Towards improving perinatal maternal mental health in Vietnam

Sammanfattning: Major depression is increasing world-wide, and is the third leading cause of the global disease burden. In Vietnam, perinatal depression is underdiagnosed and under-treated, leading to severe consequences for the pregnant mother, her child and surroundings. AIMS: The overall aim was to improve knowledge about perinatal depression to contribute to evidence based development of prevention and treatment strategies in Vietnam. The specific aims were: To generate a report of the mental health priorities in Vietnam (Study I); To elicit illness explanatory models of depression and postnatal depression (Study II); To provide information for the contextual adaptation of a mindfulness based intervention for antenatal depression for use in a semi-rural context in Vietnam (Study III); To examine the association of low birth weight and prematurity with antenatal depression (Study IV). METHODS: Study I was conducted in the Hanoi area. Studies II, III and IV were conducted within a Demographic Surveillance System, in the Ba Vi district of the Hanoi province. Study I used snowball sampling to identify informants for generating a Mental Health Country Profile, and data was gathered through semi-structured interviews and collection of reports and documents. In study II illness explanatory models of depression and postnatal depression were elicited from mothers and health workers, through semi-structured interviews. In study III, individual interviews addressing the experience of depression during pregnancy were conducted with nine women who obtained high scores in a depression self-report measure during pregnancy. Two focus group discussions with health workers and two with elderly women from the local community addressed the perceptions of depression and the suitability and provision of a mindfulness intervention. Study IV was a prospective community-based cohort study, where severity of antenatal depression symptoms was assessed and its association with low birth weight and preterm birth was examined. Reproductive and sociodemographic risk-factors were measured as potential confounders. RESULTS: Strengths of the Vietnam mental health system included the aims to move toward community management and detection of mental illness. Weaknesses include the lack of choice and availability of treatments apart from medications, the high proportion of treatments to be paid out-of-pocket, prominence of large tertiary psychiatric hospitals, and a lack of preventative measures (Study I). The causation of perinatal depression was described as predominantly somatosocial. Psychiatric treatment was seldom recommended, and depression was described as not openly spoken of by those afflicted (Studies II and III). The mindfulness intervention was thought suitable for the local context and delivery through community meetings was recommended (Study III). The prevalence of antenatal depression was 5.7%, and it was significantly associated with preterm birth (Adj OR: 3.09, CI95% 1.18-8.10) (Study IV). CONCLUSIONS: The stigma of depression emerged as potentially significant through the qualitative studies and prevalent social adversities were found to be relevant for causation of perinatal depression which is associated to preterm birth. Low-cost psychological treatment modalities that do not depend of highly trained mental health personnel should be developed. Mindfulness based interventions appear to be a locally feasible. An approach to depression management that focuses solely on individual pathology will fail to address these causes and thus, multiple sectors in society should be involved in prevention.