Postpartum Depression Help-Seeking Barriers and Maternal Treatment Preferences: A Qualitative Systematic Review

323 BIRTH 33:4 December 2006 Postpartum Depression Help-Seeking Barriers and Maternal Treatment Preferences: A Qualitative Systematic Review Cindy-L...
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BIRTH 33:4 December 2006

Postpartum Depression Help-Seeking Barriers and Maternal Treatment Preferences: A Qualitative Systematic Review Cindy-Lee Dennis, RN, PhD, and Leinic Chung-Lee, RN, MN ABSTRACT: Background: Despite the well-documented risk factors and health consequences of postpartum depression, it often remains undetected and untreated. No study has comprehensively examined postpartum depression help-seeking barriers, and very few studies have specifically examined the acceptability of postpartum depression treatment approaches. The objective of this study was to examine systematically the literature to identify postpartum depression help-seeking barriers and maternal treatment preferences. Methods: Medline, CINAHL, and EMBASE databases were searched using specific key words, and published peer-reviewed articles from 1966 to 2005 were scanned for inclusion criteria. Results: Of the 40 articles included in this qualitative systematic review, most studies focused on women’s experiences of postpartum depression where help seeking emerged as a theme. A common help-seeking barrier was women’s inability to disclose their feelings, which was often reinforced by family members and health professionals’ reluctance to respond to the mothers’ emotional and practical needs. The lack of knowledge about postpartum depression or the acceptance of myths was a significant help-seeking barrier and rendered mothers unable to recognize the symptoms of depression. Significant health service barriers were identified. Women preferred to have ‘‘talking therapies’’ with someone who was nonjudgmental rather than receive pharmacological interventions. Conclusions: These results suggest that women did not proactively seek help, and the barriers involved both maternal and health professional factors. Common themes related to specific treatment preferences emerged from women of diverse cultural backgrounds. The clinical implications outlined in this review will assist health professionals in addressing these barriers and in developing preventive and treatment interventions that are in accord with maternal preferences. (BIRTH 33:4 December 2006)

Key words: postpartum depression, help-seeking barriers, treatment preference, qualitative systematic review

Cindy-Lee Dennis is an Assistant Professor at the Faculty of Nursing, University of Toronto, Toronto, Ontario; and Leinic Chung-Lee is a Public Health Nurse at the Toronto Public Health, Toronto, Ontario, Canada. Address correspondence to Dr. Cindy-Lee Dennis, Faculty of Nursing, University of Toronto, 155 College Street, Toronto, Ontario, Canada M5T 1P8. Accepted March 2, 2006 ! 2006, Copyright the Authors Journal compilation ! 2006, Blackwell Publishing, Inc.

Childbirth represents for women a time of great vulnerability to become mentally unwell, with postpartum depression representing the most frequent form of maternal morbidity after delivery (1). Whereas longitudinal and epidemiological studies have yielded varying prevalence rates, a meta-analysis of 59 studies suggests that 13 percent of all new mothers from diverse cultures will experience postpartum depression within the first 12 weeks postpartum (2). This affective condition has well-documented health consequences for the mother, the child, and the family.


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Although women who have suffered from postpartum depression are twice as likely to experience future episodes of depression over a 5-year period (3), infants and children are particularly vulnerable due to impaired maternal-infant interactions (4) and negative perceptions of infant behavior (5). Extensive research has identified consistent risk factors (6), but postpartum depression often remains undiagnosed and untreated. Even when it is detected by health professionals, women frequently do not obtain assistance, despite research suggesting that effective treatment is available (7,8). No study has comprehensively examined postpartum depression help-seeking barriers and facilitators. Furthermore, few studies have specifically examined the acceptability of postpartum depression treatment approaches and maternal preferences (9). This is a serious limitation, considering that several postpartum depression prevention and treatment trials have experienced methodological limitations due to high rates of refusal or attrition (7,8,10–12). Moreover, acceptability of prevention and treatment strategies is an important issue due to its direct effect on intervention engagement and compliance (13,14). The purpose of this qualitative systematic review was to examine the literature to identify postpartum depression help-seeking barriers and maternal treatment preferences.

This generous time interval of 1 year postpartum was allowed to account for differing methodologies in the literature. Help-seeking barriers and facilitators were broadly defined as any factors that dissuaded or persuaded the mother in obtaining help related to her depressive symptomatology. Only primary studies were included; review articles were excluded in the results. Data were independently extracted by both authors and included study design, participants (number and characteristics), and results. Help-seeking barriers and facilitators were subcategorized as maternal, family/friend, or health professional. Categorization results were compared and differences discussed until agreement was obtained.

Results The search identified more than 50 studies, of which 40 specifically provided information related to postpartum depression help-seeking barriers and maternal treatment preferences. These studies are examined below and most focused on women’s experiences of postpartum depression where help seeking emerged as a theme. Postpartum Depression Help-Seeking Barriers and Facilitators

Methods Maternal Barriers The search strategy involved systematic review of published peer-reviewed articles from 1966 to 2005. Databases searched included MEDLINE (1966–2005), EMBASE (1980–2005), and CINAHL (1982–2005). Key words used in various combinations included the following: postpartum depression, postnatal depression, help-seeking, barriers, facilitators, treatment preferences, satisfaction, and qualitative. To measure the capture rate of relevant references, tables of contents for key journals were hand searched for the years 2004 and 2005, and reference lists of included studies and relevant reviews were examined. All qualitative investigations centering on women with postpartum depression were also scanned. Studies published in all languages were considered. Studies were eligible if they provided specific information related to maternal help-seeking barriers and facilitators and treatment preferences and if they focused on postpartum depression; other perinatal mood disorders (i.e., pregnancy or postpartum anxiety, maternity blues, puerperal psychosis) were not examined. For the purpose of this review, postpartum depression was defined as any depressive symptomatology occurring within the first year postpartum.

Women from diverse cultures do not proactively seek help for postpartum depression (15–19). Even though mothers have various interactions with health professionals in the postpartum period, they are often reluctant to obtain professional assistance (20,21) and to disclose emotional problems, particularly depression (22). For example, in a United Kingdom study of 60 primiparous mothers, most women with postpartum depression did not seek help from any source and only approximately 25 percent consulted a health professional (23). Many mothers reported not knowing where to obtain assistance (24) or being unaware of treatment possibilities (15–17,25,26). Maternal perceptions of health professionals’ roles also limited the provision of suitable care. In a large, multicultural study spanning 15 centers in 11 countries, UK Asian women considered professional or medical assistance as inappropriate for treating postpartum depression (27). Icelandic mothers also thought that health centers were inappropriate to treat emotional problems (18). Similarly, in a qualitative study incorporating first-generation UK Bangladeshi women, mothers perceived emotional distress as separate from physical


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symptoms and believed that the role of health professionals was to provide physical care (28). Not surprisingly, these mothers did not consult health professionals for emotional concerns. Correspondingly, other studies have reported the occurrence of somatization, where women translated their emotional distress into physical symptoms (15,26,28). For example, Korean mothers with postpartum depression often present with sanhupung, a postpartum pain disorder that is thought to be caused by inadequate postpartum care. Symptoms include joint pain and coldness, chest tightness, headache, numbness, sleep disturbance, tiredness, and anxiety (29). Some mothers lacked knowledge about postpartum depression (26,30,31) and thus were not aware that they were suffering from the condition (15,18,19, 24,26,32–34). Other women denied that they were experiencing depression (15–17,26,28,34–36). In a United States pilot study evaluating the treatment of group therapy, a significant recruitment obstacle was mothers’ hesitation in admitting to depression and their tendency to minimize symptoms (32). In addition, many women have difficulty in understanding the problems they experience, often assuming that their struggles are a normal part of motherhood. For these women, the onset of symptoms may be attributed to causes other than depression (37,38). For example, in a UK study of 101 black Caribbean mothers, multiple stressors were thought to lead to depressive symptoms and that this was a reasonable response to adversity (30). Comparable results were found with Korean women, since they believe that being a mother means the end of ‘‘easy free days’’ and the beginning of responsibility and work. As such, the challenge of child rearing and the accompanying distress are considered ‘‘a matter of course’’ (29). Women who did recognize that they were experiencing postpartum depression were often unwilling or unable to disclose their feelings to partners, family members, friends, or health professionals (15,19,31, 33,39). The rationale for this lack of disclosure was diverse. Several women thought that they could or were expected to cope with their depression (26,28, 34,39,40). Some women indicated that they would be ‘‘burdensome’’ if they disclosed their feelings (34), whereas others were concerned that a discussion about their emotions would give their family a ‘‘bad name’’ and risk their being seen as responsible for problems within the family (28). The fear of losing one’s baby emerged as a major help-seeking barrier (23,26,34,41). These women were afraid that revealing their depression would result in the apprehension of their children. Shame, stigma, and the fear of being labeled mentally ill were also significant factors in women’s decision to seek or accept help

(17,21,23,24,26,32,34,39,41). Other women were hesitant of mental health services (30). It is noteworthy that some depressed mothers refused to seek treatment due to perceived insufficient time (42) and the inconvenience of attending appointments (21). Different researchers portrayed culture and the various conceptualizations of the maternal role as barriers to women seeking help (16,17,28,30,31,33). In a qualitative study of 12 African-American women, several themes represented aspects of their postpartum depression experience, including ‘‘dealing with it.’’ This theme represented the cultural ways in which they managed their depression and incorporated the following subthemes: ‘‘keeping the faith,’’ ‘‘trying to be a strong black woman,’’ ‘‘living with myths,’’ and ‘‘keeping secrets’’ (39). These women suggested that in some African-American communities, depression was a sign of internal weakness and not a legitimate illness. The importance of fulfilling traditional gender roles was found among UK Bangladeshi women, resulting in their failure to inform anyone about their emotional problems for fear of an inability to perform their role as a woman and a mother (28). Similar findings of mothers not wanting to disclose their depression due to implied weakness or perceived failure were found among Caribbean (30), Finnish (36), Jordanian (31,40), Scottish (34), and Swedish (43) women. Maternal Facilitators A major maternal help-seeking facilitator was education about postpartum depression (26,31–33,44). Although health service information about postpartum depression provided antenatally was found to motivate Japanese mothers to seek treatment earlier postnatally (32,45), U.S. women participating in focus groups suggested that guest speakers in a postpartum program would help them better understand their depression and would be beneficial (46). Women also believed that any open discussion about postpartum depression would help reduce the stigma associated with this condition and promote help seeking (33). The availability of childcare facilities would encourage the obtainment of treatment for some mothers (26,32). The literature also revealed that women’s perceived close relationships with health professionals was an important facilitator in women seeking treatment (39). Family and Friends Barriers and Facilitators Research suggests that family members are often unable to provide assistance or promote help seeking due to a lack of understanding about postpartum depression (23). However, in some cultures, family

326 members may actively discourage women from obtaining help, since it is unacceptable to admit to depressive symptoms or discuss such difficulties external to the family context (15,16,26,40,45,47). For example, Bangladeshi women living in the UK indicated that they talked freely in the hospital about emotional problems; however, few discussed their difficulties at home apart from practical terms because of censorship by family members (28). Among Jordanian women, the family is the reference for assistance and mediates between the mother and the outside world (40). In Korean culture, having and raising children is a key family function; accordingly, any concern about the mother rapidly mobilizes resources as the whole family works together to resolve the crisis (29). It is noteworthy that partners who encourage mothers to seek help when they are experiencing challenges early in the postpartum period may potentially assist in preventing postpartum depression (48). Health Professional Barriers and Facilitators Health professionals play a salient role in either promoting help-seeking behaviors or hindering the obtainment of treatment since research suggests that depressed mothers may be high users of health services (49,50). Significant postpartum depression treatment barriers were found in the literature related to health professionals and included inappropriate assessments paralleled with an insufficient knowledge about postpartum depression (18,32,33). The nature of the relationship between the mother and the health professional also influenced whether or not the mothers obtained treatment (18,28). Access to health care was found to be a barrier for some women (39). Several qualitative studies suggested that health professionals had a tendency to normalize depressive symptoms and to dismiss them as self-limiting (23,33), whereas other studies reported that women believed that their depressive symptoms were given only cursory attention (39). Not surprisingly, when health professionals minimized a mother’s feelings and symptoms, she became reluctant to pursue treatment (30). A U.S. qualitative study found that after depressed mothers made the decision to seek professional help, they felt disappointment, frustration, humiliation, and anger due to their interactions with health professionals (51). In another qualitative study, Australian mothers believed that their physicians displayed disinterest and ‘‘patronizing attitudes,’’ which increased their feelings of worthlessness and guilt in their inability to cope (24). They also described dissatisfaction with their hospital doctors and family physicians, claiming that they had limited time for

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counseling and preferred to prescribe medication that alleviated symptoms and reinforced feelings of inadequacy. Comparably, UK Bangladeshi women complained that (a) they had insufficient time during consultations with their general practitioner, (b) their problems were not taken seriously, (c) they were not examined properly, and (d) they were not referred to secondary services as necessary (28). Lack of language support services further contributed to these women not seeking help. Language barriers were also obstacles for UK women in black and minority ethnic communities (26). This study further noted the generally low numbers of professionals from minority ethnic backgrounds as a barrier to health services.

Maternal Treatment Preferences Pharmacological Treatment Women are often reluctant to take antidepressant medication (19,25), even after receiving education (52). Although some women believed that their depression would resolve without pharmacological treatment (19), fear of addiction was a major concern for many mothers (19,23,25). Women were also apprehensive about potential side effects or harm related to long-term use (16,17,25). These concerns significantly influenced medication compliance since mothers self-regulated by missing doses, taking medication on an ad hoc basis (25), or pretending to take them (23). The acceptability of medication was particularly low among breastfeeding mothers due to concerns about transmission to breastmilk (25,44,52). The stigma associated with antidepressant medication use remained an important consideration for many mothers since they did not want to be labeled as a ‘‘tablet taker’’ (25). Interestingly, negative perceptions about pharmacological interventions were maintained even when symptom management was obtained (24,25). Some women believed that their physician did not provide sufficient information about pharmacological treatment (24). Consequently, these women were uncertain about what to expect from their medication and became anxious when side effects occurred. Collectively, the studies reported that many mothers preferred nonpharmacological treatment options (19,25,27,34,52). Opportunity to Talk About Feelings For many mothers, the most desired treatment was simply having the opportunity to talk about their feelings with a sympathetic and empathetic listener


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(16,17,20,23,24,33). Having someone to talk to and ‘‘talking therapies’’ with health professionals if their assistance was sought were universally expressed as a treatment preference in a cross-cultural study incorporating 11 countries (27). Specifically, women wanted: (a) to be given permission to talk in-depth about their feelings, including ambivalent and difficult feelings; (b) to talk with a nonjudgmental person who would spend time listening to them, take them seriously, and understand and accept them for who they are; and (c) recognition that there was a problem and reassurance that other mothers experience similar feelings and that they would get better (33). However, for the reassurance to be effective, the mothers needed to feel confident that the person listening had some understanding of the nature and extent of their problem (23). Provision of Peer Support The ways in which individual women interpret, negotiate, and experience social norms of motherhood depends in part on their interpersonal relationships with other mothers. As might be expected, support from other women with children was perceived as particularly important in the recovery from postpartum depression (23,32–34,36), and the inclusion of peer support in treatment may lead to higher levels of satisfaction (53). In focus groups with U.S. mothers, it was vital for women to know that they were not alone in their struggles (46). Attending a support group was a common treatment preference (24,26,32) because it provided mothers with a network of ‘‘like women’’ and a safe environment to express whatever they wished without fear of condemnation (24). Interestingly, Finnish mothers preferred peer groups arranged by the child welfare clinic and the church because it gave them the opportunity to meet other women not known to them before with a similar life situation (36). These women also believed that discussions with current friends, especially if they had children of the same age, could lead to competition and it was impossible to talk about one’s feelings or problems. Among immigrant and ethnic minority women, these groups facilitated activities such as shopping and learning English (24). In a phenomenological study with Middle Eastern women living in Australia, ‘‘Arabic community centers’’ provided immigrant women with diverse activities, such as sewing and cooking, that were aimed at relieving their stress by taking them out of their houses and enabling them to interact with other women (31). Depressed mothers using these centers reported that they could cope much better when they returned home to meet their husband and resume their traditional roles. Tem-

pleton et al found similar results where women attending a group thought that it was a break from housework and childcare responsibilities and that it allowed them to relax and meet people (26). However, it is important to note the potential negative aspects of support groups, such as becoming overwhelmed by others’ problems (24) and participation dominated by a specific ethnic group, which may lead to feelings of not belonging (26). Mothers in one study expressed concerns about the logistics of attending a group meeting due to already overburdened days (32). Supportive Interactions From Partner and Family Members Women want to receive support to help them with their postpartum depression and the partner clearly emerged as a salient source of assistance (24,27). Finnish mothers perceived support from their partner to be a ‘‘necessity’’ (36). Although the desire for emotional support was noticeably highlighted, women also required instrumental support from their partner, such as assistance with childcare or household responsibilities (15,24,27,36). Support from family members and friends was also expressed as a remedy for postpartum depression (17–19,24,27,39). It is noteworthy that in one study, mothers wanted health professionals to inform their family about their condition so that they could be included in the recovery process (24). Spiritual clergy was an important source of support for Icelandic mothers with postpartum depression (18). Other Treatment Preferences Other treatment preferences identified by women included counseling with the partner (16), relaxation techniques (32), self-care (18), and physical activity such as walking with the baby (32). In a survey of 500 Australian mothers with children aged 0–5 years, 92 percent of mothers believed that pram walking would increase mental well-being, and 87 percent believed that it would help reduce postpartum depression (54). However, focus group feedback expressed less confidence in a pram exercise program’s ability to potentially benefit mothers with postpartum depression due to stigma attached to attendance. These mothers suggested that the program should be marketed with a focus on fitness and social aspects. Women’s satisfaction with postpartum depression treatment is strongly related to a woman’s perceived relationship with her health professional (55). Professional advice was particularly appreciated and adhered to when it was in


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accord with the mother’s own perception of her depression and its causes (23). In a phenomenological study involving 10 U.S. mothers, 7 themes emerged that illustrated nurses’ caring for mothers experiencing postpartum depression and promoted satisfaction with care received: (a) having sufficient knowledge about postpartum depression; (b) using astute observation and intuition to make quick, correct diagnoses; (c) providing hope that the mother’s depression will come to an end; (d) readily sharing their time; (e) making appropriate referrals for the right path to recovery; (f) providing continuity of care; and (g) understanding what the mothers were experiencing (56). In a qualitative study of 22 Jordanian women living in Australia who had suffered from postpartum depression, 3 major themes focusing on the meaning of care were discussed: (a) care meant strong family support and kinship during the postpartum period; (b) care included preservation of Jordanian childbearing customs as expressed in the celebration of the birth of the baby; and (c) care was being allowed to fulfill traditional gender roles as mother and wife (40). As such, consideration of the traditional practices of women of various backgrounds and having cultural sensitivity with respect to treatment options is necessary (31,40).

Discussion and Conclusions This review identifies a common set of help-seeking barriers and facilitators. Although the mothers in the studies reviewed varied significantly in terms of demographic characteristics and cultural background, all struggled to fulfill their ideal perception of motherhood while at the same time concealing their needs. Their greatest difficulty was talking about their feelings, and their silence was often sustained and reinforced by the reluctance of partners, family members, and health professionals to acknowledge and respond to the mothers’ emotional and practical needs. The lack of knowledge about postpartum depression or the acceptance of myths was a significant barrier and rendered some mothers unable to recognize the signs and symptoms of depression. Furthermore, perceived social pressures hindered women from taking the initiative to obtain assistance due to shame and the fear of being labeled mentally ill. Women were also afraid that if they disclosed their depression, they may have their children taken away from them, be a burden to their family, or be perceived as weak. This review suggests that education about postpartum depression is important for women and their families and could enable earlier recognition and help seeking. Information about services and health pro-

fessional’s roles may be particularly effective in specific cultural groups if it was aimed at family members and the mothers. Educational programs could be conducted across the perinatal period with a focus on assisting the family in understanding stresses related to motherhood and identifying specific strategies to help the mother cope with these challenges. Stigmatization and lack of knowledge related to postpartum depression and treatment are common problems that promote fear, reluctance to seek help, and refusal of treatment. To reduce stigma, public education about postpartum depression, signs and symptoms, and sources of assistance may clarify common misconceptions and raise awareness about this condition. Health professionals need to keep abreast of current research to be knowledgeable about postpartum depression and to ensure thorough assessments. They should also know about resources in their communities for treating postpartum depression to promote appropriate referrals. To demonstrate caring, health professionals should display a willingness to share their time in an unhurried atmosphere and to be aware of nonverbal behavior. Because motherhood is often equated with happiness, mothers frequently believe that no one understands their condition and a health professional’s acceptance of a mother’s experience may be viewed not only as comforting but also as caring (56). Given the evidence that empathetic listening skills can be taught and that mothers often have a preference for nonpharmacological treatment strategies, educating health professionals to be knowledgeable about empathetic listening is one universal strategy for improving the care received by depressed mothers (20). This review suggests that health professionals need to be familiar with cultural issues related to childbirth since they constitute the context within which women have children in a community. They should understand the different ways in which mothers conceptualize, explain, and report symptoms of depression. This review also lends support to the notion that the term ‘‘postpartum depression’’ may not be acceptable to many mothers and an alternative approach to recognition and management may be required, especially among mothers from different cultures. This may involve the use of symptom- and context-based terms such as tension, weakness, and difficulties in one’s relationship at home (15). Furthermore, in many cultures, self-discipline is regarded as the mainstay of social identity and behavior, and self-esteem results from the knowledge that one is fulfilling one’s social role with grace and dignity and meeting expectations (16). Culturally, sensitive care is required to assist women who may be reluctant to attend postpartum


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depression health services due to shame to herself and her family (17). If women are unwilling or unable to attend clinics, outreach and home-based services could be provided. For example, telephone-based support may assist mothers at home with postpartum depression (57). Health professionals should also be aware of traditional postpartum practices and understand the reasons behind such practices since preliminary research suggests that devaluing traditional practices based on a woman’s cultural group could mean devaluing the mother as a person (31). Myths about antidepressant medication influence the acceptance of pharmacological interventions and treatment compliance. Good communication between the health professional and the mother is essential since research suggests that when patients rate the quality of communication highly, they are also more likely to be satisfied and to comply with treatment regimens (58). An alliance between depressed mothers and their health professional is necessary, so that they can make an informed decision about whether medication is the most appropriate treatment (25). If women are treated with antidepressant medication, they need to be fully informed about side effects and withdrawal to alleviate fears of dependency. In the absence of this, women are likely to self-manage their medication at a dosage that may be clinically ineffective (25). Nurses could be educated to reinforce information about antidepressant medication use. Support groups may be particularly valuable because they enable depressed mothers to offer support and to share their experiences while also assisting them to learn effective ways to deal with their emotions and to cope with their new roles. Groups could also be organized for partners to aid them in learning supportive and coping strategies (16) since research suggests that partners themselves may be at higher risk to develop depression in the postpartum period if the mother is also depressed (59). Health professionals can facilitate these groups and ensure that proper childcare services are available during these sessions. Groups offered at different times of the day with reimbursement for transportation may also encourage attendance. Continuity of professional care from pregnancy to the postnatal period may also assist mothers who are reluctant to disclose that they may be experiencing postpartum depression. Due to potential time constraints or a lack of resources, health professionals can play a vital role in suggesting other sources of assistance such as voluntary sector organizations (33). Furthermore, women’s reports of the support they derive from spiritual resources suggest

that health professionals may want to consider forging closer links with spiritual resources in their community. Such partnerships might facilitate education and increase the capacity of services to recognize postpartum depression and promote help seeking. Although health professionals can play an important role in helping mothers with postpartum depression, this review highlights several health service issues that hindered the receipt of appropriate treatment. Language differences, a lack of knowledge about available services, the feeling that some services were not useful, difficulty in arranging treatment that is convenient, and lack of health professionals from minority ethnic backgrounds were all identified barriers. Health professionals facilitating treatment services should address these issues and ensure that interpreters are available for non–English speaking women. In addition, health professionals need to recognize and take into account mothers’ own explanations of their problem and their ideas concerning what might constitute an appropriate treatment. It is important to acknowledge that each mother will be different, so individualized care is required. References 1. Stocky A, Lynch J. Acute psychiatric disturbance in pregnancy and the puerperium. Baillieres Best Pract Res Clin Obstet Gynaecol 2000;14(1):73–87. 2. O’Hara M, Swain A. Rates and risk of postpartum depression—A meta-analysis. Int Rev Psychiatry 1996;8:37–54. 3. Cooper P, Murray L. Course and recurrence of postnatal depression. Evidence for the specificity of the diagnostic concept. Br J Psychiatry 1995;166:191–195. 4. Murray L, Fiori-Cowley A, Hooper R, Cooper P. The impact of postnatal depression and associated adversity on early mother-infant interactions and later infant outcome. Child Dev 1996;67(5):2512–2526. 5. Mayberry LJ, Affonso DD. Infant temperament and postpartum depression: A review. Health Care Women Int 1993;14(2): 201–211. 6. Beck CT. Predictors of postpartum depression: An update. Nurs Res 2001;50(5):275–285. 7. Dennis CL, Stewart DE. Treatment of postpartum depression, part 1: A critical review of biological interventions. J Clin Psychiatry 2004;65(9):1242–1251. 8. Dennis CL. Treatment of postpartum depression, part 2: A critical review of nonbiological interventions. J Clin Psychiatry 2004;65(9):1252–1265. 9. Henshaw CA. What do women think about treatments for postnatal depression? Clin Eff Nurs 2004;8(3–4):170–175. 10. Dennis CL. Preventing postpartum depression part I: A review of biological interventions. Can J Psychiatry 2004;49(7): 467–475. 11. Dennis CL. Preventing postpartum depression part II: A critical review of nonbiological interventions. Can J Psychiatry 2004;49(8):526–538. 12. Dennis CL. Psychosocial and psychological interventions for prevention of postnatal depression: Systematic review. BMJ 2005;331(7507):15.

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