可預測懷孕時憂鬱的臨床風險因素

作者：Laurie Barclay, MD  
出處：WebMD醫學新聞

　　December 30, 2009 — 根據2010年1月美國婦產科期刊(American Journal of Obstetrics Gynecology)對57篇研究的回顧結果，例行產檢中可以簡單分辨的臨床風險因素，有助於預測懷孕時的憂鬱。
　　
　　密西根大學的Christie A. Lancaster醫師等人寫道，產前照顧提供了適當照護產前憂鬱的機會，首先，照護者已經掌握了照護對象，因為多數婦女在懷孕的某階段會利用產科服務，照護者也有許多機會評估、治療和追蹤這些病患，在這幾個月的期間內重複給予產科訪視。
　　
　　根據針對1980至2008年間之英文文獻的搜尋，回顧者的目標在檢視可以在例行產科照護中發現的產前憂鬱症狀的風險因素。篩選規範是評估產前憂鬱症狀和一種以上風險因素之關聯的研究，兩位不知情的獨立回顧者評估每個可能之風險因素的整體證據趨勢。
　　
　　總共有57篇研究符合篩選規範。雙變項分析中，與產前憂鬱症狀之關聯有較大可能性的因素，包括母親的焦慮、生活壓力、憂鬱症病史、缺乏社會支持、意外懷孕、Medicaid保險、家庭暴力、低收入、教育程度低、抽菸、單身與不佳的夫妻關係。
　　
　　多變項分析中，依舊與憂鬱症狀有顯著關聯的因素，包括生活壓力、缺乏社會支持、家庭暴力。
　　
　　回顧者寫道，我們的結果顯示出與懷孕期間憂鬱症狀風險增加有關的多個因素。
　　
　　他們指出，我們的研究結果對於開業醫師來說是重要的，因為他們可以在例行的產科照護中評估這些風險因素，就目前的實務而言，照護者應特別考量有這些風險因素之婦女的憂鬱症狀可能性，例如懷孕時有家暴報告或缺乏社會支持者。
　　
　　此次回顧之限制包括，各研究之間有明顯的異質性；缺乏對於憂鬱的診斷評估；篩檢工具所使用臨界點不同；樣本數有限；多數屬於觀察型、橫斷面研究。資料分析的限制包括，可能有出版偏見、只有回顧英文文獻、品質評估之主觀影響。
　　
　　研究作者結論表示，後續研究應表達出目前的產科篩檢型式如何掌握這些概念，以及我們如何利用確認風險因素來改善篩檢效果和準確度，以促進懷孕時的臨床評估。
　　
　　舉例來說，後續研究應評估憂鬱篩檢陽性婦女（不論有無其他風險因素）的重度憂鬱症可能性。
　　
　　Robert Wood Johnson Clinical Scholars Program支持本研究。


Clinical Risk Factors May Predict Depression During Pregnancy

By Laurie Barclay, MD
Medscape Medical News

December 30, 2009 — Clinical risk factors that may be easily identified during routine obstetric examination may help predict depression during pregnancy, according to the results of a review of 57 studies reported in the January 2010 issue of the American Journal of Obstetrics Gynecology.

"Prenatal care providers are uniquely suited to address antepartum depression," write Christie A. Lancaster, MD, MS, from the University of Michigan in Ann Arbor, and colleagues. "First of all, providers have already captured their target population, because most women will use obstetric services at some point during their pregnancies. Providers also have multiple opportunities to assess, treat, and follow-up with patients, as obstetric visits are recurring during a several-month span."

Based on an English-language search of the literature from 1980 through 2008, the reviewers aimed to examine risk factors for antepartum depressive symptoms that could be detected in routine obstetric care. Selection criteria were studies evaluating the association between antepartum depressive symptoms and 1 or more risk factors. Two masked, independent reviewers assessed the overall trend of evidence for each potential risk factor.

There were 57 studies identified that met selection criteria. Factors associated with a greater likelihood of antepartum depressive symptoms in bivariate analyses were maternal anxiety, life stress, history of depression, lack of social support, unintended pregnancy, Medicaid insurance, domestic violence, lower income, lower education, smoking, single status, and poor relationship quality.

In multivariate analyses, factors that continued to show a significant association with depressive symptoms were life stress, lack of social support, and domestic violence.

"Our results demonstrate several correlates that are consistently related to an increased risk of depressive symptoms during pregnancy," the review authors write.

"Our results are important for practicing clinicians because they identify risk factors that can be assessed during routine obstetric care," they add. "For current practice, providers should especially consider the likelihood of depressive symptoms in women with these risk factors, such as report of domestic violence or a lack of social support during pregnancy."

Limitations of the studies reviewed include significant heterogeneity among studies; lack of diagnostic assessments for depression; use of different cutoff points on screening tools; limited sample size; and observational, cross-sectional design in most studies. Limitations of the data analysis include possible publication bias, review of only studies published in English, and subjective assessment of quality.

"Future work should address how well our current obstetric screening forms capture these constructs and how we can use risk factor identification to improve screening efficiency and accuracy and to enhance our clinical assessments during pregnancy," the study authors conclude.

"For example, future research studies could evaluate the likelihood of major depressive disorder in women with positive depression screens that do or do not have these additional risk factors."

The Robert Wood Johnson Clinical Scholars Program supported this study.

Am J Obstet Gynecol. 2010;202:5-14.