Australian and New Zealand Journal of Obstetrics and Gynaecology 2015; 55: 59–63
DOI: 10.1111/ajo.12268
Original Article
Worries surrounding the first ultrasound do not bias the screening for depressive and anxiety symptoms during pregnancy Chantal QUISPEL,1 Gouke J. BONSEL,2 Witte J.G. HOOGENDIJK3 and Mijke P. LAMBREGTSE-VAN DEN BERG4 1
Departments of Psychiatry and Obstetrics and Gynaecology, Erasmus Medical Centre Rotterdam, 2Division of Obstetrics & Prenatal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Centre Rotterdam, 3Departments of Psychiatry and 4Psychiatry and Child and Youth Psychiatry, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
Introduction: Antenatal screening for depressive/anxiety symptoms could be biased by worries surrounding the first ultrasound (US). Therefore, we examined the potential influence of worries surrounding the first US on systematic screening for depressive/anxiety symptoms during pregnancy. Materials and Methods: We obtained data from 573 women screened consecutively in midwifery practices and hospitals in the Netherlands. Data included the Edinburgh Depression Scale (EDS), having had an US, and its perceived influence on women’s worries. Results: In total, 18% had EDS scores ≥10 (n = 105). Among 392 women who underwent an US, currently existing worries, introduced or unaltered by the US, predicted depressive/anxiety symptoms (aOR: 3.41, P < 0.001). Among 181 women who did not undergo an US, expected continuation of existing worries after the US predicted depressive/anxiety symptoms (aOR: 18.84, P = 0.046), in contrast to worries which were expected to subside. Discussion: In our cohort, depressive and/or anxiety symptoms were not associated with transient worries, reduced by a first US, suggesting no bias. If true, antenatal screening for anxiety/depressive symptoms should not depend on the timing of this US examination. Key words: anxiety, depression, pregnancy, screening, timing, ultrasonography.
Introduction For the detection of depressive and anxiety symptoms during pregnancy, the validated 10-item Edinburgh Depression Scale (EDS) is the most commonly used questionnaire.1 The EDS asks for depressive and anxiety symptoms in the past seven days and results in a sum score ranging from 0 to 30. An EDS score of 10 or more indicates clinically relevant symptoms.2 However, psychiatric treatment is not necessary for all women who score above this threshold. In some cases, an elevated EDS score reflects transient psychiatric symptoms related to stress-inducing circumstances. We hypothesised the first ultrasound (US) examination during pregnancy to be such a stress-inducing circumstance.
Correspondence: Miss Chantal Quispel, Departments of Psychiatry and Obstetrics & Gynecology, Erasmus MC, University Medical Centre Rotterdam, Room Wk-221, PO Box 2040, 3000 CA Rotterdam, The Netherlands. Emails: [email protected], [email protected] Received 30 May 2014; accepted 30 August 2014.
In the Netherlands, all pregnant women receive an US examination during their booking visit which on average takes place around the tenth week of gestation. This first US is conducted to verify whether the pregnancy is viable and to determine the gestational age. This US is typically followed by a nuchal translucency scan at 11- to 14-week gestational age and a malformation scan at 20-week gestational age. The period surrounding the first US is experienced as exciting, yet uncertain, and may lead to maternal worries.3,4 In a recent pilot on screening for depression during pregnancy,5 women with depressive and/or anxiety symptoms following screening generally indicated that their high EDS score was the consequence of worries surrounding their first US and that these worries were substantially reduced after the confirmation of a vital pregnancy. This is in line with the recent study of Matthey and Ross-Hamid,4 who found depressive and/or anxiety symptoms to be transient during early pregnancy in some women. To avoid unnecessary referral of women with falsepositive screen outcomes, it is important to investigate the possibility that screening prior to the first US may bias screen outcomes. Therefore, we examined the hypothesised influence of the first routine US on systematic screening for depressive and anxiety symptoms during pregnancy.
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists The Australian and New Zealand Journal of Obstetrics and Gynaecology
59
C. Quispel et al.
Table 1 Questions addressing the first prenatal ultrasound (US) examination
Materials and Methods Data were generated using the validated Mind2Care screenand-advice instrument (formerly known as the GyPsy instrument),5 including the EDS,1 substituted with questions about socio-demographic characteristics, obstetric characteristics and experienced worries surrounding the first routine US examination. Mind2Care was developed by the Erasmus University Medical Center as a tool for screening and subsequent treatment allocation for psychiatric and psychosocial conditions during pregnancy. Prior to this study, the Mind2Care instrument was implemented from April 2011 to July 2013 consecutively in nine midwifery practices, two general hospitals and one tertiary hospital spread across a deprived urban area and a rural area in the Netherlands. All pregnant women who sufficiently mastered the Dutch language and were able to complete the questionnaire independently were invited to complete the Mind2Care on a handheld computer. As part of routine practice, 598 women completed the questionnaire prior to a pregnancy check-up. In four of the midwifery practices and hospitals, women received the Mind2Care prior to their first pregnancy check-up and thus prior to their first US. In the other practices and hospitals, women received the Mind2Care during a later check-up, and thus after their first US. The choice to screen women prior to their first check-up or a later check-up was based on practical reasons such as the availability of practice assistants or the possibility to invite a woman 10 min prior to her next appointment. Data were anonymously processed and stored in a database, and retrieved for secondary analysis. The study was performed in accordance with the ethical standards of the Medical Ethical Board of the Erasmus University Medical Center Rotterdam (MEC 2013-522, November 13th 2013) and with the Helsinki Declaration (1975, and its later amendments). Primary outcome measures were (i) EDS scores, with a score of 10 of more indicating clinically relevant depressive and/or anxiety symptoms; and (ii) the selfreported potential/perceived influence of the US on the women’s emotional state (see Table 1). Principal determinant was having had the first US at the time of screening (yes/no). Additional determinants included maternal age, ethnicity, socioeconomic status, educational level, parity and gestational age at screening. A post hoc sample size calculation showed that our sample was sufficient to detect proportional differences in EDS scores between the group of women who had had the first US and the group of women who had not had the first US (alpha 5% and a power of 0.80). Completeness of data was expressed as the proportion of missing data per woman and per variable. In case of
DOI: 10.1111/ajo.12268
Original Article
Worries surrounding the first ultrasound do not bias the screening for depressive and anxiety symptoms during pregnancy Chantal QUISPEL,1 Gouke J. BONSEL,2 Witte J.G. HOOGENDIJK3 and Mijke P. LAMBREGTSE-VAN DEN BERG4 1
Departments of Psychiatry and Obstetrics and Gynaecology, Erasmus Medical Centre Rotterdam, 2Division of Obstetrics & Prenatal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Centre Rotterdam, 3Departments of Psychiatry and 4Psychiatry and Child and Youth Psychiatry, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
Introduction: Antenatal screening for depressive/anxiety symptoms could be biased by worries surrounding the first ultrasound (US). Therefore, we examined the potential influence of worries surrounding the first US on systematic screening for depressive/anxiety symptoms during pregnancy. Materials and Methods: We obtained data from 573 women screened consecutively in midwifery practices and hospitals in the Netherlands. Data included the Edinburgh Depression Scale (EDS), having had an US, and its perceived influence on women’s worries. Results: In total, 18% had EDS scores ≥10 (n = 105). Among 392 women who underwent an US, currently existing worries, introduced or unaltered by the US, predicted depressive/anxiety symptoms (aOR: 3.41, P < 0.001). Among 181 women who did not undergo an US, expected continuation of existing worries after the US predicted depressive/anxiety symptoms (aOR: 18.84, P = 0.046), in contrast to worries which were expected to subside. Discussion: In our cohort, depressive and/or anxiety symptoms were not associated with transient worries, reduced by a first US, suggesting no bias. If true, antenatal screening for anxiety/depressive symptoms should not depend on the timing of this US examination. Key words: anxiety, depression, pregnancy, screening, timing, ultrasonography.
Introduction For the detection of depressive and anxiety symptoms during pregnancy, the validated 10-item Edinburgh Depression Scale (EDS) is the most commonly used questionnaire.1 The EDS asks for depressive and anxiety symptoms in the past seven days and results in a sum score ranging from 0 to 30. An EDS score of 10 or more indicates clinically relevant symptoms.2 However, psychiatric treatment is not necessary for all women who score above this threshold. In some cases, an elevated EDS score reflects transient psychiatric symptoms related to stress-inducing circumstances. We hypothesised the first ultrasound (US) examination during pregnancy to be such a stress-inducing circumstance.
Correspondence: Miss Chantal Quispel, Departments of Psychiatry and Obstetrics & Gynecology, Erasmus MC, University Medical Centre Rotterdam, Room Wk-221, PO Box 2040, 3000 CA Rotterdam, The Netherlands. Emails: [email protected], [email protected] Received 30 May 2014; accepted 30 August 2014.
In the Netherlands, all pregnant women receive an US examination during their booking visit which on average takes place around the tenth week of gestation. This first US is conducted to verify whether the pregnancy is viable and to determine the gestational age. This US is typically followed by a nuchal translucency scan at 11- to 14-week gestational age and a malformation scan at 20-week gestational age. The period surrounding the first US is experienced as exciting, yet uncertain, and may lead to maternal worries.3,4 In a recent pilot on screening for depression during pregnancy,5 women with depressive and/or anxiety symptoms following screening generally indicated that their high EDS score was the consequence of worries surrounding their first US and that these worries were substantially reduced after the confirmation of a vital pregnancy. This is in line with the recent study of Matthey and Ross-Hamid,4 who found depressive and/or anxiety symptoms to be transient during early pregnancy in some women. To avoid unnecessary referral of women with falsepositive screen outcomes, it is important to investigate the possibility that screening prior to the first US may bias screen outcomes. Therefore, we examined the hypothesised influence of the first routine US on systematic screening for depressive and anxiety symptoms during pregnancy.
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists The Australian and New Zealand Journal of Obstetrics and Gynaecology
59
C. Quispel et al.
Table 1 Questions addressing the first prenatal ultrasound (US) examination
Materials and Methods Data were generated using the validated Mind2Care screenand-advice instrument (formerly known as the GyPsy instrument),5 including the EDS,1 substituted with questions about socio-demographic characteristics, obstetric characteristics and experienced worries surrounding the first routine US examination. Mind2Care was developed by the Erasmus University Medical Center as a tool for screening and subsequent treatment allocation for psychiatric and psychosocial conditions during pregnancy. Prior to this study, the Mind2Care instrument was implemented from April 2011 to July 2013 consecutively in nine midwifery practices, two general hospitals and one tertiary hospital spread across a deprived urban area and a rural area in the Netherlands. All pregnant women who sufficiently mastered the Dutch language and were able to complete the questionnaire independently were invited to complete the Mind2Care on a handheld computer. As part of routine practice, 598 women completed the questionnaire prior to a pregnancy check-up. In four of the midwifery practices and hospitals, women received the Mind2Care prior to their first pregnancy check-up and thus prior to their first US. In the other practices and hospitals, women received the Mind2Care during a later check-up, and thus after their first US. The choice to screen women prior to their first check-up or a later check-up was based on practical reasons such as the availability of practice assistants or the possibility to invite a woman 10 min prior to her next appointment. Data were anonymously processed and stored in a database, and retrieved for secondary analysis. The study was performed in accordance with the ethical standards of the Medical Ethical Board of the Erasmus University Medical Center Rotterdam (MEC 2013-522, November 13th 2013) and with the Helsinki Declaration (1975, and its later amendments). Primary outcome measures were (i) EDS scores, with a score of 10 of more indicating clinically relevant depressive and/or anxiety symptoms; and (ii) the selfreported potential/perceived influence of the US on the women’s emotional state (see Table 1). Principal determinant was having had the first US at the time of screening (yes/no). Additional determinants included maternal age, ethnicity, socioeconomic status, educational level, parity and gestational age at screening. A post hoc sample size calculation showed that our sample was sufficient to detect proportional differences in EDS scores between the group of women who had had the first US and the group of women who had not had the first US (alpha 5% and a power of 0.80). Completeness of data was expressed as the proportion of missing data per woman and per variable. In case of
