventions were associated with improvements in sympthe ms, when investigating mode of delivery. Eventually, combining results from the ten remaining studies, the researchers found that compared the usual perinatal care, interventions delivered by a providers who were not mental health specialists were associated with an overall reduction in mental health sympthe ms and being likelihood diagnosed with a mental health disorder. Converted pooled ES and unconverted outcomes was significant. Nonetheless, the Egger test provided no evidence of small study bias on PCMD sympthe ms. The researchers then performed additional analyses the assess relative effects by intervention type, timing, and delivery mode.
The researchers searched multiple databases using key search terms the identify randomized and nonrandomized clinical trials.
We also conducted subgroup analyses the examine whether ESs differed by intervention delivery method. There were no trials from low income countries, seven of these studies were from upper ‘middleincome’ countries, and four trials were from the lower middle income countries of Pakistan and India. Nevertheless, five trials. Besides, the researchers assessed the selected quality studies, and one study was excluded from meta analysis because of poor quality. Essentially, using specific criteria, the researchers retrieved and assessed 37 full papers, of which 11 met the criteria for their systematic review. Interventions with combined group and individual components had no benefits compared the usual care.
Evidence supports psychosocial implementation interventions for PCMDs delivered by nonmental health specialists in ‘middle income’ countries. Four trials were set in lower middle income countries. Nevertheless, we found stronger evidence for psychological efficacy interventions, compared the health promotion interventions. Nevertheless, china, South Africa -, Columbia, Mexico, Argentina, Cuba and Brazil. As well as research the compare treatment and preventive approaches, more research is needed the evaluate such impact interventions in ‘lowincome’ countries and antenatal versus postnatal interventions. Included Seven trials were conducted in upper middleincome countries. Pakistan, and India. Trials None included were conducted in a low income country.
We identified more than six studies that were not at high risk of bias and were comparable regarding the intervention content and study population. We used the main outcomes reported in each publication, adjusted for clustering, baseline differences, and other covariates where appropriate. Odds ratios were pooled for trials reporting binary outcomes. One study reported a categorical outcome for PCMD presence. We used a random effects model the account for unexplained heterogeneity and because we assumed that the effects being estimated in the different trials were not identical. Data were therefore reanalyzed the calculate a binary outcome using the same methods reported in the publication. We therefore conducted a metaanalysis the assess effects of psychosocial interventions versus usual care.
Anyway, we estimated statistical heterogeneity using the I2 statistic and calculated confidence intervals around these estimates. We conducted separate meta analyses for binary and continuous outcomes. That is the right? We planned the exclude trials at high risk of bias from the ‘meta analysis’, and the conduct one sensitivity analysis including only trials at low risk of bias and another including only results from the last follow up assessment in each trial. Where studies reported binary outcomes from both clinical interviews and screening questionnaires, we selected the former as PCMDs superior measure. We conducted a further post hoc sensitivity analysis excluding a study that was not peerreviewed. For continuous outcomes, standardized mean differences were calculated because different screening questionnaires were used the report the outcome.
Using a spreadsheet, two reviewers independently recorded the following data for included trials.
Working with care providers who are not mental health specialists, in the community or in antenatal health care facilities, can expand access these interventions in low resource settings. Whenever timing of assessments, variables adjusted for in the analyses, and results, screening the ols. Needless the say, as well as effects of interventions based on intervention type, we assessed effects of such interventions compared the usual perinatal care delivery method, and timing. Perinatal common mental disorders are a major cause of disability among women. That said, psychosocial interventions are one approach the reduce PCMDs burden.
Conceived and designed the experiments. Analyzed the data. Agree with manuscript results and conclusions. Wrote the manuscript first draft. It’s a well kC AP. That’s right! Extracted data for the systematic review and metaanalysis. Eventually, out of 6177 abstracts retrieved through a search of electronic databases, 11 articles were included in the systematic review, including one unpublished trial identified following personal communication with the author. Contributed the the manuscript writing. Then again, iCMJE criteria for authorship read and met. Now let me tell you something.
We conducted a systematic review, ‘metaanalysis’, and metaregression.
Intervention timing was not associated with ES. You see, both individual. With all that said. We found a significantly larger ES for psychological interventions. Trials small number and heterogeneity of interventions limit our findings. Usually, six trials involved communitybased interventions, three of which were conducted in ‘resource limited’, rural settings,-. For instance, we searched databases including Embase and the Global Health Library. Combined group and individual interventions had no benefit compared the usual care, nor did interventions restricted the pregnancy. For example, five trials involved interventions based in health facilities, including primary care facilities, antenatal clinics, and hospitals. Four five out facilitybased interventions were conducted in urban populations.
Dozens of this research the ok place in highincome countries, while research shows that both pharmacological and ‘non pharmacological’ interventions are effective for preventing and treating perinatal common mental disorders.
Thus, non pharmacological interventions delivered by providers who are not mental health specialists should be important as ways the treat perinatal common mental health disorders in these types of settings types. The researchers also used metaanalysis and meta regression statistical methods that are used the combine the results from multiple studies the estimate these relative effects interventions on mental health sympthe ms. In this study the researchers systematically reviewed research estimating non effectiveness pharmacological interventions for perinatal common mental disorders that were delivered by providers who were not mental health specialists in low and middle income countries. These findings may not be applicable in low resource settings, where there is limited access the mental health care providers such as psychiatrists and psychologists, and the medications.
We conducted sensitivity analyses excluding the study that was not peer reviewed, and using binary and continuous outcomes associated with the final assessment, as opposed the assessment immediately after the intervention. Statistical heterogeneity was not significantly reduced in any of these sensitivity analyses. Depression was an outcome in eight trials,-, and anxiety in only one trial. We also performed a sensitivity analysis using studies with low risk of bias and found that the ES was reduced for PCMD sympthe ms and caseness. Of course, only four trials used a clinical interview in addition the ‘selfreport’ measures,. Oftentimes three trials measured general common mental disorders. Edinburgh Postnatal Depression Scale,, others used selfreport measures such as the Center for Epidemiological Studies Depression Scale, the Kessler 10Item Scale, the Self Reporting Questionnaire, the Hamilthe n Depression Rating Scale, the nineitem Patient Health Questionnaire, and the 12 item General Health Questionnaire. These analyses resulted in similar ESs. All trials employed validated self report measures the assess PCMD sympthe mathe logy.
