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Childbirth represents for women a time of great vulnerability to becoming mentally unwell, with postpartum mood disorders representing the most frequent form of maternal morbidity following delivery (1). In general, women who experience these conditions form 2 subgroups: those who have been mentally well prior to pregnancy; and those who are already suffering or have suffered from a psychiatric illness, which predisposes them more in the postpartum period. Affective disorders following childbirth range in severity from the early “maternity blues” to postpartum psychosis, a serious state affecting less than 1% of mothers and usually requiring hospitalization (2). Along this spectrum is postpartum depression (PPD), classified in the DSM-IV as a depressive condition that often exhibits the disabling symptoms of dysphoria, emotional lability, insomnia, confusion, anxiety, guilt, and suicidal ideation (3). Frequently exacerbating these indicators are low self-esteem, inability to cope, negative maternal attitudes, and loneliness (4–7). The inception rate is greatest in the first 12 weeks postpartum (8), with duration frequently depending on symptom severity (9) and delay in adequate treatment (10). Residual depressive symptoms are common (11,12), and 50% of mothers will remain clinically depressed at 6 months (13,14). An estimated 25% of women with untreated PPD will experience clinical depression that continues past the first year postpartum (15,16). Unfortunately, PPD is a major health issue for many women. Longitudinal and epidemiologic studies have yielded varying prevalence rates, ranging from 3% to more than 25% of women in the first year after delivery. These rates fluctuate owing to sample size, timing of assessment, differing diagnostic criteria (that is, major or minor depression), and whether the studies were retrospective (yielding low rates) or prospective (yielding rates that are higher by six- to tenfold). A metaanalysis of 59 studies reported the overall prevalence of major PPD to be 13% (17); the absolute difference in estimates between self-report assessments and diagnostic interviews was small. While national Canadian statistics are unknown, a longitudinal study of 645 British Columbia (BC) mothers has just been completed by Dennis (unpublished data). Measured according to the Edinburgh Postnatal Depression Scale (EPDS) (18), the prevalence of probable major PPD at 4 and 8 weeks postpartum was found to be 9.1% and 8%, respectively, while the corresponding occurrence of probable minor PPD was an additional 13.5% and 12.6%. This hidden morbidity has well-documented health consequences for the mother, child, and family. While women who have suffered from PPD are twice as likely to experience future episodes of depression over a 5-year period (19), infants and children are particularly vulnerable. Mediated through impaired maternal infant interactions (20,21) and negative perceptions of infant behaviour (22,23), PPD has been linked to various adverse outcomes, including attachment insecurity (24–26), emotional developmental delay (24,27), social interaction difficulties (28,29), and development of psychopathology (30). Infants as young as age 3 months have been shown to ably detect the affective quality displayed by their mothers and to modify their own responses accordingly (31–33). While cognitive skills (34), expressive language development (35), and attention (36) have been negatively affected by PPD, it has also been reported that children of mothers suffering from depression are 2 to 5 times more likely to develop long-term behavioural problems (37–39). Child neglect or abuse (40) and marital stress resulting in separation or divorce (41,42) are other reported outcomes. Highlighted recently in the media, maternal and infant mortality is a rare but real consequence of PPD. The etiology of PPD remains unclear (11,12). Despite considerable research (43), no single causative factor has been isolated, suggesting a multifactorial cause. However, epidemiologic investigations and comprehensive meta-analyses of predictive studies have consistently implied the importance of psychosocial variables (12,17,44,45). Precipitators that significantly increase the risk of PPD include life stress (17,44,46,47), child-care stress (44,47–49), marital conflict (7,44,46–48), low maternal self-esteem (7,44), and lack of social support (5,7,8,17,44,47,50). Moreover, 2 metaanalyses propose a further risk of PPD among socially disadvantaged women (17,44). Health professionals have developed diverse psychosocial interventions congruent with the PPD vulnerability-stress model (47). Randomized controlled trials evaluating cognitive-behavioural counselling with antidepressants (51), cognitive-behavioural therapy and nondirective counselling (52), health visitor led nondirective counselling (53,54), and nurse-facilitated support groups (55) have all demonstrated the amenability of PPD to professional treatment (56). However, a growing trend in health care, and in postpartum care particularly, is the use of lay support. In predictive studies, detailed analyses of support variables suggest that the following social deficiencies significantly increase the risk of PPD: not having someone to talk openly with who has shared and understood a similar problem (50), not having an intimate confidante or friend to converse with (50,57–59), not receiving support without asking (50), and feeling socially isolated (7). Conversely, companionship and belonging to a group of similar others had a protective effect (60). When women were asked for their own explanations as to why they experienced PPD, they commonly responded with “lack of support” and “feeling isolated.” When asked what advice they would give to new mothers currently suffering from PPD, the foremost suggestion proffered was “find someone to talk to” (61). In a recent BC longitudinal study, maternal mood was significantly correlated with perceived support from other women with children (Dennis, unpublished data). Similarly, 6 focus groups conducted with BC mothers who suffered from PPD further validated the saliency of support from other mothers (62). These results suggest that support provided by an experienced mother may be a simple intervention to address PPD and its unfavourable effects on mothers and infants. However, no study evaluating the effect of peer support on PPD symptomatology was found. Therefore, this pilot randomized controlled trial evaluated the effect of mother-to-mother support on depressive symptomatology among new mothers and determined the feasibility of conducting a larger trial. It was hypothesized that new mothers who received telephone-based support from women who previously experienced PPD would have decreased depressive symptomatology, compared with mothers who did not receive the supportive intervention. MethodsParticipants Design Overview Figure 1 Trial schema
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