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Problem: Although perinatal universal depression and psychosocial assessment is recommended in Australia, its clinical performance and cost-effectiveness remain uncertain., Aim: To compare the performance and cost-effectiveness of two models of psychosocial assessment: Usual-Care and Perinatal Integrated Psychosocial Assessment (PIPA)., Methods: Women attending their first antenatal visit were prospectively recruited to this cohort study. Endorsement of significant depressive symptoms or psychosocial risk generated an 'at-risk' flag identifying those needing referral to the Triage Committee. Based on its detailed algorithm, a higher threshold of risk was required to trigger the 'at-risk' flag for PIPA than for Usual-Care. Each model's performance was evaluated using the midwife's agreement with the 'at-risk' flag as the reference standard. Cost-effectiveness was limited to the identification of True Positive and False Positive cases. Staffing costs associated with administering each screening model were quantified using a bottom-up time-in-motion approach., Findings: Both models performed well at identifying 'at-risk' women (sensitivity: Usual-Care 0.82 versus PIPA 0.78). However, the PIPA model was more effective at eliminating False Positives and correctly identifying 'at-risk' women (Positive Predictive Value: PIPA 0.69 versus Usual Care 0.41). PIPA was associated with small incremental savings for both True Positives detected and False Positives averted., Discussion: Overall PIPA performed better than Usual-Care as a psychosocial screening model and was a cost-saving and relatively effective approach for detecting True Positives and averting False Positives. These initial findings warrant evaluation of longer-term costs and outcomes of women identified by the models as 'at-risk' and 'not at-risk' of perinatal psychosocial morbidity., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Australian clinical practice guidelines support comprehensive psychosocial assessment as a routine component of maternity care., Aim: To examine the concurrent and predictive validity of the Antenatal Risk Questionnaire-Revised (ANRQ-R) when used across the perinatal period., Methods: Women completed the ANRQ-R and a diagnostic reference standard (SAGE-SR) in the second and third trimesters and at 3-months postpartum. ANRQ-R test performance for cut-off scores at each time-point was assessed using Receiver Operator Characteristic (ROC) analysis., Findings: Overall sample sizes were N=1166 (second trimester), N=957 (third trimester) and N=796 (3-month postpartum). 6.5%, 5.6% and 6.2% of women met SAGE-SR criteria for any depressive or anxiety disorder at these time-points ('cases'), respectively. ROC analysis yielded acceptable areas under the curve (AUC) when the ANRQ-R was used to detect current (AUC=0.789-0.798) or predict future (AUC=0.705-0.789) depression or anxiety. Using an example cut-off score of 18 or more, the ANRQ-R correctly classified 72-76% of concurrent 'cases' and 'non-cases' (sensitivity=0.70-0.74, specificity=0.72-0.76) and correctly predicted 74-78% of postnatal 'cases' and 'non-cases' (sensitivity=0.52-0.72, specificity=0.75-0.79). Completion of the ANRQ-R earlier in pregnancy yielded greater positive likelihood ratios for predicting depression or anxiety at 3-months postpartum (cut-off ≥18: second trimester=3.8; third trimester=2.2)., Conclusion: The ANRQ-R is a structured psychosocial assessment questionnaire that can be scored to provide an overall measure of psychosocial risk. Cut-off scores need not be uniform across settings. Such decisions should be guided by factors including diagnostic prevalence rates, local needs and resource availability., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Problem: While routine psychosocial assessment is acceptable to most pregnant women, some women will not fully disclose psychosocial concerns to their clinician., Aims: To assess the impact of psychosocial risk, current symptoms and mode of assessment on women's honesty of disclosure at psychosocial assessment., Methods: Logistic regression was used to examine associations between disclosure and a range of psychosocial characteristics in women who were 'always honest' and 'not always honest'. Mixed ANOVAs were used to test the influence of mode of assessment and honesty on scores on a repeated measure of psychosocial risk., Findings: 10.8% (N=193 of 1788) of women did not fully disclose at psychosocial assessment. Non-disclosure was associated with a mental health history (aOR=1.78, 95%CI: 1.18-2.67, p<0.01) and lack of social and partner support (aOR=1.74, 95%CI: 1.16-2.62, p<0.05; aOR=2.08, 95%CI: 1.11-3.90, p<0.05, respectively). Those reporting not always being honest at face to face assessment showed a greater increase in psychosocial risk score when the assessment was repeated online via self-report, compared to women who were always honest., Discussion: A history of mental health issues and lack of social and partner support are associated with reduced disclosure at face to face assessment. Online self-report assessment may promote greater disclosure, however this should always be conducted in the context of clinician feedback., Conclusion: Greater psychosocial vulnerability is associated with a lower likelihood of full disclosure. Preliminary findings relating to mode of assessment warrant further exploration within a clinical context., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Problem: While comprehensive psychosocial assessment is recommended as part of routine maternity care, unless women engage and disclose, psychosocial risk will not be identified or referred in a timely manner. We need to better understand and where possible overcome the barriers to disclosure if we are to reduce mental health morbidity and complex psychosocial adversity., Aims: To assess pregnant women's attitude to, and reasons for non-disclosure at, comprehensive psychosocial assessment with their midwife., Methods: Data from 1796 pregnant women were analysed using a mixed method approach. After ascertaining women's comfort with, attitude to, and non-disclosure at psychosocial screening, thematic analysis was used to understand the reasons underpinning non-disclosure., Findings: 99% of participants were comfortable with the assessment, however 11.1% (N = 193) reported some level of nondisclosure. Key themes for non-disclosure included (1) Normalising and negative self-perception, (2) Fear of negative perceptions from others, (3) Lack of trust of midwife, (4) Differing expectation of appointment and (5) Mode of assessment and time issues., Discussion: Factors associated with high comfort and disclosure levels in this sample include an experienced and skilled midwifery workforce at the study site and a relatively advantaged and mental health literate sample. Proper implementation of psychosocial assessment policy; setting clear expectations for women and, for more vulnerable women, extending assessment time, modifying mode of assessment, and offering continuity of midwifery care will help build rapport, improve disclosure, and increase the chance of early identification and intervention., Conclusions: This study informs approaches to improving comprehensive psychosocial assessment in the maternity setting., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: To report rates of Medicare Benefits Schedule (MBS) mental health item use among a sample of women who gave birth in NSW (2009-2015) and examine if the SAFE START policy increased use of these items among perinatal women., Methods: Data was drawn from women participating in the Australian Longitudinal Study on Women's Health 1973-1978 cohort, linked to data from the NSW Perinatal Data Collection and MBS., Results: Use of Medicare-subsidised mental health items increased 2.7-fold among perinatal women (n=1,453) between 2009 and 2015 (4.1% versus 11.0% respectively), compared to a 1.3-fold increase among non-perinatal women (n=1,800, 6.3% versus 8.4% respectively). However, the increased use of MBS mental health items among perinatal women was not observed to be impacted by the SAFE START policy, after accounting for time trends., Conclusion: There was a substantial increase in the use of MBS mental health items among women in NSW between 2009 and 2015, with a more pronounced increase among women who had given birth compared to those who had not. Implications for public health: This study provides important information about changes in mental health service use during a time of significant investment in perinatal mental health, and demonstrates the value of longitudinal survey data linked with administrative health data to evaluate the impact of health policy., (© 2021 The Authors.)

Objectives: To report rates of perinatal mental health screening from 2000 to 2017 and investigate factors associated with not being screened both antenatally and postnatally more recently (2013-2017)., Methods: A longitudinal community-based study of self-reported perinatal mental health screening with a national sample of 7,566 mothers from the Australian Longitudinal Study on Women's Health reporting on 9,384 children. The main outcome measure was whether mothers were asked about their emotional wellbeing by a health professional, including completing a questionnaire., Results: From 2000 to 2017, the percentage of women not screened decreased from 40.6% to 1.7%. The percentage of women screened both antenatally and postnatally increased from 21.3% to 79.3%. From 2013 to 2017, women who were older (aOR, 0.65; 95%CI, 0.52-0.81) or had reported emotional distress (aOR, 0.77; 95%CI, 0.60-0.99) were less likely to have been screened both antenatally and postnatally., Conclusions: Despite improvements, perinatal mental health screening is not yet universal. One-in-five women are not screened both antenatally and postnatally, including women in high-risk populations such as those who have reported emotional distress. Implications for public health: Women are in regular contact with health professionals in the perinatal period. This opportunity to detect women at risk of perinatal mental health issues is too important to be missed., (© 2020 The Authors.)

Purpose: To evaluate the degree of honesty and level of comfort reported by women when questioned about their emotional wellbeing during the perinatal period; to investigate if honesty and comfort are associated with perinatal depression or perinatal anxiety; and to examine the reasons why women may not always respond honestly., Methods: Qualitative and quantitative data from 1597 women from the cross-sectional perinatal mental health substudy (part of the Australian Longitudinal Study on Women's Health) were analysed using a mixed methods approach., Results: When questioned by their health practitioner about their emotional wellbeing in the perinatal period, 20.7% of women indicated they had not always responded honestly. Reasons for not being honest reflected four main themes: normalizing of symptoms/coping; negative perceptions (self-and others); fear of adverse repercussions; and fear of involvement of health services (trust and confidentiality). The 38.9% of women who did not feel comfortable when questioned by their health practitioner about their emotional wellbeing were four times more likely to report perinatal depression (odds ratio = 4.09; 95% confidence interval = 2.55, 6.57) and nearly twice as likely to report perinatal anxiety (odds ratio = 1.90; 95% confidence interval = 1.24, 2.94) than other women., Conclusions: Women who are most likely to need mental health care during the perinatal period are also those least likely to be honest about their mental health. A non-judgemental, open and reassuring approach by clinicians may help to reduce the stigma and fears contributing to lack of honest responses, and improve early diagnosis and treatment of mental health problems., (Copyright © 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Clinical practice guidelines recommend that women be screened for depression as a routine component of maternity care however there is ongoing debate about the benefits of depression screening programs in this context., Aim: This narrative review identifies and describes the clinical effectiveness of perinatal depression screening programs in relation to one or more of the following interrelated domains: referral for additional mental health support or treatment; engagement with mental health support or treatment options; and, maternal mental health or parenting outcomes., Methods: English-language studies, published up to July 2017, were identified and their methodological quality was assessed. RCTs and non-RCTs were included., Results: Overall, the majority of the fourteen studies identified showed that participation in a perinatal depression screening program increases referral rates and service use, and is associated with more optimal emotional health outcomes. One of four available studies demonstrated an improvement in parenting outcomes as a result of participation in an integrated postnatal depression screening program., Conclusion: This small but important body of work is integral to the continuing debate over the merits of screening for depression in the perinatal period. Current evidence favours the overall benefits of perinatal depression screening programs across the three focus areas of this review. Future research should consider a woman's broader psychosocial context and should address the economic as well as clinical outcomes of these programs. Rigorous evaluation of emerging digital approaches to perinatal depression screening is also required., (Copyright © 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

The RAD51 family is integral for homologous recombination (HR) mediated DNA repair and maintaining chromosome integrity. RAD51D, the fourth member of the family, is a known ovarian cancer susceptibility gene and required for the repair of interstrand crosslink DNA damage and preserving chromosomal stability. In this report, we describe the RNF138 E3 ubiquitin ligase that interacts with and ubiquitinates the RAD51D HR protein. RNF138 is a member of an E3 ligase family that contains an amino-terminal RING finger domain and a putative carboxyl-terminal ubiquitin interaction motif. In mammalian cells, depletion of RNF138 increased the stability of the RAD51D protein, suggesting that RNF138 governs ubiquitin-proteasome-mediated degradation of RAD51D. However, RNF138 depletion conferred sensitivity to DNA damaging agents, reduced RAD51 focus formation, and increased chromosomal instability. Site-specific mutagenesis of the RNF138 RING finger domain demonstrated that it was necessary for RAD51D ubiquitination. Presence of RNF138 also enhanced the interaction between RAD51D and a known interacting RAD51 family member XRCC2 in a yeast three-hybrid assay. Therefore, RNF138 is a newly identified regulatory component of the HR mediated DNA repair pathway that has implications toward understanding how ubiquitination modifies the functions of the RAD51 paralog protein complex., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Background: Clinical practice guidelines now recommend that women be asked about their past or current mental health as a routine component of maternity care. However, the value of this line of enquiry in increasing engagement with support services, as required, remains controversial., Aim: The current study aimed to examine whether assessment of past or current mental health, received with or without referral for additional support, is associated with help-seeking during pregnancy and the postpartum., Methods: A subsample of women drawn from the Australian Longitudinal Study on Women's Health (young cohort) who reported experiencing significant emotional distress during pregnancy (N=398) or in the 12 months following birth (N=380) participated in the study., Results: Multivariate analysis showed that women who were not asked about their emotional health were less likely to seek any formal help during both pregnancy (adjOR=0.09, 95%CI: 0.04-0.24) and the postpartum (adjOR=0.07, 95%CI: 0.02-0.13), as were women who were asked about these issues but who were not referred for additional support (antenatal: adjOR=0.26, 95%CI: 0.15-0.45; postnatal: adjOR=0.14, 95%CI: 0.07-0.27). However, considerable levels of consultation with general practitioners, midwives and child health nurses, even in the absence of referral, were evident., Conclusion: This study demonstrates that enquiry by a health professional about women's past or current mental health is associated with help-seeking throughout the perinatal period. The clinical and resource implications of these findings for the primary health care sector should be considered prior to the implementation of future routine perinatal depression screening or psychosocial assessment programmes., (Copyright © 2014 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Objectives: To assess the value of the antenatal risk questionnaire (ANRQ) as a predictor of postnatal depression, to evaluate its acceptability to pregnant women and midwives, and to consider its use as part of a model for integrated psychosocial risk assessment in the antenatal setting., Method: This paper further analysed published data from the pregnancy risk questionnaire in a sample of 1196 women. We extracted 12 items from the original 23 item pregnancy risk questionnaire to assess how the shorter ANRQ would perform, and undertook the analysis in the subset who were administered the composite international diagnostic interview (CIDI) at 2 or 4 months postpartum to assess for major depression (N=276). We also sampled a subset of pregnant participants (N=378) and midwives (N=44) to assess the tool's acceptability to these groups respectively., Findings: ROC curve analysis for the ANRQ yielded an acceptable area under the curve of 0.69. The most 'clinically' useful cut off on the ANRQ was a score of 23 or more, yielding a sensitivity of 0.62 and specificity of 0.64 with positive predictive value of 0.3. The odds that a woman scoring 23 or more on the ANRQ is also a case was 6.3 times greater than for a woman scoring less than 23. Acceptability of the ANRQ was high among both women and midwives., Conclusion: The ANRQ is a highly acceptable self-report psychosocial assessment tool which aids in the prediction of women who go on to develop postnatal depression. In combination with a symptom based screening measure (e.g., the Edinburgh postnatal depression scale) and routine questions relating to drug and alcohol use and domestic violence, the ANRQ becomes most useful as a key element of a "screening intervention" aimed at the early identification of mental health risk and morbidity across the perinatal period. Evaluation of this model in terms of clinical outcomes remains to be undertaken., (Copyright © 2011 Australian College of Midwives. All rights reserved.)

Background: Mood disorders arising in the perinatal period (conception to the first postnatal year), occur in up to 13% of women. The adverse impact of mood disorders on mother, infant and family with potential long-term consequences are well documented. There is a need for clear, evidence-based, guidelines for midwives and other maternity care providers., Aim: To describe the process undertaken to develop the Australian Clinical Practice Guidelines for Depression and Related Disorders in the Perinatal Period and to highlight the key recommendations and their implications for the maternity sector., Method: Using NHMRC criteria, a rigorous systematic literature review was undertaken synthesising the evidence used to formulate graded guideline recommendations. Where there was insufficient evidence for recommendations, Good Practice Points were formulated. These are based on lower quality evidence and/or expert consensus., Findings: The quality of the evidence was good in regards to the use of the Edinburgh Postnatal Depression Scale and psychological interventions, but limited as regards medication use and safety perinatally. Recommendations were made for staff training in psychosocial assessment; universal screening for depression across the perinatal period; and the use of evidence based psychological interventions for mild to moderate depression postnatally. Good Practice Points addressed the use of comprehensive psychosocial assessment--including risk to mother and infant, and consideration of the mother-infant interaction--and gave advice around the use and safety of psychotropic medications in pregnancy and breastfeeding. In contrast to their international counterparts, the Australian guidelines emphasize a more holistic, woman and family centred approach to the management of mental health and mood disorders in the perinatal setting., Conclusion: The development of these Guidelines is a first step in translating evidence into practice and providing Australian midwives and other maternity care providers with clear guidance on the psychosocial management of women and families., (Crown Copyright © 2011. Published by Elsevier Ltd. All rights reserved.)

Objective: To describe the Australian perinatal mental health reforms and explore ways of improving surveillance of maternal mental health morbidity and mortality in this context., Approaches: We reviewed the Australian perinatal (defined as conception to one year postpartum) mental health reforms, in association with an appraisal of the population health methods that could be used for their evaluation., Conclusion: Despite the increasing focus of public health reforms on maternal mental health in the perinatal period, there is currently no national data available to evaluate these reforms or to provide an evidence base for improved health outcomes. National data development and linkage of relevant datasets would go a long way towards enabling such an endeavour., Implications: Inclusion of key mental health items in the Perinatal National Minimum Dataset and use of data linkage techniques will allow for monitoring of trends in maternal mental health morbidity and mortality in response to the Australian reforms. Once this is implemented, cost-benefit analyses can be undertaken., (© 2012 The Authors. ANZJPH © 2012 Public Health Association of Australia.)

Background: Animal studies have shown that postnatal rearing style can modify the association between prenatal stress exposure and offspring neurodevelopmental outcomes. However, little is known about how parenting quality impacts the association between maternal prenatal anxiety and development in human infants., Aim: This prospective study examined the impact of maternal prenatal anxiety disorder and maternal caregiving sensitivity on cognitive and psychomotor development in healthy, full-term, 7-month-old infants., Measures: Women completed a clinical interview during the third trimester of pregnancy to assess anxiety symptoms meeting DSM-IV diagnostic criteria. At infant age 7 months, maternal sensitivity to infant distress and non-distress were observed and coded during the still-face procedure. Maternal postnatal (concurrent) anxiety and depression were also assessed at this time. Infant mental and psychomotor development was assessed at infant age 7 months using the Bayley Scales of Infant Development II., Results: Analyses were based on 77 mother-infant dyads. Maternal sensitivity to infant distress moderated the association between maternal prenatal anxiety disorder and infant mental development, F (1, 77)=5.70, p=.02. Whereas there was a significant positive association between sensitivity and mental development among infants whose mothers were anxious during pregnancy, sensitivity had little impact on mental development among infants of control (non-anxious) women. Results were independent of prenatal depression and postnatal anxiety and depression. A caregiving moderation effect was not found for infant psychomotor development, p>.10., Conclusions: These findings are consistent with a cumulative risk model suggesting that maternal prenatal anxiety and quality of maternal care act in concert to shape infant outcomes., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Background: Although it has long been acknowledged that chronic HPA axis dysregulation impacts on adult neural function, little attention has been paid to the impact that disturbances of the maternal HPA axis may have on the developing fetal brain., Aim: This editorial examines the associations between prenatal stress, neuroendocrine functioning, and behavioural outcome in both animal and human offspring, with a particular focus on the relationship between prenatal stress and human fetal and infant neurobehaviour., Study Design: Using electronic databases, a computerized search of published and unpublished data was undertaken., Results: There is growing evidence that prenatal stress impacts on offspring neural function and behaviour in animal populations. That these findings may be applicable to human fetal neurobehaviour and infant development and outcome is gaining research attention, and the potential importance of the timing of pregnancy stress is being increasingly highlighted., Conclusions: There is a pressing need for more research into the role of maternal stress and anxiety during pregnancy on human fetal and infant outcomes. Future studies should prospectively pair physiological and psychological measures both pre- and postnatally if the HPA axis function of the mother and her infant is to be more fully understood.