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This is a source which is relevant for my research question because it is focused on the role of the NHS in tackling poverty, which is the tile of my research project. It is a reliable source because it is based on serious academic research. It is a starting point for my own research because it provides links to substantial academic studies.

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The role of the NHS in tackling poverty and the wider determinants of health

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Despite all the pressures, the NHS remains, and will continue to remain, a massive economic and social entity. Are we making the most of this enormous power?

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Habbiba

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Postnatal depression can affect women in different ways. It can start at any point in the first year after giving birth and may develop suddenly or gradually.

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We have a Child Protection team at the Children's Hospital and a Safeguarding team at the Women's Hospital.

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People under age 40 who are diagnosed with Type 2 diabetes are more likely to have or die from cardiovascular disease than those of similar age without diabetes and the excess risks were more pronounced in younger women, according to new research in the American Heart Association's journal Circulation.

Researchers also found the excess risk for death, regardless of cause, for people diagnosed with Type 2 diabetes at age 80 or older significantly decreased and was the same as those of similar age without diabetes.

"Our study shows the differences in excess diabetes risk are tied to the how old the person is when they are diagnosed with Type 2 diabetes," said Naveed Sattar, M.D., Ph.D., lead author of the study and professor of Metabolic Medicine at the University of Glasgow in the United Kingdom.

Obesity rates have steadily increased in high-income countries and in young people over the last 30-40 years. As a result, more adolescents and young adults are being diagnosed with Type 2 diabetes more than ever before, according to the study.

This is the first study to compare the excess risks of dying from or developing cardiovascular disease in people diagnosed with Type 2 diabetes and to adjust the risk for such outcomes given how long a person has had diabetes -- an independent risk factor associated with cardiovascular disease risk.

Using data from the Swedish National Diabetes Registry, researchers followed 318,083 Type 2 diabetes patients and 1,575,108 age, sex and county-matched people as a control group from 1998 to 2013 for heart disease-related conditions. Death resulting from heart disease or any other cause was followed from 1998 to 2014.

Patients with Type 2 diabetes and similar aged controls had their risk for developing heart disease, heart attack, stroke, hospitalization from heart failure and atrial fibrillation assessed. Researchers also evaluated death from cardiovascular disease and any other conditions.

During a median follow-up of nearly two and half years, researchers compared results to control participants of similar age without Type 2 diabetes and found:

Participants diagnosed before age 40 with Type 2 diabetes had the greatest excess risk for death, stroke, heart attack, heart failure or atrial fibrillation.

Women generally carried higher excess cardiovascular disease and mortality risks than men in most categories.

Excess risks for cardiovascular disease and life years lost declined steadily with the age of diagnosis.

"This suggests we need to be more aggressive in controlling risk factors in younger Type 2 diabetes populations and especially in women," Sattar said. "And, far less effort and resources could be spent screening people 80 and older for Type 2 diabetes unless symptoms are present. Furthermore, our work could also be used to encourage middle-aged people at elevated diabetes risk to adopt lifestyle changes to delay their diabetes by several years."

The study followed a majority white European population, so additional studies examining the role of cardiovascular disease in non-white populations who have Type 2 diabetes are needed.

Co-authors are Araz Rawshani, M.D.; Stefan Franzen, Ph.D.; Aidin Rawshani, M.D.; Ann-Marie Svensson, Ph.D.; Annika Rosengren, M.D.; Darren McGuire, M.D.; Bjorn Eliasson, M.D.; and Soffia Gudbjo?rnsdottir, M.D. Author disclosures are on the manuscript.

The Swedish Association of Local Authorities Regions, Swedish Heart and Lung Foundation, and Swedish Research Council funded the study.

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diabetes; heart disease; chronic illness; personalized medicine; stroke prevention; healthy aging; diseases and conditions; hormone disorders

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People under 40 diagnosed with type 2 diabetes face excess risk of cardiovascular disease, death

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People under age 40 diagnosed with type 2 diabetes are more likely to have or die from cardiovascular disease than people of a similar age who do not have type 2 diabetes. The excess cardiovascular risks were more pronounced in younger women with type 2 diabetes and excess risk significantly decreased in those who develop diabetes much later in life.

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The term obese describes a person who has excess body fat.
In the UK it's estimated that around 1 in every 4 adults and around 1 in every 5 children aged 10 to 11 are living with obesity.

How to tell if you're living with obesity

The most widely used method to check if you're a healthy weight is body mass index (BMI).

BMI is a measure of whether you're a healthy weight for your height. You can use the NHS BMI healthy weight calculator to find out your BMI.

For most adults, if your BMI is:

below 18.5 - you're in the underweight range

18.5 to 24.9 - you're in the healthy weight range

25 to 29.9 - you're in the overweight range

30 to 39.9 - you're in the obese range

40 or above - you're in the severely obese range

If you have a South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean family background you'll need to use a lower BMI score to measure overweight and obesity:

23 to 27.4 - you're in the overweight range

27.5 or above - you're in the obese range

BMI score has some limitations because it measures whether a person is carrying too much weight but not too much fat. For example, people who are very muscular, like professional sportspeople, can have a high BMI without much fat.

But for most people, BMI is a useful indication of whether they're a healthy weight.

Another measure of excess fat is waist to height ratio, which can be used as an additional measure in adults who have a BMI under 35.

To calculate your waist to height ratio, measure around your waist just above your belly button, and divide it by your height, measured in the same units (for example, centimetres or inches).

A waist to height ratio of 0.5 or higher means you may have increased health risks.

Risks of living with obesity

Obesity is a serious health concern that increases the risk of many other health conditions.

These include:

Living with overweight and obesity can also affect your quality of life and contribute to mental health problems, such as depression, and can also affect self-esteem.

Causes of obesity

Obesity is a complex issue with many causes. Obesity and overweight is caused when extra calories, particularly those from foods high in fat and sugar, are stored in the body as fat.

Obesity is an increasingly common problem because the environment we live in makes it difficult for many people to eat healthily and do enough physical activity.

Genetics can also be a cause of obesity for some people. Your genes can affect how your body uses food and stores fat.

There are also some underlying health conditions that can occasionally contribute to weight gain, such as an underactive thyroid gland (hypothyroidism), although these types of conditions do not usually cause weight problems if they're effectively controlled with medicines.

Some medicines can also make people more likely to put on weight, including steroids and some medicines for high blood pressure, diabetes or mental health conditions.

Treating obesity

The best way to treat obesity is to eat a healthy reduced-calorie diet and exercise regularly.

To do this, you can:

eat a balanced calorie-controlled diet as recommended by a GP or weight loss management health professional (such as a dietitian)

take up activities such as fast walking, jogging, swimming or tennis for 150 to 300 minutes (2.5 to 5 hours) a week

You may benefit from joining a local weight management programme with group meetings or online support. Your GP can tell you about these.

You may also benefit from receiving support and counselling from a trained healthcare professional to help you better understand your relationship with food and develop different eating habits.

If you're living with obesity and lifestyle and behavioural changes alone do not help you lose weight, a medicine called orlistat may be recommended.

If taken correctly, this medicine works by reducing the amount of fat you absorb during digestion. Your GP will know whether orlistat is suitable for you.

A specialist may prescribe other medicines called liraglutide or semaglutide. They work by making you feel fuller and less hungry.

For some people living with obesity, a specialist may recommend weight loss surgery.

Other obesity-related problems

Living with obesity can cause a number of further problems, including difficulties with daily activities and serious health conditions.

Day-to-day problems related to obesity include:

breathlessness

increased sweating

difficulty doing physical activity

often feeling very tired

joint and back pain

low confidence and self-esteem

feeling isolated

The psychological problems associated with living with obesity can also affect your relationships with family and friends, and may lead to depression.

Serious health conditions

Living with obesity can also increase your risk of developing many potentially serious health conditions, including:

type 2 diabetes

high blood pressure

high cholesterol and atherosclerosis (where fatty deposits narrow your arteries), which can lead to coronary heart disease and stroke

metabolic syndrome, a combination of diabetes, high blood pressure and obesity

several types of cancer, including bowel cancer, breast cancer and womb cancer

gastro-oesophageal reflux disease (GORD), where stomach acid leaks out of the stomach and into the gullet

gallstones

reduced fertility

osteoarthritis, a condition involving pain and stiffness in your joints

sleep apnoea, a condition that causes interrupted breathing during sleep, which can lead to daytime sleepiness with an increased risk of road traffic accidents, as well as a greater risk of diabetes, high blood pressure and heart disease

liver disease and kidney disease

pregnancy complications, such as gestational diabetes or pre-eclampsia, when a woman experiences a potentially dangerous rise in blood pressure during pregnancy

Obesity reduces life expectancy by an average of 3 to 10 years, depending on how severe it is.

Outlook

Managing a complex issue like obesity can be hard. Losing weight takes time and commitment.

The healthcare professionals involved with your care can provide encouragement and advice about how to mange your weight, build healthy lifestyle habits and maintain weight loss achieved.

Completing a weight management programme, regularly monitoring your weight, setting realistic goals, and involving your friends and family with ways to lose weight can also help.

It's important to remember that losing what seems like a small amount of weight, such as 3% or more of your original body weight, and maintaining this for life, can significantly reduce your risk of developing obesity-related complications like diabetes and heart disease.

Social care and support guide

If you:

need help with day-to-day living because of illness or disability

care for someone regularly because they're ill, disabled or because of their age (including family members)

Our guide to care and support explains your options and where you can get support.

Couch to 5K

If it's been a long time since you did any exercise, you should check out the Couch to 5K running plan.

It consists of podcasts delivered over the course of 9 weeks and has been specifically designed for absolute beginners.

To begin with, you start running for short periods of time, and as the plan progresses, gradually increase the amount.

At the end of the 9 weeks, you should be able to run for 30 minutes non-stop, which for most people is around 5 kilometres (3.1 miles).

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Read about obesity and how it can seriously affect your health. Ways to lose weight safely include eating a healthy, reduced-calorie diet and exercising regularly.

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In type 2 diabetes the cause is generally weight related. If you are slim it is likely your body is not producing enough insulin to convert the carbohydrate you eat into energy. You may need tablets and/or insulin to help. If you are overweight it is more likely that insulin resistance is responsible.

Reducing your weight and being physically active will reduce your insulin resistance, but you may need medication or to inject insulin to help.

Type 2 diabetes is more likely to affect older people, although it is being found increasingly in younger people - especially if they are overweight and lacking in physical activity.

Type 2 diabetes is strongly linked to obesity and tends to run in families. It is more prevalent in people of South Asian and Afro-Caribbean descent. Many people with type 2 diabetes have high blood pressure and cholesterol and may need tablets to control these too.

The backbone of treating type 2 diabetes is always healthy eating plus physical activity. But type 2 diabetes is a progressive condition and, in time, tablets and/or other forms of medication are likely to become necessary and may even progress to insulin injections.
The above is an extract from the DRWF Patient Information Leaflet What is Diabetes? V7.0, published August 2018 (reviewed within an 18 month period).

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In type 2 diabetes the cause is generally weight related. If you are slim it is likely your body is not producing enough insulin to convert the carbohydrate you eat into energy. You may need tablets and/or insulin to help. If you are overweight it is more likely that insulin resistance is responsible.

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Bella
Mental health and poverty

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See also separate Health and Social Class article.

There is a growing contribution of mental health problems to the global disease burden - neuropsychiatric disorders now account for about 13% of the total.

The link between individual poverty and mental health is well known.The relationship between poor mental health and health inequality within neighbourhoods is, however, more complex.

One study found that living in neighbourhoods with the highest levels of income inequality was significantly associated with better mental health. The authors forwarded several explanations for these somewhat surprising findings. These included an increase in social capital (the collective value of social networks) in areas with low deprivation and a reduction in the risk of stress experienced by persons living in deprived areas.

The 'social capital' concept is supported by a study which found that older people in Hertfordshire, UK, who had a strong sense of cohesion within their neighbourhood and reported fewer neighbourhood problems, had higher levels of mental well-being.

Those with mental health problems are more likely to experience poverty: once incapacitated, an individual's socio-economic status is likely to fall further ('selective social drift'). One study, for example, showed a decline in social position and financial circumstances over time in people who were depressed.In another study, the GHQ-28 (a general health questionnaire used for the detection of psychiatric conditions) was employed to assess a cohort of people born in 1947. Poorer reported mental health in men (although not in women) was associated with downward socio-economic trajectory over the whole life course.

Consider potential confounding variables:

Employment

Having mental illness has a number of adverse effects on the ability to earn:

When unwell, It is more difficult to study and to achieve qualifications.

It is more difficult to obtain a job - mental illness carries a heavy social stigma. Surveys have shown a widespread reluctance amongst employers to take on employees with a disability at any level and that applies especially to those with a mental disability.

Of people actively seeking employment, the rate of unemployment is much lower amongst those without any medical problems than it is amongst those with physical disability. Those with mental disability face even greater difficulty.

It is more difficult to hold down a job - a person with mental illness may need intermittent and unpredictable time off when the illness needs more intense treatment. Employers may perceive this, whether due to mental or physical ill health, as 'unreliability'. They may also have concerns that there could be risk involved in the individual working whilst unwell.

Even once employed, individuals may feel unsupported both by employers and colleagues. They may experience disparaging remarks at work. There is often a lack of sympathy and understanding, symptomatic of society's general unease with mental illness.

The Disability Discrimination Act (1995) makes it unlawful to discriminate against employees with a disability.The Equality Act 2010 clarifies that those with mental illness that has a substantial, adverse and long-term (>12 months) effect on their ability to carry out normal day-to-day activities are considered to have a disability.It is intended to offer protection but attitudinal changes towards disability and mental health lag behind legislation.

Unemployment

A report of Mental Health and Social Exclusion, published by the Social Exclusion Unit in 2004, showed that amongst those with long-term mental health problems, fewer than a quarter were employed.

It should be recognised that not everyone with mental health problems is capable of working and the nature of mental illness means that this capacity may fluctuate. Welfare benefits, therefore, are the major source of financial support for many working-age adults with significant mental health problems. The Employment and Support Allowance replaced Incapacity Benefit, Severe Disablement Allowance and Income Support in 2008. People who wish to claim such an allowance are expected to undertake a work-related assessment and are then put into either a Work Related Activity Group in which support is provided to find work, or into a Support Group in which the person is recognised as being unfit to work and provided with appropriate support.

Unemployment levels were stable for many years but rose steadily since the recession and reached 2.49 million in the UK in June 2011. There were concerns about the mental health of people exposed to such economic conditions. However, recent years have seen a gradual fall in the number of unemployed, which stood at 1.75 million in the quarter April to June 2015.

Unemployment has a complex relationship with suicide rates. Studies suggest that during a recession, suicide rates increase in the employed but decrease in the unemployed.

One UK study found that the risk of common mental health disorders increased in those who had been out of work for three years or more.

Debt

When people using mental health services are asked about the major issues that concern them in their daily lives, personal finances are consistently identified as a major source of difficulty and distress. 1 in 3 people with a serious mental health condition is thought to be in debt.Concerns and anxieties regarding finance constitute a significant stressor.

Financial strain is thought by some to be a better predictor of future psychiatric morbidity than either poverty or unemployment, although the nature of this risk factor and its relationship with poverty and unemployment remain unclear.

One UK study suggested that the relationship between poverty and mental illness was mediated largely by debt - a cross-sectional design showed that those with low income were more likely to have mental disorder but that this relationship was significantly attenuated after adjustment for debt. People with six or more separate debts had a six-fold increase in mental disorder after adjustment for income.

Inequality

As with physical ill health, common mental disorders are more common in people who are socially disadvantaged.The gulf between those living affluent lifestyles and those living in poverty in the UK has widened over the last few decades and the concern is that this poses an increased threat to health as well as raising issues of social justice. A report published by the National Equality Panel in 2010 stated that the richest 10% of the population were more than 100 times as wealthy as the poorest 10%.

One UK study looking at evidence on a population basis supported the hypothesis that greater income inequality was associated with lower standards of population health.

Both income and income inequality affect infant health outcomes in the USA. The health of the poorest infants was affected more by absolute wealth than relative wealth.

Child poverty

Because of the social decline associated with mental illness, research has looked at mental health of young people who are still dependent upon their parents for their economic position:

Most surveys suggest an increased rate of mental health problems in children in families with low incomes compared to those in better-off households (1 in 6, compared to 1 in 20).This difference is most exaggerated in boys, with double the risk. Attention deficit hyperactivity disorder (ADHD), bedwetting and self-harming behaviours show strong social patterns, whilst autistic spectrum disorders show no social difference.

However, a paper from the Institute of Psychiatry in London found that none of the variables they examined was associated with all types of disorder:

Poor general health and life events were related to emotional disorders.

Conduct disorders were most closely associated with family variables.

ADHD was only related to child characteristics.

They concluded that disadvantaged schools, deprived neighbourhoods, low socio-economic status, parental unemployment, cohabiting, large family size and poverty were not independently associated with disorder. Individually assessed child and family factors may be more influential than aggregate measures of school and neighbourhood factors.

Evidence from the 1958 and 1970 British prospective birth cohort studies cited socio-economic deprivation as one of the issues which affected childhood mental well-being.

Do interventions work? A Cochrane Review found no benefits to child mental health from studies looking at the use of financial support to poor families.However, they also comment that the studies were limited given the small increases in total household income, the lack of conditions as to the use of the money and strict conditions for receipt of payments.

Adults who have grown up in financial hardship are more likely to experience mental health problems (and adult poverty). A Swedish study found that children reared in families with a disadvantaged socio-economic position had an increased risk for psychosis.

Mental illness itself is a significant contributory factor to child poverty. An American study found that 68% of women and 57% of men with a mental illness are parents. In addition, many children live with a parent who has long-term mental health problems, as well as alcohol or drug problems and personality disorders. Given the huge over-representation of unemployment and benefits' dependence amongst those with mental illness, this represents a significant number of children living in financially challenged households.

The findings from the East London First Episode Psychosis Study confirmed a higher risk of psychosis in first- and second-generation immigrants to the UK, in comparison to white British people.

The excess risk is not specific to Afro-Caribbean immigrants; it is also present among African-born black immigrants to the UK and, to a lesser extent, among Asian immigrants.

Incidence rates of schizophrenia in Caribbean countries are similar to those found in the indigenous UK population and much lower than reported rates among immigrants from the region. The rate for schizophrenia in black Caribbean, black African and South Asian groups in England was higher than in the white British population. There was no evidence of a change in incidence over time, although a change in diagnosis (away from schizophrenia) was observed.

Immigrant populations are disadvantaged in terms of socio-economic status, educational attainment, employment and housing standards, as well as subject to racial discrimination.

Typically, immigrants experience delay in seeking professional help, a lower probability of medical referral, more frequent involvement of the police and emergency services and higher proportions of compulsory and secure unit admissions.

High incidence rates are also found amongst the lowest social class in the indigenous white population.

The association has been seen in several immigrant groups across Europe.It is clear that a personal or family history of immigration is a risk factor for schizophrenia.There is an increasing interest in how chronic social stressors may interact with other factors to cause the development of schizophrenia.

Urban environment

Studies have shown higher risk of mental disorder among persons living in urban versus rural areas.Epidemiological research has documented that associations between particular features of the urban environment, such as concentrated disadvantage, residential segregation and social norms, contribute to the risk of mental illness.Some studies have suggested a link between urban environmental factors and a higher risk of mental illness, particularly schizophrenia.

As ever, there is the question as to whether this is causation (urbanity causing psychosis) rather than selection (high-risk individuals move into urban areas, often as part of the social drift accompanied by onset of illness). Some consider the effect of the urban environment to be conditional on genetic risk (a gene-environment interaction).

There are important within-city variations in the incidence of schizophrenia associated with different neighbourhood social characteristics. For example, the incidence of non-affective psychoses varies widely across South East London and this is is not adequately explained by looking at individual-level risks.The cause of these neighbourhood variations is unknown but may be a reflection of social fragmentation.

Abuse of drugs or alcohol is likely to lead to social decline: it is a financial drain, makes the individual more unemployable and often is associated with criminal behaviour.

Although substance abuse should not be seen as a mental illness, it is not uncommon to find that there is a dual diagnosis of both substance abuse and mental illness.

This leads to the question of primacy: has the substance abuse caused the mental illness or has the mental illness led to 'self-medication' with alcohol or illicit drugs? Probably both are true. Genetic factors may also play a part.

Criminality

Closure of the 'asylums' and the ascendance of 'care in the community' radically changed mental healthcare provision in the UK. Many saw this as a cost-cutting device and, whilst it is generally true that care in the community is cheaper than in hospital, psychiatric care in the community should be seen as a humanitarian aim rather than a financial expedience. There is a view that asylums should not have been abolished but reformed.'Care in the community' has not always proved adequate and too often those with mental health problems have broken the law and been incarcerated in prison.

According to the Mental Health Foundation, only 1 in 10 prisoners does not have a mental health problem, counting substance abusers (and those with dual diagnosis), those with a primary mental illness and others who become unwell under the psychological stresses of imprisonment.

Despite the Rehabilitation of Offenders Act, it is very difficult for anyone with a criminal record to obtain work and hence they are more likely to re-offend.

Poor physical health

A study by the South London and Maudsley Trust found that people diagnosed with serious mental illness had significantly reduced life expectancy (8.0 to 14.6 life years for men and 9.8 to 17.5 life years for women). Highest reductions were found for men with schizophrenia (14.6 years lost) and women with schizoaffective disorders (17.5 years lost). Living with schizophrenia and bipolar disorder increases the risk of certain physical diseases (cardiovascular and chronic respiratory disease, diabetes, hepatitis C, HIV).Possible reasons for this are multi-fold:

Poor access to physical healthcare - eg, lack of primary healthcare attached to mental health inpatient wards. People with severe mental health problems may not feel empowered to take the initiative with their physical health and to demand good healthcare.

'Diagnostic overshadowing' - healthcare workers focus on anxiety and mental health problems and may not attend to physical symptoms, preventing early treatment.

Lack of communication/interplay between physical and mental health systems.

Lifestyle - people with severe mental illness have a high incidence of smoking and obesity. This may be in part related to low income but also factors such as decreased responsiveness to public health campaigns and messages.

Medication - some medication used for severe mental health problems may increase the risk of certain conditions, such as diabetes.

The aetiology of mental illness is undoubtedly multifactorial and, although arguments relating its development to poverty are strong, genetics, upbringing and subsequent lifestyle are possible major confounders. Poverty is neither sufficient nor necessary to cause mental illness and the impact of social disadvantage may also be different for different mental illnesses.

Living in poverty causes chronic stress and struggle and this may have an ultimate biological impact on brain function, particularly if experienced at certain critical points in development. According to one hypothesis, schizophrenia is the result of chronic experience of social defeat disturbing dopaminergic function in the brain.

Regardless, a society may be judged on how it treats its most disadvantaged. The problems of poverty, as described in Charles Dickens' David Copperfield, and social rehabilitation, or lack of it, as portrayed by Victor Hugo in Les Misérables, remain as pressing today.

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Mental Health and Poverty. Mental health info from Patient

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See also separate Health and Social Class article. There is a growing contribution of mental health problems to the global disease burden - neuropsychiatric disorders now account for about 13% of the total. The link between individual poverty and mental health is well known.The relationship between poor mental health and health inequality within neighbourhoods is, however, more complex.

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This is relevant to my research project as I would like to talk about depression in middle aged women.

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Your access to the NCBI website at www.ncbi.nlm.nih.gov has been temporarily blocked due to a possible misuse/abuse situation involving your site. This is not an indication of a security issue such as a virus or attack. It could be something as simple as a run away script or learning how to better use E-utilities, http://www.ncbi.nlm.nih.gov/books/NBK25497/, for more efficient work such that your work does not impact the ability of other researchers to also use our site. To restore access and understand how to better interact with our site to avoid this in the future, please have your system administrator contact info@ncbi.nlm.nih.gov.

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Your access to the NCBI website at www.ncbi.nlm.nih.gov has been temporarily blocked due to a possible misuse/abuse situation involving your site. This is not an indication of a security issue such as a virus or attack.

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This is a relevant and reliable source for my research project as it is regarded as a reliable news source

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epression is in the news these days. We love to read and write about it and yet, whenever we discuss it, we offer the same routine disclaimer. Sufferers from depression, we are told, are too ashamed or embarrassed to admit to their condition. They are reluctant to seek help, although we all piously agree there is nothing to be ashamed of in mental illness. And we keep on repeating this to ourselves, despite the glaring examples of distinguished depressives who have been far from reticent about their state. These include Alastair Campbell, Stephen Fry, Professor Lewis Wolpert and, most recently, the highly successful novelist Marian Keyes, whose outburst of near-despair last week has provoked a good deal of commentary, both sympathetic and snide. She says she can't eat, sleep, write, read or talk to people and that she doesn't know when she will ever emerge from this darkness. She has told the world about this on her website, so she won't mind my repeating it.

So, is depression fashionable or is it unmentionable? Is it a taboo or a mark of distinction? Is a confession an act of exhibitionistic self-indulgence? It's not clear whether we think we run risks by ignoring it or whether we talk about it too much. It is obviously unwise for politicians to admit openly to depression, at least while they are in or seeking office, and dentists and doctors don't often own up to it, although many suffer from it. I was told by a reliable source that the suicide rate for dentists in the United States is higher than that in any other profession, yet most dentists appear to be quite jolly. It's all right for actors, performers, writers, artists and women to admit to weakness, because they aren't responsible and they don't count.

Fashions in illness come and go. Appendixes, adenoids and tonsils are no longer as smart or as suspect as they were and it appears that the vogue for ulcers has given way to the label of acid reflux. There are fashions in mental health, too, and the recent proliferation of dramatic eating disorders such as anorexia and bulimia begins to make depression look seriously old-fashioned. Feminist scholars Elaine Showalter and Lisa Appignanesi have written about the changing history of women's afflictions, noting that the 19th-century diagnosis of hysteria (etymologically, a womb-related disorder) more or less disappeared and was overtaken by a blanket diagnosis of depression. And it would appear, from such inevitably unreliable statistics as we have, that women are more liable to depression than men, despite the exceptions cited above. More women take anti-depressants and more women are succumbing to depression year by year, or so recent surveys suggest.

In the old days, the days of my mother and grandmother, female depression was often linked to the menopause and took the form of low spirits, mood swings, a sense of worthlessness and redundancy and odd acts of eccentricity (kleptomania was often excused as menopausal). These states were very different from the florid hysteria from which some of Freud's patients suffered. Hormonal changes were blamed for what was seen as a not very welcome but inevitable rite of passage: you expected this kind of thing to happen to you at a certain age. The woman, no longer fertile and made uncomfortably aware of her diminishing biological attractions, sank into a period of gloom from which she would emerge when the hormones settled and she meekly accepted her reduced role. The word "menopausal" was flung around as a routine insult, but I suspect that, like the words "cretin" and "spastic", it may be less acceptable now. Men didn't have to go through this middle-aged valley, because they remained potent and didn't have to confront bodily change so bleakly. They went under later, at retirement.

Female expectations changed dramatically with the availability of hormone replacement therapy (HRT), which delayed the menopause and some of its associated ills. My generation eagerly swallowed those little reddish brown pellets of mare's urine, or whatever they were made of, as though they were the elixir of life, just as we had swallowed the contraceptive pills that had given us our freedom. We didn't care about the long-term effects, we just wanted to stay young a bit longer. We didn't want to go down into the vale just yet. I remember having serious doubts about all of this when I met a 68-year-old woman at a charity luncheon, who confided to me over the soup that she was still menstruating and proud of it. I was taken aback. I think it occurred to me then, with justified foreboding, that the depression traditionally associated with the menopause might not have been avoided by HRT, it might just have been postponed, and that it would kick in later, with all the more force because the body and spirit would be older and weaker and future prospects less bright.

The chronological curve of women's expectations has changed spectacularly during Marian Keyes's writing life. She is 46 years old, but nowadays a 46-year-old is not even seen as middle-aged. She is in the prime of life and is more likely to be accused of suffering from the hangover of celebrity and success than from the once-inevitable "change of life". I read one or two of her novels 10 years ago when I was writing an essay about chick lit and the courtship novel, inspired by the emergence of Bridget Jones. The heroines of chick lit are 10 years older than the heroines of Jane Austen, in their thirties rather than their early twenties. They are financially independent and enjoy unlimited freedom of speech and movement; Bridget Jones is noticeably more confident about sexual intercourse than she is about fancy cooking. This is a very different social world from Austen and even from early Drabble.

Women's lives have in one generation changed almost out of recognition. Keyes's Sushi for Beginners (2000), set largely in the offices of a women's magazine, is a characteristic example of high-spirited chick lit with a subplot of mum lit and contrasts the fates of three women, one ambitious and separated from her husband, one single and caring and one married to her "dream man", but hampered and exhausted by small children. These are pioneer lives, in a rapidly changing society, and they clearly mirror the aspirations and experiences of millions of readers, who made their creator a bestseller.

Some mental health experts argue that women are unhappier now than they used to be because their expectations are too high. They fail to achieve eternal youth and beauty, but are forced to live in a consumer culture that celebrates youth. This, these experts suggest, may be even more painful than the fear that, at the age of 46, they would be sinking into menopausal gloom and thence descending rapidly into old age.

I doubt it. All change brings risks. Women are less passive than they used to be, live longer and have more resilience, even though they encounter new hazards as they age. They are still at work on the shape of the future. Marian Keyes, in speaking out about her current desperate state, is already moving on. She is a writer and she will probably write her way out of it. That's what writers do.

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Why are so many middle-aged women cursed by depression? | Margaret Drabble

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epression is in the news these days. We love to read and write about it and yet, whenever we discuss it, we offer the same routine disclaimer. Sufferers from depression, we are told, are too ashamed or embarrassed to admit to their condition.

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The Joseph Rowntree Foundation's UK Poverty 2017, shows that over half of people living in poverty are in working households and many are in vulnerable groups. Too often, work doesn't pay enough or people fall into poverty through circumstances beyond their control. Poverty is, in part, about lacking basic material resources. People are struggling to put food on the table and a recent review by housing and homelessness charity Shelter found that one in every 200 people in the UK is homeless.

But it's also about exclusion and missed opportunities - the child who is singled out for having free school meals or the person who misses a job interview because they don't have the 'right' clothes. When people are prevented from accessing resources and experiences, it can compromise their ability to participate and feel valued and included in society.

How does poverty affect health?

The healthy life expectancy gap between the most and least deprived parts of the UK is 19 years. The reasons for this are complex and money is just one part of the picture - the index of multiple deprivation also includes other determinants of our health such as housing, employment and education. Yet, in many conversations I have about inequalities in health, 'deprivation' or 'disadvantage' are quickly translated into 'poverty'. While we mustn't lose sight of the other factors involved, the importance of having enough money cannot be ignored.

An adequate income can help people to avoid stress and feel in control, to access experiences and material resources, to adopt and maintain healthy behaviours, and to feel supported by a financial safety net. Through these mechanisms, people are more able to access the opportunities needed for a healthy life. These opportunities include meaningful work, secure housing and high self-esteem - all of which affect our long-term physical and mental health.

The relationship also works in the other direction. Good health can enable people to access social and economic opportunities, such as secure and good quality work. Without these opportunities, people can become trapped in cycles of poor health and poverty.

Poverty constrains choice

There is much debate about the balance between individual 'lifestyle' choices versus wider structural factors in shaping our health. It's true that individuals can have agency over decisions that affect their health, but this agency can be severely limited by poverty. Decisions to buy unhealthy food, cigarettes, or a TV should be viewed in this wider context.

The novelist James Baldwin put it well when he said 'anyone who has ever struggled with poverty knows how extremely expensive it is to be poor'. While the links between cold, damp housing and poor health are well known, prepaid energy meters can mean people on low incomes need hundreds of pounds more to meet energy costs each year. This can be a challenge for many of the 48% of those aged 21-24 who don't earn the living wage. Similarly, our infographic shows that it can be three times more expensive to get the energy we need from healthy foods than unhealthy foods.

Poverty also expends emotional resources, and affects people's ability to comprehend the future. Viewed through this lens, it's possible to see how unhealthy behaviours such as smoking are used as quick fixes in stressful circumstances. Or how, if you're suffering with loneliness and on a low income, buying a TV is not as unwise as it might seem. Poverty also limits people's ability to invest in the future and thereby improve their future health prospects. Studying, retraining or moving to a new city can open up valuable opportunities, but without a financial safety net, the risks are simply too high for many people.

Tackling poverty to improve health

There are many stories of people overcoming a lack of money, perhaps through getting a place at a school or college, or using a talent in music or sport. But given the scale of the problem, a few 'golden tickets' is not the answer. Tackling poverty requires cross-sectoral action. Education and skills, good work, a benefits system that responds to need, debt support, and tighter gambling laws all have their part to play.

As Liverpool Councillor Richard Kemp highlights in our recent publication Policies for a healthy life: a look beyond Brexit, we must seize opportunities to develop 'more aggressive policies to encourage the creation of wealth across the country', and in doing so address inequalities across society as a whole.

The moral and economic case for action is huge. £1 in every £5 of all spending on public services is needed because of the impact and cost that poverty has on people's lives. A UK in which more people are living, and not just surviving, requires a more ambitious approach - one that responds to the experiences and priorities of the 1 in 5 people who understand the issues best.

Sarah Lawson is a Policy and Programme Support Officer in our Healthy Lives team.

References

48% of 21-24-year-olds earn less than the living wage
Office for National Statistics.Proportion of employees earning below £8.75 per hour working outside London, £10.20 per hour working in London: April 2017. 2017.
Available fromONS website

Why do people in disadvantaged circumstances tend to have poorer health at most stages in life?
Joseph Rowntree Foundation.How does money influence health? 2014.
Available from:https://www.jrf.org.uk/report/how-does-money-influence-health

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Infographic looking at how our money and resources can influence our health.

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https://figshare.shef.ac.uk/collections/Children_Technology_and_Play/4876659

https://core.ac.uk/download/pdf/72840163.pdf

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Obesity in Children

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Abstract

Childhood obesity has reached epidemic levels in developed as well as in developing countries. Overweight and obesity in childhood are known to have significant impact on both physical and psychological health. Overweight and obese children are likely to stay obese into adulthood and more likely to develop non-communicable diseases like diabetes and cardiovascular diseases at a younger age. The mechanism of obesity development is not fully understood and it is believed to be a disorder with multiple causes. Environmental factors, lifestyle preferences, and cultural environment play pivotal roles in the rising prevalence of obesity worldwide. In general, overweight and obesity are assumed to be the results of an increase in caloric and fat intake. On the other hand, there are supporting evidence that excessive sugar intake by soft drink, increased portion size, and steady decline in physical activity have been playing major roles in the rising rates of obesity all around the world. Childhood obesity can profoundly affect children's physical health, social, and emotional well-being, and self esteem. It is also associated with poor academic performance and a lower quality of life experienced by the child. Many co-morbid conditions like metabolic, cardiovascular, orthopedic, neurological, hepatic, pulmonary, and renal disorders are also seen in association with childhood obesity.

Keywords: Childhood obesity, consequences, epidemiology, lifestyle, non-communicable disease, overweight

Introduction

The world is undergoing a rapid epidemiological and nutritional transition characterized by persistent nutritional deficiencies, as evidenced by the prevalence of stunting, anemia, and iron and zinc deficiencies. Concomitantly, there is a progressive rise in the prevalence of obesity, diabetes and other nutrition related chronic diseases (NRCDs) like obesity, diabetes, cardiovascular disease, and some forms of cancer. Obesity has reached epidemic levels in developed countries. The highest prevalence rates of childhood obesity have been observed in developed countries; however, its prevalence is increasing in developing countries as well.[ 1] Females are more likely to be obese as compared to males, owing to inherent hormonal differences.[ 2]

It is emerging convincingly that the genesis of Type 2 Diabetes and Coronary Heart Disease begins in childhood, with childhood obesity serving as an important factor.[ 3] There has been a phenomenal rise in proportions of children having obesity in the last 4 decades, especially in the developed world. Studies emerging from different parts of India within last decade are also indicative of similar trend.[ 4, 5, 6, 7, 8, 9] This view has been challenged over recent years and we presently consider these as different forms of the global malnutrition problem. This new conceptualization leads us to simultaneously address the root causes of nutritional deficiencies which in turn will contribute to the control of under nutrition and the prevention of obesity, diabetes, and other NRCDs. This summary provides a public health overview of selected key issues related to the prevention of obesity and chronic diseases with a life-course perspective of nutrition and child growth.

Childhood obesity is one of the most serious public health challenges of the 21 st century. The problem is global and is steadily affecting many low and middle income countries, particularly in urban settings. The prevalence has increased at an alarming rate. Globally in 2010, the number of overweight children under the age of five is estimated to be over 42 million. Close to 35 million of these are living in developing countries.

Definition of Childhood Obesity

Although definition of obesity and overweight has changed over time, it can be defined as an excess of body fat (BF). There is no consensus on a cut-off point for excess fatness of overweight or obesity in children and adolescents. A study by conducted by Williams et al. (1992), on 3,320 children in the age-group of 5-18 years classified children as fat if their percentage of body fat was at least 25% for males and 30% for females, respectively.[ 10] The Center for Disease Control and Prevention defined overweight as at or above the 95 th percentile of body mass index (BMI) for age and "at risk for overweight" as between 85 th to 95 th percentile of BMI for age.[ 11, 12] European researchers classified overweight as at or above 85 th percentile and obesity as at or above 95 th percentile of BMI.[ 13]

An Indian research study has defined overweight and obesity as overweight (between ≥85 th and <95 th percentile) and obesity (≥95 th percentile).[ 14] Another study has followed World Health Organization 2007 growth reference for defining overweight and obesity.[ 15]

There are also several methods to measure the percentage of body fat. In research, techniques include underwater weighing (densitometry), multi-frequency bioelectrical impedance analysis (BIA), and magnetic resonance imaging (MRI). In the clinical environment, techniques such as BMI, waist circumference, and skin-fold thickness have been used extensively. Although, these methods are less accurate than research methods, they are satisfactory to identify risk. While BMI seems appropriate for differentiating adults, it may not be as useful in children because of their changing body shape as they progress through normal growth. In addition, BMI fails to distinguish between fat and fat-free mass (muscle and bone) and may exaggerate obesity in large muscular children. Furthermore, maturation pattern differs between genders and different ethnic groups. Studies that used BMI to identify overweight and obese children based on percentage of body fat have found high specificity (95-100%), but low sensitivity (36-66%) for this system of classification.[ 16] While health consequences of obesity are related to excess fatness, the ideal method of classification should be based on direct measurement of fatness. Although methods such as densitometry can be used in research practice, they are not feasible for clinical settings. For large population-based studies and clinical situations, bioelectrical impedance analysis (BIA) is widely used. Waist circumference seems to be more accurate for children because it targets central obesity, which is a risk factor for type II diabetes and coronary heart disease.

Causes of Childhood Obesity

It is widely accepted that increase in obesity results from an imbalance between energy intake and expenditure, with an increase in positive energy balance being closely associated with the lifestyle adopted and the dietary intake preferences. However, there is increasing evidence indicating that an individual's genetic background is important in determining obesity risk. Research has made important contributions to our understanding of the factors associated with obesity. The ecological model, as described by Davison et al., suggests that child risk factors for obesity include dietary intake, physical activity, and sedentary behavior.[ 17] The impact of such risk factors is moderated by factors such as age, gender. Family characteristics parenting style, parents' lifestyles also play a role. Environmental factors such as school policies, demographics, and parents' work-related demands further influence eating and activity behaviors.

Genetics are one of the biggest factors examined as a cause of obesity. Some studies have found that BMI is 25-40% heritable.[ 18] However, genetic susceptibility often needs to be coupled with contributing environmental and behavioral factors in order to affect weight.[ 19] The genetic factor accounts for less than 5% of cases of childhood obesity.[ 18] Therefore, while genetics can play a role in the development of obesity, it is not the cause of the dramatic increase in childhood obesity.

Basal metabolic rate has also been studied as a possible cause of obesity. Basal metabolic rate, or metabolism, is the body's expenditure of energy for normal resting functions. Basal metabolic rate is accountable for 60% of total energy expenditure in sedentary adults. It has been hypothesized that obese individuals have lower basal metabolic rates. However, differences in basal metabolic rates are not likely to be responsible for the rising rates of obesity.[ 18]

Review of the literature investigates factors behind poor diet and offers numerous insights into how parental factors may impact on obesity in children.[ 20] They note that children learn by modeling parents' and peers' preferences, intake and willingness to try new foods. Availability of, and repeated exposure to, healthy foods is key to developing preferences and can overcome dislike of foods. Mealtime structure is important with evidence suggesting that families who eat together consume more healthy foods. Furthermore, eating out or watching TV while eating is associated with a higher intake of fat. Parental feeding style is also significant. The author's found that authoritative feeding (determining which foods are offered, allowing the child to choose, and providing rationale for healthy options) is associated with positive cognitions about healthy foods and healthier intake. Interestingly authoritarian restriction of "junk-food" is associated with increased desire for unhealthy food and higher weight.[ 21]

Government and social policies could also potentially promote healthy behavior. Research indicates taste, followed by hunger and price, is the most important factor in adolescents snack choices.[ 22] Other studies demonstrate that adolescents associate junk food with pleasure, independence, and convenience, whereas liking healthy food is considered odd.[ 23] This suggests investment is required in changing meanings of food, and social perceptions of eating behavior. As proposed by the National Taskforce on Obesity (2005), fiscal policies such as taxing unhealthy options, providing incentives for the distribution of inexpensive healthy food, and investing in convenient recreational facilities or the esthetic quality of neighborhoods can enhance healthy eating and physical activity.[ 24]

Dietary factors have been studied extensively for its possible contributions to the rising rates of obesity. The dietary factors that have been examined include fast food consumption, sugary beverages, snack foods, and portion sizes.

Fast food Consumption: Increased fast food consumption has been linked with obesity in the recent years. Many families, especially those with two parents working outside the home, opt for these places as they are often favored by their children and are both convenient and inexpensive.[ 25] Foods served at fast food restaurants tend to contain a high number of calories with low nutritional values. A study conducted examined the eating habits of lean and overweight adolescents at fast food restaurants.[ 26] Researchers found that both groups consumed more calories eating fast food than they would typically in a home setting but the lean group compensated for the higher caloric intake by adjusting their caloric intake before or after the fast food meal in anticipation or compensation for the excess calories consumed during the fast food meal. Though many studies have shown weight gain with regular consumption of fast food, it is difficult to establish a causal relationship between fast food and obesity.

Sugary beverages

A study examining children aged 9-14 from 1996-1998, found that consumption of sugary beverages increased BMI by small amounts over the years.[ 18] Sugary drinks are another factor that has been examined as a potential contributing factor to obesity. Sugary drinks are often thought of as being limited to soda, but juice and other sweetened beverages fall into this category. Many studies have examined the link between sugary drink consumption and weight and it has been continually found to be a contributing factor to being overweight.[ 18] Sugary drinks are less filling than food and can be consumed quicker, which results in a higher caloric intake.[ 19]

Snack foods

Another factor that has been studied as a possible contributing factor of childhood obesity is the consumption of snack foods. Snack foods include foods such as chips, baked goods, and candy. Many studies have been conducted to examine whether these foods have contributed to the increase in childhood obesity. While snacking has been shown to increase overall caloric intake, no studies have been able to find a link between snacking and overweight.[ 18]

Portion size

Portion sizes have increased drastically in the past decade. Consuming large portions, in addition to frequent snacking on highly caloric foods, contribute to an excessive caloric intake. This energy imbalance can cause weight gain, and consequently obesity.[ 18]

Activity level

One of the factors that is most significantly linked to obesity is a sedentary lifestyle. Each additional hour of television per day increased the prevalence of obesity by 2%.[ 18] Television viewing among young children and adolescents has increased dramatically in recent years.[ 18, 27] The increased amount of time spent in sedentary behaviors has decreased the amount of time spent in physical activity. Research which indicates the number of hours children spend watching TV correlates with their consumption of the most advertised goods, including sweetened cereals, sweets, sweetened beverages, and salty snacks.[ 22] Despite difficulties in empirically assessing the media impact, other research discussed emphasizes that advertising effects should not be underestimated. Media effects have been found for adolescent aggression and smoking and formation of unrealistic body ideals. Regulation of marketing for unhealthy foods is recommended, as is media advocacy to promote healthy eating.

Environmental factors

While extensive television viewing and the use of other electronic media has contributed to the sedentary lifestyles, other environmental factors have reduced the opportunities for physical activity. Opportunities to be physically active and safe environments to be active in have decreased in the recent years. The majority of children in the past walked or rode their bike to school. A study conducted in 2002 found that 53% of parents drove their children to school.[ 18] Of these parents, 66% said they drove their children to school since their homes were too far away from the school. Other reasons parents gave for driving their children to school included no safe walking route, fear of child predators, and out of convenience for the child.[ 18] Children who live in unsafe areas or who do not have access to safe, well-lit walking routes have fewer opportunities to be physically active.[ 18]

Socio-cultural factors

Socio-cultural factors have also been found to influence the development of obesity. Our society tends to use food as a reward, as a means to control others, and as part of socializing.[ 28] These uses of food can encourage the development of unhealthy relationships with food, thereby increasing the risk of developing obesity.

Family factors

Family factors have also been associated with the increase of cases of obesity. The types of food available in the house and the food preferences of family members can influence the foods that children eat. In addition, family mealtimes can influence the type of food consumed and the amount thereof. Lastly, family habits, whether they are sedentary or physically active, influence the child.[ 28] Studies have shown that having an overweight mother and living in a single parent household are associated with overweight and childhood obesity.[ 29]

Psychological factors

Depression and anxiety

A recent review concluded that the majority of studies find a prospective relationship between eating disturbances and depression.[ 30] However, this relationship is not unidirectional; depression may be both a cause and a consequence of obesity.[ 31] Additionally, in a clinical sample of obese adolescents, a higher life-time prevalence of anxiety disorders was reported compared to non-obese controls.[ 32] Although some studies demonstrate no significant relationship between increased BMI and increased anxiety symptoms.[ 33] Thus, the relationship between obesity and anxiety may not be unidirectional and is certainly not conclusive.

Self-esteem

Research findings comparing overweight/obese children with normal-weight children in regards to self-esteem have been mixed.[ 34] Some studies have found that obese children have lower self-esteem while others do not.[ 35, 36, 37] There is some consensus in the literature that the global approach to self-esteem measurement with children who are overweight/obese is misleading as the physical and social domains of self-esteem seem to be where these children are most vulnerable.[ 38]

Body dissatisfaction

Research has consistently found that body satisfaction is higher in males than females at all ages.[ 39] Gender differences may reflect the westernized cultural ideals of beauty in that thinness is the only culturally defined ideal for females, while males are encouraged to be both lean and muscular. Thus, there is a linear relationship between body dissatisfaction and increasing BMI for girls; while for boys a U-shaped relationship suggests that boys with BMIs at the low and high extremes experience high levels of body dissatisfaction.[ 40, 41]

Eating disorder symptoms

Traits associated with eating disorders appear to be common in adolescent obese populations, particularly for girls.[ 42] A number of studies have shown higher prevalence of eating-related pathology (i.e. Anorexia, Bulimia Nervosa, and impulse regulation) in obese children/youth.[ 43, 44]

Emotional problems

In one of the few studies to investigate the psychological impact of being overweight/obese in children, a review of 10 published studies over a 10-year period (1995-2005) with sample sizes greater than 50 revealed that all participants reported some level of psychosocial impact as a result of their weight status.[ 45] Being younger, female, and with an increased perceived lack of control over eating seemed to heighten the psychosocial consequences.

Consequences of childhood obesity

Childhood obesity can profoundly affect children's physical health, social, and emotional well-being, and self esteem. It is also associated with poor academic performance and a lower quality of life experienced by the child. These potential consequences are further examined in the following sections.

Medical consequences

Childhood obesity has been linked to numerous medical conditions. These conditions include, but are not limited to, fatty liver disease, sleep apnea, Type 2 diabetes, asthma, hepatic steatosis (fatty liver disease), cardiovascular disease, high cholesterol, cholelithiasis (gallstones), glucose intolerance and insulin resistance, skin conditions, menstrual abnormalities, impaired balance, and orthopedic problems.[ 25, 46] Until recently, many of the above health conditions had only been found in adults; now they are extremely prevalent in obese children. Although most of the physical health conditions associated with childhood obesity are preventable and can disappear when a child or adolescent reaches a healthy weight, some continue to have negative consequences throughout adulthood.[ 46] In the worst cases, some of these health conditions can even result in death. Below, three of the more common health problems associated with childhood obesity are discussed, diabetes, sleep apnea, and cardiovascular disease.

Socio-emotional consequences

In addition to being implicated in numerous medical concerns, childhood obesity affects children's and adolescent's social and emotional health. Obesity has been described as being "one of the most stigmatizing and least socially acceptable conditions in childhood."[ 38] Overweight and obese children are often teased and/or bullied for their weight. They also face numerous other hardships including negative stereotypes, discrimination, and social marginalization.[ 46] Discrimination against obese individuals has been found in children as young as 2 years old.[ 28] Obese children are often excluded from activities, particularly competitive activities that require physical activity. It is often difficult for overweight children to participate in physical activities as they tend to be slower than their peers and contend with shortness of breath.[ 25] These negative social problems contribute to low self esteem, low self confidence, and a negative body image in children and can also affect academic performance.[ 46] All of the above-mentioned negative effects of overweight and obesity can be devastating to children and adolescents.

The social consequences of obesity may contribute to continuing difficulty in weight management. Overweight children tend to protect themselves from negative comments and attitudes by retreating to safe places, such as their homes, where they may seek food as a comfort. In addition, children who are overweight tend to have fewer friends than normal weight children, which results in less social interaction and play, and more time spent in sedentary activities.[ 25] As aforementioned, physical activity is often more difficult for overweight and obese children as they tend to get shortness of breath and often have a hard time keeping up with their peers. This in turn inevitably results in weight gain, as the amount of calories consumed exceeds the amount of energy burned.[ 25]

Academic consequences

Childhood obesity has also been found to negatively affect school performance. A research study concluded that overweight and obese children were four times more likely to report having problems at school than their normal weight peers.[ 38] They are also more likely to miss school more frequently, especially those with chronic health conditions such as diabetes and asthma, which can also affect academic performance.

Conclusion

The growing issue of childhood obesity can be slowed, if society focuses on the causes. There are many components that play into childhood obesity, some being more crucial than others. A combined diet and physical activity intervention conducted in the community with a school component is more effective at preventing obesity or overweight. Moreover, if parents enforce a healthier lifestyle at home, many obesity problems could be avoided. What children learn at home about eating healthy, exercising and making the right nutritional choices will eventually spill over into other aspects of their life. This will have the biggest influence on the choices kids make when selecting foods to consume at school and fast-food restaurants and choosing to be active. Focusing on these causes may, over time, decrease childhood obesity and lead to a healthier society as a whole.

Footnotes

Source of Support: Nil.

Conflict of Interest: None declared.

References

2. Gupta RK. Nutrition and the Diseases of Lifestyle. In: Bhalwar RJ, editor. Text Book of Public health and Community Medicine. 1st ed. Pune: Department of community medicine AFMC, New Delhi: Pune in Collaboration with WHO India Office; 2009. p. 1199. [ Google Scholar]

23. Chapman G, Maclean H. "Junk food" and "healthy food": Meanings of food in adolescent women's culture. J Nutr Educ Behav. 1993;25:108-13. [ Google Scholar]

24. Dublin: Department of Health and Children; 2005. Department of Health and Children. Obesity: The policy challenges: The report of the national taskforce on obesity. [ Google Scholar]

25. Niehoff V. Childhood obesity: A call to action. Bariatric Nursing and Surgical Patient. Care. 2009;4:17-23. [ Google Scholar]

39. O'Dea JA. School-based health education strategies for the improvement of body image and prevention of eating problems: An overview of safe and successful interventions. Health Educ. 2005;105:11-33. [ Google Scholar]

Articles from Journal of Family Medicine and Primary Care are provided here courtesy of Wolters Kluwer -- Medknow Publications

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Childhood obesity: causes and consequences

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Childhood obesity has reached epidemic levels in developed as well as in developing countries. Overweight and obesity in childhood are known to have significant impact on both physical and psychological health. Overweight and obese children are likely ...

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This source is a reliable and relevant for my research project as it has given out full information in Leukaemia for children .It will provided me to gather full information about Leukaemia.

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Institute of Immunity and Transplantation

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Leukaemia is cancer of the white blood cells. It affects people of any age.

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This source is a reliable and relevant for my research project. It includes data about a survey for post natal depression which will be helpful for my research. It will be useful for me to gather information about postnatal depression

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This source is relevant because its a result of a research carried out by Aston University.

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Research has just been published which unfortunately shows a growing gap in the quality of health care in England between the poorest and richest areas.

New analysis has found that people living in the most deprived areas of England experience a worse quality of NHS care and poorer health outcomes than people living in the least deprived areas. These include spending longer in A&E and having a worse experience of making a GP appointment.

The research, undertaken by QualityWatch, a joint Nuffield Trust and Health Foundation programme, has looked at 23 measures of healthcare quality to see how these are affected by deprivation. In every single indicator looked at, care is worse for people experiencing the greatest deprivation.

Using NHS and the Index of Multiple Deprivation data, the researchers found that for 11 out of the 23 measures, the inequality gap was widening.

In general, indicators where the quality of care has got worse over time, the inequality gap between the most and least deprived has widened too. They include:

In 2014/15, there was almost no difference in the proportion of people missing the four-hour A&E target in the most deprived areas versus least deprived. In 2017/18 a gap emerged where 14.3% of people from the most deprived areas of England who attended A&E were not seen within the target compared to 12.8% of people from the least deprived areas.

Between 2011/12 and 2017/18, the proportion of GP Patient Survey respondents from the most deprived areas reporting a 'very good' or 'fairly good' experience of making an appointment decreased from 77% to 64%. For those from the least deprived areas it fell from 81% to 72%.

In 2017/18, there were 394 emergency admissions for pressure sores per 100,000 people from the most deprived areas, compared to 134 per 100,000 people from the least deprived areas - almost three times as many. In 2008/09, this was just more than twice as many.

The researchers also found that the inequality gap is greatest for measures that are heavily affected by issues beyond the NHS's control such as poor housing and social care. These measures include avoidable deaths, smoking prevalence and emergency admissions to hospital. Measures relating to children and young people also showed large inequalities.

However, for a number of the measures where the quality of care is getting better, the inequality gap has narrowed. This includes unplanned hospital admissions for asthma, diabetes and epilepsy in children, recovery rate following psychological therapy and people being able to die at their usual place of residence.
Responding to the findings, Nuffield Trust Deputy Director of Research Sarah Scobie said:
"These findings show some concerning trends about the knock-on effect an overstretched NHS is having on the people in England who often need it the most.

"My worry is that continued pressure on the NHS is only going to exacerbate inequalities, despite the very best of intentions from staff to provide fair and equal care.

"The NHS Long Term Plan, which the new Government is embracing, makes reducing inequalities a priority. This is absolutely right, but achieving this will require quite a turnaround."
Health Foundation Assistant Director of Policy, Ruth Thorlby said:
"Poverty is bad for your health, and people in the poorest parts of England face a vicious cycle. Poor living conditions, low quality work, and underfunded local services lead to worse health. These findings show that added to this, those in the most deprived areas are routinely experiencing longer waits in A&E, lower satisfaction and more potentially avoidable hospital admissions.

"Relieving growing pressure on the NHS must be part of the solution, but as important for the new government is investing in housing, education and good work to keep people healthy in the first place."

See details here https://www.nuffieldtrust.org.uk/public/files/2020-01/quality_inequality/v2/ and at https://www.nuffieldtrust.org.uk/qualitywatch

# data[].attributes.attachment_link.description
Research has just been published which unfortunately shows a growing gap in the quality of health care in England between the poorest and richest areas. New analysis has found that people living in the most deprived areas of England experience a worse quality of NHS care and poorer health outcomes than people living in the least deprived areas.

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Increase in Obesity in the UK

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Centers for Disease Control and Prevention

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What should you know?

Autism spectrum disorder (ASD or autism) is a group of developmental disabilities that can cause significant social, communication and behavioral challenges. CDC estimates that an average of 1 in 54 children in the U.S. has ASD or autism. Let's learn more...
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Here are some facts that may help you answer some of your Web Quest questions. Remember, these facts will only give you basic information. You'll need to search the Web further to find more in-depth information for your Quest.

CDC estimates that an average of 1 in 54 children in the U.S. has ASD.

Children with autism, like all children, are different in their behaviors and abilities. No two children with autism will have the same symptoms. A symptom may be easy to see in one child and hard to see in another child. Here are some examples of the types of problems and behaviors a child with autism may have:

Problems being friendly. Children with autism may not make eye contact and may just want to be alone.

Repeat words or phrases over and over (echolalia)

Problems dealing with changes to their daily routines. Children with autism may repeat actions over and over again. They may want steady routines where things stay the same so they know what to expect.

Flap their hands, rock their body, or spin in circles

Have unusual reactions to the way things sound, smell, taste, look, or feel

World-Wide Web Search

This fun site has information about what autism is, what causes it, what doctors do, and how it is treated. Take a look and learn more about autism.

Learn facts about autism like the types of Autism Spectrum Disorders (ASDs), signs and symptoms; and how children are treated.

People

Learn about some kids who have autism. Learn how they are doing at school and at home.

Jason McElwain

View this CNN news video where Jason talks about how he played basketball and made 6 three-point shots in the last few minutes of a basketball game. Jason has autism. Ask your parents or teachers if you can watch this video.

Movies and Books

Here are some books about Kids and people with autism or one of the types of autism called Asperger's.

Blue Bottle Mystery: An Asperger's Adventure

by Kathy Hoopmann
Jessica Kingsley Publishers; 1 edition (May 2001)
Reading Level: Ages 9-12

Nothing seems to be going right for Ben. Sometimes he has trouble understanding what his teachers are saying, and they get frustrated and yell at him. And because he sometimes acts strangely, he only has one friend, Andy. The boys are in a miserable mood, digging in the dirt in the schoolyard, when they unearth a mysterious blue bottle. The story is a gentle introduction to the challenges and unique qualities of people living with Asperger's.

Different Like Me: My Book of Autism Heroes

by Jennifer Elder
Publisher: Jessica Kingsley Pub (November 30, 2005)
Reading Level: Ages 8 to 12 years

"Different Like Me is a book describing the lives of various people who found it difficult to fit into society. There are both famous and historical people who found it difficult to fit into society. There are both famous and historical people who all excelled in their chosen fields.

My Friend with Autism: A Coloring Book for Peers and Siblings

By Beverly Bishop
The author explains autism to young children in a tactful and relatable way, while the parent section helps grown-ups answer those tough questions. An excellent addition to any family library.

The Autism Acceptance Book: Being a Friend to Someone With Autism

by Ellen Sabin
Publisher: Watering Can Press; 1 edition (January 30, 2006)
Reading Level: Ages 9-12

The Autism Acceptance Book is an interactive, educational, and character-building book that introduces children to the challenges faced by people with autism while also supporting their personal journey toward appreciating and respecting people's differences.
This book invites children to "walk in someone else's shoes" as they learn to treat others the same ways they would like to be treated themselves.

My School and Neighborhood

Look around your school and neighborhood to see how many barriers need to be changed to help kids with autism to have the same opportunities to be friends and participate in activities just like kids without disabilities.

1. Do you have any kids in your school who have autism? If so, see if you can invite them to visit your class. Try to be a friend and play with them on the playground.

2. You can show that you support efforts to learn more about autism spectrum disorders (ASDs) by wearing a ribbon that represents this cause. Find out where you might get some ribbons for you and your classmates to display. Autism Awareness month is celebrated in April each year.

We provide links to other web pages if you want to learn more about a topic. Some of these pages are on the CDC web site and others are on outside websites. Links to organizations and companies outside of CDC are included for information only. CDC has no control over the information at these sites. The views and opinions of these organizations are not necessarily those of CDC, the Department of Health and Human Services (HHS), or the U.S. Public Health Service (PHS).

Page last reviewed:

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Autism spectrum disorder (ASD or autism) is a group of developmental disabilities that can cause significant social, communication and behavioral challenges. CDC estimates that an average of 1 in 54 children in the U.S. has ASD or autism. Let's learn more... Follow the 8 steps below for your Web Quest.

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Does your child seem unusually sad, irritable or quiet lately? Such changes in mood could be due to a temporary stress in life. But how do you know if it's something more? According to the Centers for Disease Control and Prevention, the number of children with depression and anxiety has increased over time, and 3.2% of children between the ages of 3 and 17 have a current diagnosis of depression.

Types of depression and mood disorders in children

Children may experience different types of depression and mood disorders. A licensed mental health professional can provide a diagnosis based on your child's symptoms and recommend the best treatment.

The most common types of depression and mood disorders in children include:

Major depressive disorder (MDD): Also called major depression, MDD is diagnosed when a child experiences severe or intense depression that lasts more than two weeks.

Persistent depressive disorder (PDD): Also called dysthymia, a child with PDD experiences milder symptoms of depression, but the symptoms last for a longer time (more than one year in children, two years in adults).

Adjustment disorder with depressed mood: This diagnosis describes depressed mood that develops within 3 months after an upsetting or stressful event, such as a death in the family or parental separation. Some adjustment difficulties are normal and expected in children; this diagnosis only is given if the difficulties are out of proportion to the triggering event and cause impairment in daily functioning.

Seasonal affective disorder (SAD): SAD is a form of MDD with a seasonal pattern. Children with this form of depression tend to experience symptoms primarily when the hours of daylight are shorter, as occurs during the winter months in the northern hemisphere.

Bipolar disorder: A diagnosis of bipolar disorder describes episodic periods of mania (persistently euphoric or irritable mood together with an increase in goal-directed behaviors, present most of the day, nearly every day for at least a week) alternating with episodic periods of depression. Bipolar disorder is rare in children. Sudden anger outbursts are not bipolar disorder.

Disruptive mood dysregulation disorder (DMDD): DMDD is diagnosed when a child over age 6 displays a lasting and intense pattern of irritability, aggression, anger, severe tantrums and frequent outbursts. The child's mood is persistently irritable or angry most of the day, nearly every day, even between temper outbursts, and has been this way for over a year.

What are risk factors for childhood depression?

It's important for parents and caregivers to understand the risk factors for depression in children, which can include anxiety, family history of mental disorders, hormonal changes in puberty and life stressors.

"Chronic anxiety is one of the most common risk factors we see for depression in children," explains Alice Ann Holland, Ph.D., ABPP, Research Director of the Neuropsychology Service at Children's Health℠ and Assistant Professor at UT Southwestern. "This is anxiety that hasn't been properly diagnosed or treated for anywhere from months to years, which wears children down emotionally over time."

Risk factors for childhood depression can include life stressors such as:

In addition to the above life stressors, adolescents and teens may also deal with the following situations that can trigger depression:

Academic stress, especially related to college admissions

Athletic performance pressure

Dating relationships, including negative relationships and breakups

Sleep deprivation

Is my child depressed?

Symptoms of depression can vary in children and are different from a temporary change in mood or sadness. If your child displays signs of depression lasting more than two weeks, or if symptoms seem to occur around the same time as certain stressors (such as tests) or at certain times of the week (such as Sunday evenings before the school week starts), anxiety or depression may be the cause.

Signs of depression in children

Signs of depression in children age 12 and younger may include the following:

Decreased interest in favorite activities

Difficulty initiating and/or maintaining social relationships

Extreme sensitivity to rejection or failure

Frequent absences from school and/or a sudden decline in grades

Physical symptoms with no medical cause

Frequent sadness, tearfulness or crying

Hopelessness

Low energy

Low self-esteem

Increased irritability

Increased frequency or severity of tantrums (for younger children)

Major change in eating and/or sleeping patterns

Obsessive fears or worries about death

Social isolation

Talking about or attempting to run away from home

Thoughts or expressions of suicide or self-harming behavior

Trouble concentrating

Signs of depression in teens

Signs of depression in adolescents age 13 to 18 may include all of the above, plus:

Increased interest in topics related to death

Increased risk-taking behaviors

Excessive or inappropriate feelings of guilt

Feelings of worthlessness or self-hatred

Substance use

Short temper

Trouble making decisions

Dr. Holland notes that two signs of depression are commonly missed in children. One of those signs is increased irritability. "People often associate depression with sadness, but children and adolescents may simply demonstrate increased irritability rather than overt signs of sadness like crying," she says. It's normal for children to be irritable at times - such as when they're overtired, stressed or not feeling well. But if your child has been unusually short-tempered or moody for weeks to months, this could be a sign of depression.

The other commonly missed sign of depression in children is somatic symptoms, meaning any health issues, such headaches or stomach aches, that do not have a physical cause. Again, it's normal for children to not feel well occasionally. However, "If the school nurse says your child is getting a stomachache every day during math class, that could be a red flag," says Dr. Holland.

How can I help my child with depression?

Medication can have an important role in the treatment of depression in children and teenagers, and it is especially indicated for cases of severe depression. "If a child is too depressed to engage in therapy, medication can kick-start engagement and get them to better engage with therapy and benefit from it," says Dr. Holland. However, parents may find it reassuring to know that medication is not always necessary when treating depression in children.

Studies have shown that in the majority of cases, therapy is as effective or more effective than medication alone when it comes to treating depression in children and adolescents. Cognitive Behavioral Therapy, or CBT, is one common type of therapy that research has shown to be effective for childhood depression treatment. For very young children or those with limited language skills, research indicates that play therapy is the preferred approach.

If you're concerned that your child may be experiencing symptoms of depression, consider the following steps to help:

Start by talking with your child: On a regular basis, ask them about how they're doing in all aspects of their life. "Establish open communication with your child before you have any concerns, so that if concerns arise, they're comfortable talking to you about what's going on," says Dr. Holland. Still, if concerns do arise, don't assume your child will tell you if they're feeling depressed. Young children in particular have difficulty putting their feelings into words. Adolescents and teens may feel ashamed or embarrassed about acknowledging feelings of depression. With children of all ages, parents should convey their concern and ask questions in a loving, supportive way.

Get other adults engaged: Speak with your child's teachers, coaches and anyone else who works with your child regularly. Ask them if they've noticed any changes in your child's mood or behavior. Request they keep an eye on your child and let you know about any out-of-the-ordinary behavior.

Consult with a mental health professional: You can go alone to meet with a mental health professional - such as a school psychologist, counselor, therapist or psychiatrist - to discuss your concerns about your child. In speaking with you, this specialist may be able to help you discern if your child is dealing with chronic anxiety, coping with a temporary life stressor, exhibiting typical behavior for their age or is demonstrating symptoms of depression. This initial conversation should help guide your decision whether to have your child by evaluated by or pursue treatment (such as therapy or medication) with that specialist or be evaluated by another mental health professional (since not all mental health providers conduct evaluations).

Does my child need counseling?

To know when to seek counseling for your child, parents should look for noticeable changes in behavior, such as decreased interest in fun activities, social isolation or statements such as "I don't want to be alive anymore." A mental health professional can help your child process these feelings and provide an appropriate diagnosis.

If you are unsure if your child needs counseling for depression, speak to a physician about your child's symptoms. Teenagers in particular are at high risk for acting impulsively on feelings of depression and suicidal thoughts, so parents should seek professional help before those thoughts and feelings escalate.

Dr. Holland notes that teenagers may be resistant to counseling and therapy and recommends involving them in the process. Get their buy-in by asking them if they have a preference on a provider (e.g., male or female, young or old) and listen to their feedback. Encourage your child to be patient at the beginning of counseling, as it can take a few sessions to develop a therapeutic relationship. However, if after a few sessions it becomes clear that your child is not comfortable with that provider, you can look for a new therapist. Ask your child what he or she did and didn't like about that therapist, as this can guide your search for a new one.

Who can treat depression in children?

Different types of mental health professionals can help your child with symptoms of depression. Masters-level professionals licensed in the state of Texas include marriage and family therapists (LMFT), professional counselors (LPC) and social workers (LCSW). Doctoral-level mental health professionals include psychologists (Ph.D. or Psy.D.) and psychiatrists (M.D. or D.O.). These abbreviations after a provider's name will tell you what level of training they have.

Psychiatrists typically provide medication management rather than weekly therapy, although some offer both. It is important to know that research shows that medication alone is less effective than a combination of medication plus therapy. However, mild cases of depression may not require medication at all, only therapy/counseling. A licensed mental health provider can help determine the best treatment for your child.

Your child's safety is your number one priority

If your child or teen is engaging in behaviors that cause you concern for their immediate safety - such as discussing plans for suicide or other forms of self-harm - immediately take them to the nearest emergency room or call 911. Your child's safety is the top priority. "Better safe than sorry" should be your guiding philosophy in such situations.

Learn more about depression in children

Children's Health offers one of the most comprehensive specialty programs available for children and teens who need mental health services, staffed by experts with access to the latest research and treatments for depression and other mood disorders. Learn more about our Pediatric Psychiatry and Psychology services.

You can also access emotional care and support from the comfort of your home with Virtual Visit Behavioral Health. With a behavioral health care appointment, you can speak to a board-certified psychiatrist or licensed therapist using video technology. Learn more about Virtual Visit Behavioral Health.

Sign up

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Signs of Depression in Children & How to Help - Children's Health

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Does your child seem unusually sad, irritable or quiet lately? Such changes in mood could be due to a temporary stress in life. But how do you know if it's something more?

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Abstract

From 1000 studies published in 2007 on all aspects of autism, those that reached clear conclusions or included quantitative data were selected for this review. Possible etiologies include elemental metals, especially the inconsistent evidence regarding mercury from the vaccine preservative thimerosal, not used after 2001, and chromosomes and genes with the conclusion that autism has a complex genetic architecture. Also, various parental conditions are considered, as are many different abnormalities in the central nervous system, especially underconnectivity within the cortex. Furthermore, deficiencies in mirror neurons have been proposed, leading to the "theory of mind" explanation that autistic children tend to disregard others. In addition, various global deficiencies, like an increase in inhibitory synaptic transmission, are proposed. Characteristics of these children include selective (inward) attention; underresponsiveness; stereotyped repetitive motor behavior; increased head size, weight, and height; various cognitive and communicative disorders; and also epilepsy. Therapy has emphasized risperidone, but some atypical antipsychotic medications have been helpful, as have robotic aids, massage, hyperbaric oxygen, and music. Nearly every conceivable problem that a child could have can be observed in these unfortunate children.

View full text

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A review of recent reports on autism: 1000 studies published in 2007

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From 1000 studies published in 2007 on all aspects of autism, those that reached clear conclusions or included quantitative data were selected for this review. Possible etiologies include elemental metals, especially the inconsistent evidence regarding mercury from the vaccine preservative thimerosal, not used after 2001, and chromosomes and genes with the conclusion that autism has a complex genetic architecture.

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This is an article based on the scale of PND Edinburgh. This is a relevant and reliable source that will give me information about how the scale was used in a research and what the figures show.

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7633 Accesses

17 Citations

1 Altmetric

Metrics

Abstract

Background

The Edinburgh Postnatal Depression Scale (EPDS) is widely used in many countries to screen women for depression in the perinatal period. However, across studies the psychometric properties and cutoff scores of the EPDS have varied considerably; potentially due to different depression criteria and diagnostic systems being used. Therefore, we validated the Danish EPDS against a depression diagnosis according to both DSM-5 and ICD-10. Furthermore, we examined whether the Danish EPDS is multidimensional, as it has previously been suggested.

Methods

Women ( N  = 324) were recruited after routine screenings with the EPDS between 2 and 10 months postpartum (T1). At a subsequent home visit (T2), the EPDS and the Structured Clinical Interview for DSM-5 were administered. Diagnostic interviews were audio recorded to enable subsequent coding for ICD-10 diagnoses and inter-rater reliability analysis. A two-phase stratified sampling strategy with three sampling categories (EPDS-score at T1) was used. Using the distribution of 4931 T1 EPDS-scores from the same population from which we sampled the participants, we used sampling weighing to reweight the sample. The calculation of weights was based upon the mother's sampling category at T1 (i.e. the probability of being sampled) and the weights were applied when assessing the receiver operation characteristics (ROCs) of the EPDS. Sensitivity, specificity, positive predictive value, negative predictive value and area under the ROC curve were computed from the reweighted data for all relevant cutoff values. CIs were computed by embedding the calculations in a weighted logistic regression. Exploratory factor analysis was done using oblique rotation. Parallel analysis was used to assess the number of factors.

Results

A score of 11 or more was found to be the optimal cutoff for depression according to both DSM-5 and ICD-10 criteria. Factor analysis suggested that the Danish EPDS consists of three factors, including an 'anxiety factor'.

Conclusions

The Danish EPDS has reasonable sensitivity and specificity at a cutoff score of 11 or more. There are no notable differences with respect to using ICD-10 or DSM-5 criteria for depression in terms of optimal cutoff. The variation in cutoff scores is likely to be due to cultural variations in the expression of depressive symptoms.

Peer Review reports

Background

The Edinburgh Postnatal depression Scale (EPDS) [ 1] has been established as a useful screening instrument for detection of women at risk for depression in the perinatal period [ 2, 3]. In addition, it has been identified as the most frequently validated instrument to screen for perinatal depression [ 4], and in 2014 the EPDS had been validated against a diagnosis of depression in at least 37 languages [ 5]. Although recently, a discussion has begun to emerge regarding several shortcomings in the scale, including the multitude of different validated cutoff scores required for women (and men) from different cultures and during the ante- and postnatal periods, as well as the exclusion of certain types of psychological distress often occurring in the perinatal period (e.g. perinatal anxiety) [ 6], the current use of the EPDS in Denmark warrants understanding its properties further.

For almost two decades, a translation of the EPDS [ 7] has been in used for screening purposes in primary care in Denmark by public health visitors, and this translation was also used in a large-scale study to assess risk factors and point prevalence of postnatal depression in Danish women [ 7]. Nevertheless, the Danish EPDS has not been validated in a Danish population, and no official guidelines exist regarding cutoff scores for further monitoring of symptoms or referral to other services. This has resulted in various cutoff scores being used across the public health visiting districts where the scale is most frequently used. Moreover, the scale has only rarely been used in general practice or as part of perinatal psychiatric services where it is required that a screening instrument must go through a formal validation before implemented in practice.

The most commonly used cutoff score in postnatal women is 13 or more [ 8]. However, across studies, and in particular across languages, the optimal cutoff scores of the EPDS have varied considerably [ 5]. For example, the optimal cutoff for a diagnosis of depression in postnatal woman was found to be 7 or more in a Lithuanian population [ 9], 9 or more in a Sinhala population [ 10], 11 or more in a French population [ 11], and 12 or more in a Swedish population [ 12]. These differences in identified cutoff scores may be due to cultural variation in the expression of depressive symptoms in the perinatal period [ 13, 14], and consequently, researchers stress that the EPDS should be validated in a particular population before implementation in screening programs [ 15].

Another reason for the differing identified cutoff scores may be that across studies different diagnostic criteria and different diagnostic systems have been used [ 16]. Some, (e.g. [ 17]) have used criteria for depression according to their current version of the Diagnostic and Statistical Manual for Mental disorders (DSM-III-R; IV-TR; 5) [ 18, 19]. Others, (e.g. [ 10]) have used the International Classification of Diseases 10th revision (ICD-10) [ 20]. The original and some subsequent early validation studies [ 1, 21] used the Research Diagnostic Criteria (RDC) [ 22]. Differences between the diagnostic systems, with respect to diagnoses of depression, are marked. Whereas DSM-IV allows for a diagnosis of minor depression, this diagnosis does not exist in DSM-III, DSM-5, or ICD-10. Some studies have reported the optimal cutoff score for detecting just DSM major depression [ 12], while others have reported the optimal cutoff score for minor and major depression, sometimes referred to as 'combined depression' [ 23, 24]. Yet other studies have reported separate cutoffs, i.e. for minor or major as well as for just major depression [ 25]. Yet another difference between the ICD and DSM is that ICD-10 requires a minimum of two out of three core symptoms (depressed mood, anhedonia, and energy loss) for a diagnosis of depression, whereas DSM (III, IV, and 5) only requires the presence of one of two core symptoms (depressed mood and anhedonia). Moreover, none of the ICD-10 diagnoses of mild, moderate, or severe depression correspond to DSM-IV minor or DSM-III/IV/5 major depression in terms of symptom requirements (ICD-10 mild: 2 core symptoms + 2 or 3 associated symptoms; ICD-10 moderate: 2 core symptoms + 4 or 5 associated symptoms; ICD-10 severe: 3 core symptoms + 5-7 associated symptoms. DSM-IV minor: at least 1 core symptom + 2-4 symptoms; DSM-III/ IV/ 5 major: at least 1 core symptom + 5-9 symptoms). Similar discrepancies occur in the RDC diagnostic system in which a diagnosis of major depression requires at least one core symptom and at least five associated symptoms [ 22]. It is not, known whether ICD-11 which, if endorsed by member states, is planned to come into use in 2022, will be any different in these respects from ICD-10. Finally, some diagnoses have been made determining if criteria are met using in-depth diagnostic interviews, such as the Structured Clinical Interview for DSM-IV axis I disorders [ 26] which allows for probing and further exploration of answers, i.e. to determine if a symptom is in fact present, while others have used interviews that do not allow such probing, e.g., the Mini-International Neuropsychiatric Interview [ 27].

All of these issues could account for some of the differences in optimal cutoff scores reported across EPDS studies, notwithstanding the language or cultural differences [ 16]. As yet, however, no study has investigated whether using different diagnostic systems influence receiver operating characteristics of the EPDS. Therefore, we validate the EPDS against both ICD-10 and DSM-5. Whilst the DSM is most frequently used in EPDS validation studies, and in research more generally [ 28], the ICD is the official coding system in most of the countries where the EPDS is being used for screening purposes. Indeed, the ICD-10 has been identified as the most frequently used in clinical practice across countries [ 29], and hence, from a clinical perspective, it is relevant to include ICD criteria in a validation of the EPDS.

Apart from the EPDS's utility in screening for depression, several investigators [ 30, 31] have commented on its properties for screening for perinatal anxiety given that this mood disorder is also prevalent, often co-occurs with depression, and has significant impacts not only on the mother's well-being but also on her offspring [ 32, 33]. Although the EPDS was intended to be unidimensional, using exploratory factor analysis (EFA), many studies have suggested that the scale contains two factors, a depressive factor and an anxiety factor (e.g. [ 11, 34, 35]). Other studies have suggested that a three-factor structure with depression, anxiety, and anhedonia (e.g. [ 36, 37]), or depression, anxiety, and self-harm/suicide (e.g. [ 38, 39]) fits the data better. There is also variation as to which items load on the anxiety scale. While the anxiety factor most frequently include items 3 (guilt),4 (anxiety),and 5 (panic attacks) [ 40], some studies have found other item combinations to comprise the anxiety factor, e.g. Italian version: items 4, 5 & 6 [ 41]; Iranian version: items 3,4,5 and 8 [ 42]. More recently, a researchers have questioned the utility of continously conducting EFA as opposed to data and theory-driven confirmatory factor analyses (CFAs), (e.g. [ 40, 43]) and related to this, the optimal length of the EPDS has been questioned [ 44]. However, as there is currently no genereally agreed upon factor structure that could serve as the basis for a CFA, in the present study, we decided to assesss the factor structure of the EPDS using EFA.

Aims of the study

To address these issues, the aims of the present study were to a) validate the Danish version of the EPDS against a diagnosis of depression in a sample of new mothers by assessing the sensitivity, specificity, and predictive values of different cutoff scores; b) investigate whether these receiver operating characteristics (ROCs) of the scale differ depending upon whether the DSM-5 or the ICD-10 is used, and (3) using an exploratory factor analytic approach, examine the factor structure of the Danish EPDS.

As ICD-10 mild depression in some contexts is considered to be subthreshold [ 45], for comparison, we conducted ROC analyses with and without including ICD-10 mild depression as 'depressed'. In the determination of the optimal cutoff, for first-phase screening purposes, we intended to select a value that provides good sensitivity (the true-positive rate) and high specificity (the true-negative rate) without lowering the positive predictive value (PPV: proportion of subjects with positive test results who are correctly diagnosed) so much that it would overwhelm clinical services. Based on the view that a missed case of depression in the postnatal period can have significant negative consequences, we aimed at a sensitivity of 80% or more, a specificity of 90% or more, and a positive predictive value of 50% or more.

Methods

Study setting and procedure

As part of the general social security and health care system in Denmark, all families in are offered health visits by public health visitors (specialized nurses) in their home during the first year postpartum. This study was conducted in collaboration with the health visitors from the municipality of Copenhagen and was part of a larger project, the Copenhagen Infant Mental Health Project (CIMHP), which also includes a treatment trial (Clinical trials identifier: NCT02497677) [ 46]. Enrollment of participants started July 2015 and data collection for the present study terminated June 2017.

During the project period, all mothers in Copenhagen received home visits at 2 and 8 months postpartum by public health visitors. First-time mothers received an additional visit at 4 months postpartum. The EPDS was routinely administered at the two month visit, however, in addition, some women were also administered the EPDS at 4 or 8 months based upon the clinical judgement of the health visitor. This score is the Time 1 (T1) EPDS score. To ensure that sufficient numbers of women who met criteria for depression were recruited, an oversampling strategy was used, similar to that used in other studies [ 17, 21, 47]. Therefore, all mothers scoring 10 or more at T1 were invited to participate in CIMHP. Additionally, a subgroup of health visitors, equally distributed across districts, invited (from April 2016 - February 2017) not only mothers scoring 10 or more, but also those who scored 0-9 at the routine two month visit to the project. The sampling strategy is described in further detail below.

After screening with the EPDS, the health visitor informed the mother about the research project, and if interested, contact information was given to the research team. Interested mothers were offered a home visit by a clinical psychologist from CIMHP (Time 2: T2). During this visit, written informed consent was obtained, the EPDS was again administered, and a diagnostic interview was conducted. For logistic and practical reasons, the time-period from T1 to T2 could vary from a few days to several weeks. Therefore, to obtain the most precise ROC estimates, the EPDS score obtained at the T2 was validated in the current study.

Sampling strategy and weighting

Mothers were eligible for participation in the current study if they were at least 18 years old, if they had an infant between 8 weeks and 10 months, and if they could read and speak Danish. We used a two-phase stratified sampling design [ 48] also used in other validation studies e.g. [ 17, 49]. A data extraction from the health visitors' digital filing system (14 February 2016) including the latest 4931 EPDS-screenings (i.e. T1 scores) from mothers with infants under one year in Copenhagen showed that 69% of all screened mothers scored in the range 0-5, and 21% scored in the range 6-9, and 10% scored 10 or more. Thus, the vast majority were expected to score less than 6. In order to enrich the sample in the range where the cutoff was expected to be found, and to ensure roughly equal representation of these groups, we included all mothers scoring 10 or above (probable cases) at T1, and a larger proportion of those in the range 6-9 (possible cases) than of those scoring in range 0-5 (probable non-cases). The aim was to include at least 35 mothers from each of the two lower groups. To obtain these goals after October 2016 we only invited mothers who scored 6-9 or 10 or more at T1. The 4931 scores effectively gave us the population wide distribution and we could therefore use sampling weighing to reweight the sample corresponding to if we had done a random sample from the full population. The calculation of weights was based upon the mother's sampling category at T1 (i.e. the probability of being sampled), and the weights were subsequently applied to the ROC analyses of T2 EPDS scores. Because all mothers scoring 10 or above were included, this group had the weight 1. The 0-5 and 6-9 groups got the sampling weights 28.8 and 16.9, respectively. By construction, after applying these weights, the distribution of T1 scores in our weighted sample matched the one observed in the full population, and as no other systematic effects of the sampling procedure exists, the weighted analysis can therefore be thought of as a simple random sample from the full population, but with substantial higher statistical power compared to a true random sample from the full population. This mimics well known techniques from survey literature (see [ 50]).

Measures

The Edinburgh Postnatal Depression Scale [ 1] is a 10-item self-report questionnaire (range 0-30) designed to screen for possible depression in new mothers, and was completed by the mothers at T1 and T2. While the original published version of the Danish translation [ 7] had some formatting differences to the English version (i.e. inclusion of response scores; altering the item wording, and exclusion of the introduction), these were amended so that the Danish version used in the study was identical to the English version, having gone through the usual translation and back-translation methodology and complied with the principles for translation of the EPDS described in the EPDS manual [ 5]. The Danish EPDS is provided as Additional files 1 and 2.

The Structured Clinical Interview for the DSM-5 (SCID-5) [ 51] was used at T2 to establish a diagnosis of major depression according to DSM-5 as well as to assess history of depression. The interviewers were trained to explore the mothers' answers to the standardized questions to be able to differentiate between normal and depressive reactions in the postnatal period (such as sleep problems and changes in appetite) because it has been found that depression might be otherwise over diagnosed in new mothers [ 52]. The interviews were conducted by trained SCID-5 interviewers who received ongoing supervision, and the interviews were audiotaped to allow for inter-rater reliability analyses to be conducted. The SCID-5 scorings and audio recordings of the interviews were also used to diagnose mothers according to ICD-10 diagnostic criteria for depression (mild, moderate, and severe depression). The interviewers did not score the T2 EPDS filled in by the mother prior to the interview. However, it was not possible to blind the interviewers entirely to the T1 or T2 EPDS scores (e.g., sometimes, the mother mentioned her T1 score prior to or during the interview). Therefore, to prevent interviewer-biases and ensure interrater reliability, a randomly selected subset ( n = 70, 22%) of the audio recorded interviews were rated by a certified SCID-5 interviewer. This rater had no previous knowledge about the mothers and was blind to EPDS score and the diagnoses made by the interviewers. Interrater agreement for DSM-5 diagnostic status (no depression vs. major) was 90.2%, κ = .89 ( p = .000); for ICD-10 diagnostic status (no depression vs. mild or more) interrater agreement was 94.6%, κ = .94 ( p = .000), and for ICD-10 diagnostic status, four-way, interrater agreement was 94.6% (no depression); 81.8% (Mild), 78,6%; (Moderate), and 80% (Severe), κ = .76, ( p = .000) which are all considered to represent excellent levels of interrater reliability [ 53].

Statistical methods

Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under the ROC curve (AUC) were computed directly from the reweighted data and the calculations were done for all relevant cutoff values. Confidence intervals were computed by embedding the calculations in a weighted logistic regression as implemented in R version 3.3.1. Confidence intervals corrected for weights were then obtained. Exploratory factor analysis (EFA) was done in R using the Psych Package [ 54]. To allow for factors' inter-correlation, as would be expected of the underlying assumed dimensions of depression, anhedonia, and anxiety [ 55] we employed oblique rotation (promax). We used parallel analysis, i.e. using scree plots comparing actual loadings with random data with the same properties as the real data, to assess the appropriate number of factors. Continuous variables were summarized using means and standard deviations while categorical variables were summarized using raw counts and percentages.

Results

A total of 350 mothers agreed to be contacted by the research team after T1 screening. Of these, 23 declined to participate when contacted, 2 did not consent to participate after having received a home visit from the research team, and one mother was not able to fill in the EPDS in Danish, and was therefore excluded, resulting in a final sample size of 324 women for whom we had T2 EPDS scores and a diagnostic interview. For four of these mothers, the T1 EPDS score was not available, and therefore data from these mothers were only included in unweighted analyses and not in the weighted analyses for which n  = 320.

The distribution of mothers across the three sampling categories at T1 were as following: EPDS range 0-5: n = 56 (17.5%), EPDS range 6-9: n = 29 (9.1%), and EPDS range 10-30: n = 235 (73.4%). Thus, the desired size of 35 mothers from the each of the two lowest sampling groups (at T1) was achieved for the lowest group and almost for the middle group. The distribution of raw EPDS scores at T2 is presented in Fig. 1. The unusual distribution is due to the sampling mechanism. The reweighted distribution, reflecting the distribution in the population, i.e. based on the distribution of the latest 4931 EPDS screenings in Copenhagen, is presented in Fig. 2.

EPDS scores (T2 raw counts)

EPDS scores (T2 weighted)

Sample characteristics and distribution across diagnostic categories are presented in Table 1. As shown in Table 1, the majority (83%) of the mothers had an infant between 8 and 20 weeks at T2 when the diagnostic interview was conducted. Non-weighted EPDS means for the diagnostic categories were: DSM-5 Major: M = 15.0 ( SD = 4.5), not depressed: 7.0 ( SD = 4.5); ICD-10 mild: M = 12.5 ( SD = 4.0), ICD-10 moderate: M = 14.9 ( SD = 4.2), ICD-10 severe: 18.4 ( SD = 3.8), not depressed: M = 7.1 ( SD  = 4.9).

Table 2 shows the overlap between the two diagnostic systems. As shown, 10 mothers had a discrepant diagnostic status: four of the 118 mothers fulfilling criteria for DSM-5 major depression, did not fulfill criteria for any ICD-10 diagnosis. Inspecting the data further showed that these mothers only had one core symptom (but five symptoms in total), and hence, they did not get a ICD-10 diagnosis. Of the 38 mothers fulfilling criteria for ICD-10 mild depression, six did not fulfill criteria for DSM major depression. These mothers all had four symptoms (two core and two associated symptoms), thereby lacking one symptom to fulfill criteria for DSM-5 major depression but had the lowest possible number of symptoms to fulfill criteria for ICD-10 mild depression.

Cronbach's alpha, a measure of a scale's reliability, was 0.822 in the raw data, and in the weighted data it was 0.835, indicating good internal consistency [ 56].

Receiver operating characteristics

Tables 3 presents estimates of sensitivity, specificity, PPV, NPV, and AUC for DSM Major depression, ICD-10 mild depression or more, and ICD-10 moderate+severe depression for different EPDS cutoff-scores and based on the reweighted data. For all three diagnostic categories of depression, the AUC values were close to 1 (ranging from 0.957-0.960) indicating that the Danish EPDS has a high discriminative power (i.e. how well the test separates the group being tested into those with and without the condition).

For DSM-5 major depression as well as ICD-10 mild depression or more, a cutoff score of 11 or more is suggested by the data, both yielding a sensitivity close to 80%, a specificity above 90%, and a PPV close to 50%. For ICD-10 moderate and severe depression, a cutoff score of 12 or more was suggested with a sensitivity of 77%, specificity of 96% and a PPV of 49.5%.

As shown in Table 3, the ROC values between DSM-5 major and ICD-10 (any) are very similar. This is because only 10 women had a discrepant diagnostic status. However, the ROC values for ICD-10 moderate+severe are in some cases more different than DSM-5 because using this classification as 'depressed', and the ICD-10 mild as 'not depressed', resulted in 38 having a discrepant diagnostic status.

Factor analysis

Using parallel analysis [ 54] we found that either two or three factors would be appropriate. To ensure a good fit we employ three factors, and the associated factor loadings are presented in Table 4. For clarity, only loadings of 0.3 and above are reported.

As shown in Table 4, items 6 and 7 cross loaded on factor 1 and factor 2. Likewise, the factor loadings of item 6 and 7 did not discriminate adequately to be included in either factor 1 or factor 2, and these were therefore omitted from both factors. Following, the result indicated that the Danish EPDS consists of three factors: Factor 1 (depression): items 1,2,8, and 9; Factor 2 (anxiety): items 3,4, and 5; and Factor 3 (self-harm/suicide): item 10. As shown, Factor 1 and Factor 2 are vastly more important than Factor 3 in terms of explained variance. It is noted that the third factor included essentially only loads on Item 10 (self-harm and suicidal ideas) and that this item did not load on the two other factors. For these reasons Factor 3 did not truly meet the criteria for being a factor as it is essentially just a rescaled version of item 10. We did, however, include it in this EFA, because it is important to realize that this item works in a different dimensionality from the rest.

Discussion

In the EPDS literature, there is a wide variation as to what criteria have been used when the receiver operating characteristics of the scale have been assessed (i.e., the 'gold standard' has been defined by different diagnoses within and between different diagnostic systems). As previously suggested [ 16], we suspected that the variation in optimal cutoff scores reported across studies might at least partly be explained by this. Therefore, we validated the Danish EPDS against both DSM-5 and ICD-10 diagnostic criteria for depression.

In this Danish postnatal sample, for DSM-5 major as well as for ICD-10 mild, moderate or severe depression, a cutoff score of 11 or more was suggested by the data as the best cutoff. With sensitivities of 79.2 and 78.2%, specificities of 94.4%, and PPVs of 49% respectively, this value reflected the best trade-off in terms of the EPDS's ability to detect the majority of cases of depression without an undue sacrifice of PPV.

Interestingly, four mothers met criteria for DSM-5 major depression but not ICD-10 mild depression (Table 2). This was due to the ICD-10 requirement of having at least two core symptoms out of three (as opposed to one of two in DSM-5), suggesting that there is an unfortunate inconsistency between the two diagnostic systems.

Because ICD-10 mild depression (which requires at least four versus five depressive symptoms in DSM-5 major depression) in clinical practice sometimes is considered "subthreshold", for comparison, we also conducted analyses not including ICD-10 mild depression as 'depressed'. In this case, and using our a priori defined 'criteria' for selecting cutoff scores, the optimal cutoff was 12 or more (sensitivity: 77.0%, specificity: 96%, PPV: 49.5%). However, given that the symptom threshold for ICD-10 moderate and severe depression is higher than for DSM-5 major depression (at least six symptoms in ICD-10 moderate versus at least five symptoms in DSM-5 Major), a missed case of moderate or severe depression is highly undesirable, and increasing sensitivity at the cost of PPV seems reasonable in this context. Hence, for the use in first-phase screening of Danish postnatal mothers, for ICD-10 moderate and severe depression, we recommend using a cutoff of 11 or more (sensitivity of 82.3%, specificity of 93.4%, and a PPV of 38.6%).

In sum, our results suggest that there are no notable differences with respect to using ICD-10 or DSM-5 criteria for depression in terms of optimal cutoff on the EPDS. Indeed, the ROC values are almost identical given that there were only 10 cases that showed discrepant caseness status. Thus, the optimum postpartum Danish cutoff (11 or more) differs from the English-speaking cutoff (13 or more for DSM major depression) as well as from a number of the cutoff scores found for other translations of the scales (e.g. [ 9, 10, 12, 14]). As also proposed previously [ 15], our results may suggest that the variation in cutoff scores across studies reflect differences in the expression of psychological distress across cultures, though, to our knowledge, no perinatal study have tested this assumption. More generally, our study stresses the importance of validating self-report instruments, originally validated in another culture (and another language), before use in a specific culture because cultural differences may impact results.

In the vast majority of EPDS validation studies, a diagnosis of depression has been used as the criterion or 'gold standard' against which the scale has been validated. This was also the case in our study where we used a thorough diagnostic interview. It should, however, be realized that some would argue that using such a criterion will miss many women who have significant levels of worry or low mood, yet do not meet diagnostic criteria for a mood disorder (e.g. [ 57, 58, 59]). Diagnostic status, therefore, may not be the most suitable criterion against which to validate mood screening instruments, but currently, this is the accepted methodology in the perinatal mental health field.

Another reason for the various cutoffs reported across studies could also be that, within the EPDS literature, there exist no agreed upon standards for what are acceptable levels of sensitivity, specificity, PPV and NPV. For screening purposes, high sensitivity is often desirable to ensure the detection of the majority of cases in the screened population. This was the case in the present study where we aimed at a sensitivity of 80% or more, a specificity of 90% or more, and a positive predictive value of 50% or more. However, high sensitivity is not always the first priority. For example, in a recent study, where a cutoff of 19 or more was selected, high specificity was prioritized and a sensitivity of 30% was considered acceptable for screening purposes in order to use the available resources in the most effective way and not overwhelm clinical services with many inappropriate referrals [ 60]. More generally, when using validated cutoff scores, the context in which the EPDS score is used is of crucial importance. For some research purposes, using an EPDS score as a measure of depression without further assessment (which is sometimes the case in epidemiological studies, e.g. [ 61]) it could be argued that the PPV should have a higher priority than sensitivity. This would ensure that those screening positive are very likely to meet diagnostic criteria for depression (if the PPV is, for example, 80% or 90%). In the current sample, if using a cutoff of 11 or more as a measure of depression, only approximately 5 out of every 10 screen positive mothers would, in fact, be depressed, which in turn would overestimate the prevalence of clinical depression in the population by a factor of two.

Using an exploratory factor analytic approach, our results indicate that the Danish EPDS is multidimensional as previously suggested. The first 'depression factor' included item 1 (anhedonia), item 2 (anhedonia), item 8 (sadness), and item 9 (tearfulness); the second 'anxiety factor' included item 3 (guilt), item 4 (anxiety), item 5 (panic attacks). As such, this result is in line with previous studies that have found an 'anxiety factor' of the EPDS to include items 3,4,5 [ 34, 35, 37, 38, 52, 62]. The anxiety subscale is sometimes referred to as the EPDS-3A or the EDS-3A in pregnancy [ 34, 63], and there is some evidence suggesting that it can be used to screen for perinatal anxiety [ 34, 52, 64]. However, more research is warranted to establish a separate cutoff score if this subscale should be used in clinical practice to screen for perinatal anxiety. Consistent with three previous studies [ 38, 39, 64], a third 'self-harm/suicide factor' (only including item 10) also emerged. However, in terms of proportion of explained variance, the two first factors were far more important than the third factor which accounted for less than 10% of the variance and fit statistics (parallel analysis) do not firmly establish whether the correct number of factors is two or three.

A limitation of the current study is that only women from urban Copenhagen area were included. This may limit generalizability to the whole population. Another limitation is that we did not have access to the number of mothers initially screened at T1 but who did not agree to be referred to the project, and thus we cannot report on the number of approached mothers who declined to participate. Neither are we able to report whether these mothers differ from our sample in terms of sociodemographic characteristics or EPDS scores. However, of the 350 mothers who were referred to the project, only 25 (7%) declined to participate. Yet, as these mothers did not give consent to participate, all of these mothers' data were deleted, and therefore we were not able to report EPDS scores or sociodemographic characteristics on these mothers either. This problem, however, is very common within the EPDS literature, and to our knowledge, only two previous studies [ 25, 65] have reported on the number of approached women who declined to participate.

As we assessed depression according to the current diagnostic standards, we used the DSM-5 and ICD-10 diagnostic systems. Because the notion of minor depression (requiring two but less than five depressive symptoms) does not exist in DSM-5, this meant that the diagnostic interviews were not coded for DSM-IV minor depression. It could be argued that this would be relevant in terms of comparing our results with previous studies that have included women meeting criteria for minor depression as cases of depression and have reported cutoff scores for 'combined depression'; and as such, this can be considered as a limitation of our study. Finally, when interpreting our findings the timeframe for T2 assessments should be considered. One of our inclusion criteria was that the mother had an infant between 2 and 10 months and although the majority (83%) of the T2 assessments were conducted between 8 and 20 weeks postpartum, T2 assessments were conducted with a quite wide timeframe (Table 1). Recently, a paper by Martin and Redshaw reported that mothers, who did not differ on other background variables, scored significantly different on the EPDS at three and six months postpartum [ 43]. However, based on the current data, it is not possible to address the question of whether an EPDS-score obtained for example at two months postpartum is more or less likely to reflect an underlying depression than at a later time point in the postpartum period.

Strengths of the study include the use of oversampling to ensure that a high number of depressed women were included, the sampling weighting method yielding good statistical power, and conducting interrater-reliability check of the clinicians who conducted the diagnostic interviews.

Conclusions

The Danish EPDS is a valid and reliable screening instrument to detect possible depression in new mothers in a Danish postnatal population. The best cutoff score for the EPDS to screen for depression according to both DSM-5 and ICD-10 in Danish women is 11 or more. It should be noted, however, that the antenatal cutoff could be different, and possible, different for each trimester [ 15], and consequently, the scale should be validated in a antenatal sample before it is used to screen for depression in pregnancy. Moreover, the Danish EPDS is multi-dimensional, and, additional to measuring depressive symptoms and self-harm/suicidal ideas, it also contains a subscale measuring symptoms of anxiety. Thus, the appropriate validated cutoff score for this subscale would also need to be calculated for both the ante- and postnatal periods before being used to screen for perinatal anxiety.

Abbreviations

AUC:

Area under the ROC curve

AUC:

Area under the ROC curve

CIMHP:

Copenhagen Infant Mental Health Project

DSM-III-R:

Diagnostic and Statistical Manual for Mental disorders, third edition, revised

DSM-5:

Diagnostic and Statistical Manual for Mental disorders, fifth edition

DSM-IV-TR:

Diagnostic and Statistical Manual for Mental disorders, fourth edition, revised

EFA:

Exploratory factor analysis

EPDS:

The Edinburgh Postnatal depression Scale

ICD-10:

International Classification of Diseases 10th revision

NPV:

Negative predictive value

PPV:

Positive predictive value

ROCs:

Receiver operating characteristics

SCID-5:

The Structured Clinical Interview for the DSM-5

T1:

Time 1

T2:

Time 2

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Acknowledgements

The authors wish to thank the health visitors and The Children and Youth Administration (Børne- Ungdoms Forvaltningen) in the City of Copenhagen for a fruitful collaboration. Special thanks go to the health visitors who agreed to recruit control mothers.

The authors wish to declare that the first and last authors' institution have paid BMC Psychiatry a substantial 'processing fee'. This is in accordance with the Journal's requirement for all manuscripts, stating that this then allows for the manuscripts to be available on 'Open Access'.

Funding

The project was funded by a grant from the charitable foundation Tryg Foundation (Grant ID no 107616). The Tryg Foundation had no role in the design of the study, data collection, analyses, interpretation of data, or in writing the manuscript.

Availability of data and materials

The datasets used and/or analyzed during the current study is available from the corresponding author on reasonable request.

Author information

Affiliations

1. Centre for Early Intervention and Family Studies, Department of Psychology, University of Copenhagen, Oester Farimagsgade 2A, DK-1353, Copenhagen, Denmark

Johanne Smith-Nielsen & Mette Skovgaard Væver

2. South West Sydney Local Health District, Liverpool Hospital, University of Sydney, Sydney, Australia

Stephen Matthey

3. Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark

Theis Lange

Contributions

JSN was overall responsible for the study design and writing of the manuscript, managed data collection, and interpreted the results. SM contributed to data analysis, interpreted the data, and contributed in writing the manuscript. TL contributed to the study design, performed the statistical analyses, and contributed in writing the manuscript. MSV received the original grant financing the project, contributed to the study design, supervised the project, and reviewed and contributed to drafting the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Johanne Smith-Nielsen.

Ethics declarations

Ethics approval and consent to participate

The project was approved by the Institutional Ethical Review Board, Department of Psychology, University of Copenhagen (Approval # 2015-10). Written informed consent was obtained from each participating woman enrolled in the study at T2 before any data was collected.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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# data[].attributes.attachment_link.title
Validation of the Edinburgh Postnatal Depression Scale against both DSM-5 and ICD-10 diagnostic criteria for depression

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The Edinburgh Postnatal Depression Scale (EPDS) is widely used in many countries to screen women for depression in the perinatal period. However, across studies the psychometric properties and cutoff scores of the EPDS have varied considerably; potentially due to different depression criteria and diagnostic systems being used.

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Schizophrenia is a serious chronic, lifelong condition. However, it can be managed with appropriate treatment, so it is important to seek help from a doctor or mental health professional if you are experiencing symptoms of this disorder.

Prevalence

The term prevalence is used to indicate how many people are currently living with a specific condition at or during a particular period of time. It is often used in the field of epidemiology, an area of medicine that seeks to understand disease prevalence, risk factors, and outcomes.

Estimates suggest that less than 1% of people are affected by schizophrenia.

The World Health Organization reports that 20 million people worldwide have schizophrenia.﻿﻿

The National Institute of Mental Health (NIMH) suggests that between 0.25 and 0.64% of the U.S. population has schizophrenia and related psychotic disorders. NIMH estimates that the worldwide prevalence of schizophrenia is around 0.33 to 0.75% (among non-institutionalized individuals).﻿﻿

However, it can be difficult to estimate the exact number of people affected by schizophrenia for several reasons. Some factors that influence the ability to gather statistics on the condition are due to the complexity of making a diagnosis, the overlap with other psychiatric conditions, and the number of people who go undiagnosed and untreated.

Who Is Affected?

Schizophrenia can impact people throughout the entire lifespan, but people are usually diagnosed sometime between late adolescence and their early 30s. Symptoms tend to begin earlier in men than in women, but many of the more subtle signs of the condition may be present for some time before more obvious symptoms begin and a diagnosis is made.﻿﻿

It is also important to note that the condition does not always occur in isolation. Around half of the people who have schizophrenia also have co-occurring mental health or behavioral conditions.﻿﻿

Research has found that anxiety, depression, and substance use disorders commonly co-occur with schizophrenia. Having a comorbid mental disorder may result in overall poorer quality of life and worse clinical outcomes depending on the nature and severity of the condition.

While schizophrenia has a relatively low prevalence, it is linked to significant social, health, and economic issues, which is often referred to as a condition's 'disease burden.' The burden of the disease is an assessment of the societal and individual impact of a condition as measured by a variety of indicators including the impact on individual health, overall mortality, and economic costs associated with the disease.

A study published in The Lancet found that schizophrenia is one of the top 15 causes of disability throughout the world.﻿﻿

Another study published in JAMA Psychiatry found that the lifespan of those with schizophrenia is shortened by an average of 28.5 years compared to that of the general population.﻿﻿ The study looked at adults between the ages of 20 and 64 starting in 2001 and followed up in 2007.

Overall, adults who had schizophrenia were 3.5 times likely to die during those years compared to adults in the general population. The results indicated that the leading causes of death among people with schizophrenia included:

Cardiovascular disease

Lung cancer

Influenza

Pneumonia

Accidental death

Nonsuicidal substance-induced death.

Deaths linked to substance use highlight the possible dangers of comorbid substance use.

While accidental deaths accounted for more than twice as many deaths as suicide, research suggests that almost 5% of people with schizophrenia die by suicide. This rate is much higher than it is for the general population.﻿﻿ NIMH notes that this risk of suicide tends to be the highest during the earliest stages of the condition.

WHO reports that people who have schizophrenia are two to three more times likely to die early.﻿﻿ This is largely due to preventable physical illnesses such as infections, cardiovascular disease, and metabolic conditions.

Prognosis can be difficult to estimate since mental health experts often have different definitions of what recovery means. One 2013 study suggested that approximately one in seven people with schizophrenia recover, meaning they experience improvements in clinical and social domains lasting at least two years.﻿﻿

Other statistics related to the outlook for schizophrenia include:

While the condition is treatable, approximately 69% of people who have schizophrenia do not receive appropriate care

90% of people who have untreated schizophrenia live in low- or middle-income countries, which often leads to a lack of access to mental health treatment

Another significant barrier to treatment is that people with schizophrenia are less likely to seek out treatment for their condition.

The overall outlook for schizophrenia tends to vary considerably from one individual to the next, but the management of symptoms is possible with appropriate treatment.

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Schizophrenia is a relatively uncommon but serious mental illness characterized by changes in a person's thoughts, feelings, and behaviors. It is a chronic brain disorder that can affect a person's ability to interpret reality. People with this condition often experience hallucinations, delusions, disorganized thinking, and abnormal behaviors.

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Several research studies performed by the National Institute of Mental Health (NIMH)

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Schizophrenia is a chronic and severe mental disorder that affects how a person thinks, feels, and behaves. People with schizophrenia may seem as though they have lost touch with reality. They may experience symptoms such as hearing voices that are not heard by others or believing that other people are reading their minds, controlling their thoughts, or plotting to harm them. Although schizophrenia is not as common as other mental disorders, the symptoms can cause serious interference in daily life. Learn more about schizophrenia.

Join A Study
For opportunities to participate in NIMH research on the NIH campus, visit the clinical research website. Travel and lodging assistance may be available.

Featured Studies

Featured studies include only those currently recruiting participants. Studies with the most recent start date appear first.

Study Type: Observational
Start Date: July 31, 2010
Location: New Haven, Connecticut
Eligibility: Males, Ages 18-55, Accepts Healthy Volunteers

The aim of the present study is to assess the availability of cannabinoid receptors (CB1R) in the human brain. CB1R are present in everyone's brain, regardless of whether or not someone has used cannabis. The investigators will image brain cannabinoid receptors using Positron Emission Tomography (PET) imaging and the radioligand OMAR, in healthy individuals and several conditions including 1) cannabis use disorders, 2) psychotic disorders, 3) prodrome of psychotic illness and 4) individuals with a family history of alcoholism, 5) Post-Traumatic Stress Disorder 6) Opioid Use Disorder using the PET imaging agent or radiotracer, [11C]OMAR. This will allow us to characterize the number and distribution of CB1R in these conditions. It is likely that the list of conditions will be expanded after the collection of pilot data and as new data on cannabinoids receptor function and psychiatric disorders becomes available.

Those in the cannabis us disorder arm of the study will have a PET scan on at least three occasions: once while smoking as usual, once after 48-hours of abstinence from cannabis, and a final time after 4 weeks of abstinence. Additional scans may be conducted within the 4 weeks and the last scan may be conducted well beyond 4 weeks. Similarly, while most schizophrenia patients may get scanned just once, a subgroup of patients may get scanned more than once. For example to tease out the effects of medications, unmedicated patients may get scanned while unmedicated and again after treatment with antipsychotic medications. Similarly prodromes may get scanned while in the prodromal stage off medications, on medications and after conversion to schizophrenia.

Study Type: Observational
Start Date: February 17, 2000
Location: Bethesda, Maryland
Eligibility: Ages 18 and Older, Accepts Healthy Volunteers

The purpose of this study is to use brain imaging technology to compare differences in brain structure, chemistry, and functioning in individuals with brain and mental disorders compared to healthy volunteers.

Schizophrenia is a brain disorder that results from subtle changes and abnormalities in neurons. These deficits likely occur in localized regions of the brain and may result in widespread, devastating consequences. The neuronal abnormalities are inherited through a complex combination of genetic and environmental factors. Brain imaging technologies can be used to better characterize brain changes in individuals with schizophrenia. This study will use magnetic resonance imaging (MRI) scans to identify predictable, quantifiable abnormalities in neurophysiology, neurochemistry and neuroanatomy that characterize schizophrenia and other neurological and neuropsychiatric disorders....

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Schizophrenia is a chronic and severe mental disorder that affects how a person thinks, feels, and behaves. People with schizophrenia may seem as though they have lost touch with reality. They may experience symptoms such as hearing voices that are not heard by others or believing that other people are reading their minds, controlling their thoughts, or plotting to harm them.

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Summary and key facts about schizophrenia across the globe and how it's being treated in today's society.

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Fact sheet on schizophrenia: key facts, symptoms, causes, support, WHO response

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Further statistics about schizophrenia in the UK

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1. In the UK about 1 in 6 people will need treatment for mental ill health during their lifetime.¹
2. At some time during their life about 1 in 100 people will suffer an episode of schizophrenia. ²

3. Schizophrenia occurs in all countries and societies of the world.

4. Schizophrenia affects men and women alike and sufferers come from all walks of life and social backgrounds.

5. Schizophrenia is a major illness. At any one time about 220,000 people are being treated for schizophrenia in the UK by the NHS. ³

6. Schizophrenia is a killer. Sufferers have a 5 to 10% chance of dying by their own hand within ten years of diagnosis ⁴ around two and half times higher than the general population. ¹¹

7. Schizophrenia strikes most often in late teens and early twenties. Slightly later in women than in men. However late onset can occur as late as 70 years old.

8. Schizophrenia runs in families. If you have a parent or sibling with the illness you are more likely to suffer from it yourself.

9. Schizophrenia is not caused by poor parenting or over-concerned mothers: nor is it caused by adversity in childhood.

10. Episodes of schizophrenia are often triggered by environmental factors such as stress and by hormonal changes such as are associated with puberty, childbirth and the menopause.

11. There is now some evidence that using street drugs especially cannabis may increase your chances of suffering an episode of schizophrenia but the picture is still not clear.

12. About 25% of people who suffer an episode of schizophrenia will go on to recover completely without any further problems in the future. ⁵

13. Modern medication is very effective and reduces the risk of relapse to about 10%.

14. There is no evidence that psychotherapy alone can treat schizophrenia effectively however it can be very useful in conjunction with medication.

15. About 25% of people with schizophrenia exhibit physical changes in their brains that can be seen on CT scans.

16. There are links between schizophrenia and certain physical illnesses. For instance coeliac disease and schizophrenia are often found in the same family and people with schizophrenia may be less vulnerable to certain physical conditions such as rheumatoid arthritis.

17. The economic cost of schizophrenia is very great. The cost of treating a patient with schizophrenia through their life is about six times the cost of treating a patient with heart disease.

18. Schizophrenia accounts for around 30% of all spending on adult mental health in the NHS. ³

19. Only around 13% of people living with schizophrenia in the UK are in any kind of work. ⁶

20. Mental illness generally will cost the UK economy around £77 billion ⁷ each year or around 4% of GDP. ⁹

21. Because of the higher risk of suicide and greater vulnerability to physical conditions like diabetes people with schizophrenia will die on average 10 - 20 years earlier than the general population. ⁸

22. In the UK mental illness represents around 10% of the total disease burden yet receives only 5.5 % of the research funding. ¹⁰ Mental illness as a whole receives less than 1% of the research funding that cancer does.

References
1. Office for National Statistics.

2. Royal College of Psychiatrists, Factsheet, Schizophrenia: information for parents, carers and anyone who works with young people, viewed on http://www.rcpsych.ac.uk/healthadvice/parentsandyouthinfo/parentscarers/schizophrenia.aspx, 14th June 2017.

3. National Institute for Health and Care Excellence, 2014, Costing statement: Psychosis and schizophrenia in adults: treatment and management.

4. Palmer B, Pankratz V, Bostwick J, 2005, The Lifetime Risk of Suicide in Schizophrenia: A Re-examination.

5. Fuller Torrey E, 2013, Surviving Schizophrenia, Harper Perennial.

6. Warner R, 2000, The Environment of Schizophrenia, Brunner Routledge.

7. Sainsbury Centre for Mental Health, 2003, The Economic and Social Costs of Mental Illness,.

8. Chesney E, Goodwin G, Fazel S, 2014, Risks of All-Cause and Suicide Mortality in Mental Disorders: a Meta-Review, published in World Psychiatry.

9. OECD estimate cited in The Economist 24th October 2015.

10. The Economist 24th October 2015.

11. Caldwell C, Gottesman I, 1992, Depression, Suicide and Suicide Prevention in Schizophrenia, Schizophrenics Kill Themselves Too, Published in Schizophrenia Bulletin.

Copyright © June 2017 LWS (UK) CIC.

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Facts and Figures - Living With Schizophrenia

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1. In the UK about 1 in 6 people will need treatment for mental ill health during their lifetime.1 2. At some time during their life about 1 in 100 people will suffer an episode of schizophrenia.2 3. Schizophrenia occurs in all countries and societies of the world. 4.

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Fundamental facts about schizophrenia in the UK including causes, demographics and treatments available

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Facts and Statistics

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Leukemia, lymphoma, myeloma and myelodysplastic syndromes (MDS) are types of cancer that can affect the bone marrow, the blood cells, the lymph nodes and other parts of the lymphatic system.

Click on the links below to view statistics about each disease:

General Blood Cancers
New Cases

Approximately every 3 minutes one person in the United States (US) is diagnosed with a blood cancer.

An estimated combined total of 178,520 people in the US are expected to be diagnosed with leukemia, lymphoma or myeloma in 2020.

New cases of leukemia, lymphoma and myeloma are expected to account for 9.9 percent of the estimated 1,806,590 new cancer cases diagnosed in the US in 2020.

Prevalence

Prevalence is the estimated number of people alive on a certain date in a population who previously had a diagnosis of the disease. An estimated 1,297,027 people in the US are either living with, or are in remission from, leukemia, lymphoma or myeloma.

With the release of the 1975-2016 Cancer Statistics Review, the calculation of limited-duration prevalence estimates were modified to use data from the SEER 13 areas (not including the Alaska Natives Registry) using cases diagnosed from 1992 through 2015. Prior publications used data from the SEER 9 registries using cases diagnosed from 1975+. SEER 13 provides a larger population base and one which is more representative of the entire US, which allows better projections of US counts. Due to this methodology change, the estimates may differ significantly from those published in previous years.

Survival

Relative survival compares the survival rate of a person diagnosed with a disease to that of a person without the disease. The most recent survival data available may not fully represent the outcomes of all current therapies and, as a result, may underestimate survival to a small degree.

Deaths

Approximately every 9 minutes, someone in the US dies from a blood cancer. This statistic represents approximately 156 people each day or more than 6 people every hour.

Leukemia, lymphoma and myeloma are expected to cause the deaths of an estimated 56,840 people in the US in 2020.

These diseases are expected to account for 9.4 percent of the deaths from cancer in 2020, based on the estimated total of 606,520 cancer deaths.

*Data specified for "blood cancer" include leukemia, lymphoma and myeloma, and do not include data for myelodysplastic syndromes (MDS) or myeloproliferative neoplasms (MPNs)
Leukemia
New Cases

In 2020, 60,530 people are expected to be diagnosed with leukemia.

Prevalence

There are an estimated 376,508 people living with or in remission from leukemia in the US.

Survival

The 5-year relative survival rate for leukemia has more than quadrupled, from 14 percent in whites from 1960 to 1963 (the only data available) to 65.8 percent for all races from 2009 to 2015.

From 2009 to 2015, the five-year relative survival rates overall were

ALL - 71.7 percent overall, 91.9 percent for children and adolescents younger than 15 years, and 94.1 percent for children younger than 5 years

AML - 29.4 percent overall and 68.7 percent for children and adolescents younger than 15 years

CLL - 88.2 percent

CML - 69.7 percent*.

*The survival rate of CML in clinical trials is higher than the survival rate reported here, based on SEER data. It is speculated that close clinical monitoring and better medication adherence in clinical trials are associated with a lower risk of disease progression and higher rates of survival.

Deaths

In 2020, 23,100 people are expected to die from leukemia (13,420 males and 9,680 females).

From 2012 to 2016, leukemia was the sixth most common cause of cancer deaths in both men and women in the US.

Hodgkin (HL) and Non-Hodgkin (NHL) Lymphoma
New Cases

In 2020, there are expected to be 85,720 new cases of lymphoma diagnosed in the US (8,480 cases of HL, 77,240 cases of NHL).

Prevalence

There are an estimated 791,550 people living with, or in remission from, lymphoma in the US.

There are 146,789 people living with or in remission from Hodgkin lymphoma

There are 644,761 people living with or in remission from non-Hodgkin lymphoma

With the release of the 1975-2016 Cancer Statistics Review, the calculation of limited-duration prevalence estimates were modified to use data from the SEER 13 areas (not including the Alaska Natives Registry) using cases diagnosed from 1992 through 2015. Prior publications used data from the SEER 9 registries using cases diagnosed from 1975+. SEER 13 provides a larger population base and one which is more representative of the entire US, which allows better projections of US counts. Due to this methodology change, the estimates may differ significantly from those published in previous years.

Survival

The 5-year relative survival rate for people with HL has more than doubled, from 40 percent in whites from 1960 to 1963 (the only data available) to 88.5 percent for all races from 2009 to 2015. The 5-year relative survival rate is 94.4 percent for all people with HL who were younger than 45 years at diagnosis.
HL is now considered to be one of the most curable forms of cancer.

The 5-year relative survival rate for people with NHL has risen from 31 percent in whites from 1960 to 1963 (the only data available) to 74.7 percent for all races from 2009 to 2015.

Deaths

In 2020, an estimated 20,910 members of the US population are expected to die from lymphoma (19,940 NHL and 970 HL).

Myeloma
New Cases

An estimated 32,270 new cases of myeloma (17,530 males and 14,740 females) are expected to be diagnosed in the US in 2020.

Prevalence

An estimated 128,969 people in the US are living with or in remission from myeloma.

With the release of the 1975-2016 Cancer Statistics Review, the calculation of limited-duration prevalence estimates were modified to use data from the SEER 13 areas (not including the Alaska Natives Registry) using cases diagnosed from 1992 through 2015. Prior publications used data from the SEER 9 registries using cases diagnosed from 1975+. SEER 13 provides a larger population base and one which is more representative of the entire US, which allows better projections of US counts. Due to this methodology change, the estimates may differ significantly from those published in previous years.

Survival

Five-year relative survival has increased from 12 percent from 1960 to 1963 (for whites, the only data available) to 53.7 percent from 2009 to 2015 (for all races and ethnicities).

The 3-year survival rate as of January 1, 2015, was 66.3 percent (for all races and ethnicities).

The 5-year survival rate is 76.2 percent for people with myeloma who were younger than 45 years at diagnosis.

Deaths

Approximately 12,830 deaths from myeloma are anticipated in 2020 (7,190 males and 5,640 females).

Myelodysplastic Syndromes (MDS)
New Cases

For the 5-year period from 2012 to 2016, there were 74,667 new cases of MDS throughout the US, averaging an estimated 14,933 cases per year.
Approximately 43,292 cases were diagnosed in males (averaging 8,658 per year) and approximately 31,375 cases were diagnosed in females (averaging 6,275 per year).

Prevalence Survival

The SEER program only recently began maintaining statistics for MDS. Survival statistics were not reported by SEER for MDS in 2020 at the time of this publication.

Deaths

The SEER program only recently began maintaining statistics for MDS. Mortality statistics were not reported by SEER for MDS in 2020 at the time of this publication.

Myeloproliferative Neoplasms
New Cases

For the 5-year period from 2012 to 2016, there were 57,151 new cases of MPNs throughout the US, averaging an estimated 11,430 cases per year.
Approximately 27,882 cases were diagnosed in males (averaging 5,576 per year) and approximately 29,269 cases were diagnosed in females (averaging 5,854 per year).

Prevalence
The SEER program only recently began maintaining statistics for MPNs. Prevalence statistics were not reported by SEER for MPNs in 2020 at the time of this publication.

Survival
The SEER program only recently began maintaining statistics for MPNs. Survival statistics were not reported by SEER for MPNs in 2020 at the time of this publication.

Deaths
The SEER program only recently began maintaining statistics for MPNs. Mortality statistics were not reported by SEER for MPNs in 2020 at the time of this publication.

Source:

Facts 2019-2020. Facts 2019-2020 provides updates from the American Cancer Society's Cancer Facts & Figures 2020 (published online in 2020, https://www.cancer.org/research/cancer-facts-statistics.html) for estimated numbers of new blood cancer cases and estimated numbers of deaths due to blood cancers. The incidence rates, prevalence and mortality data in Facts 2019-2020 reflect the statistics from the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program, Cancer Statistics Review (CSR) 1975-2016 (published online in April 2019, www.seer.cancer.gov). National incidence counts are generated from the United States Cancer Statistics (USCS) Public Use Database for 2001-2016 (www.cdc.gov/cancer/uscs/public-use/). Incidence rates by state are provided by the North American Association of Central Cancer Registries, Cancer in North America: 2012-2016 (published online in May 2019, www.naaccr.org).

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Leukemia, lymphoma, myeloma and myelodysplastic syndromes (MDS) are types of cancer that can affect the bone marrow, the blood cells, the lymph nodes and other parts of the lymphatic system. Click on the links below to view statistics about each disease: New Cases Approximately every 3 minutes one person in the United States (US) is diagnosed with a blood cancer.

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https://www.who.int/mental_health/prevention/suicide/lit_review_postpartum_depression.pdf

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This information is for anyone who wants to know more about postnatal depression (PND for short).

We hope it will be helpful to:

women who have, or think they might have postnatal depression

pregnant women who are worried about getting postnatal depression

partners, family and friends.

Disclaimer

This leaflet provides information, not advice.

The content in this leaflet is provided for general information only. It is not intended to, and does not, mount to advice which you should rely on. It is not in any way an alternative to specific advice.

You must therefore obtain the relevant professional or specialist advice before taking, or refraining from, any action based on the information in this leaflet.

If you have questions about any medical matter, you should consult your doctor or other professional healthcare provider without delay.

If you think you are experiencing any medical condition you should seek immediate medical attention from a doctor or other professional healthcare provider.

Although we make reasonable efforts to compile accurate information in our leaflets and to update the information in our leaflets, we make no representations, warranties or guarantees, whether express or implied, that the content in this leaflet is accurate, complete or up to date.

Postnatal Depression is a depressive illness which affects between 10 to 15 in every 100 women having a baby. ¹ The symptoms are similar to those in depression at other times. ² These include low mood and other symptoms lasting at least two weeks. Depending on the severity, you may struggle to look after yourself and your baby. You may find simple tasks difficult to manage.

Sometimes there is an obvious reason for PND, but not always. You may feel distressed, or guilty for feeling like this, as you expected to be happy about having a baby. However, PND can happen to anyone and it is not your fault.

It's never too late to seek help. Even if you have been depressed for a while, you can get better. The help you need depends on how severe your illness is. Mild PND can be helped by increased support from family and friends.

If you are more unwell, you will need help from your GP and health visitor. If your PND is severe, you may need care and treatment from a mental health service.

The timing varies. PND often starts within one or two months of giving birth. It can start several months after having a baby. About a third of women with PND have symptoms which started in pregnancy and continue after birth. ³

You may have some or all of the following symptoms:

Depressed

You feel low, unhappy and tearful for much or all of the time. You may feel worse at certain times of the day, like mornings or evenings.

Irritable

You may get irritable or angry with your partner, baby or other children.

Tired

All new mothers get pretty tired. Depression can make you feel utterly exhausted and lacking in energy.

Sleepless

Even though you are tired, you can't fall asleep. You may lie awake worrying about things. You wake during the night even when your baby is asleep. You may wake very early, before your baby wakes up.

Appetite changes

You may lose your appetite and forget to eat. Some women eat for comfort and then feel bad about gaining weight.

Unable to enjoy anything

You find that you can't enjoy or be interested in anything. You may not enjoy being with your baby.

Loss of interest in sex

There are several reasons why you lose interest in sex after having a baby. It may be painful or you may be too tired. PND can take away any desire. Your partner may not understand this and feel rejected.

Negative and guilty thoughts

Depression changes your thinking:

you may have very negative thoughts

you might think that you are not a good mother or that your baby doesn't love you

you may feel guilty for feeling like this or that this is your fault

you may lose your confidence

you might think you can't cope with things.

Most new mothers worry about their babies' health. If you have PND, the anxiety can be overwhelming. You may worry that:

your baby is very ill

your baby is not putting on enough weight

nowhere is clean or safe enough for your baby

your baby is crying too much and you can't settle him/her

your baby is too quiet and might have stopped breathing

you might harm your baby

you have a physical illness

your PND will never get better.

You may be so worried that you are afraid to be left alone with your baby. You may need re-assurance from your partner, health visitor or GP.

When you feel anxious, you may have some of the following:

racing pulse

thumping heart

breathless

sweating

fear that you may have a heart attack or collapse.

You may avoid situations, such as crowded shops because you are afraid of having panic symptoms.

Avoid other people

You may not want to see friends and family. You might find it hard to go to postnatal support groups. You may agree to go out and then make excuses at short notice.

Hopeless

You may feel that things will never get better. You may think that life is not worth living. You may even wonder whether your family would be better off without you.

Thoughts of suicide and self harm

If you have thoughts about harming yourself, you should ask your doctor for help. If you have a strong urge to harm yourself, seek urgent help (see below).

Psychotic symptoms

A small number of women with very severe depression develop psychotic symptoms. They may hear voices and have unusual beliefs. If this happens, you should seek help urgently (see below).

You may feel guilty that you don't feel the way you expected to.

You may or may not love your baby.

You may not feel close to your baby.

You might find it hard to work out what your baby is feeling, or what your baby needs.

You may resent the baby or blame the baby for the way you feel.

You may feel as if you are missing out on motherhood.

Depressed mothers often worry that they might do this, but it is very rare. Occasionally, through utter tiredness and desperation, you might feel like hitting or shaking your baby. Many mothers (and fathers) occasionally feel like this, not just those with PND. In spite of having these feelings at times, most mothers never act on them. If you do feel like this, tell someone.

Women often worry that if they tell someone how they feel, their baby may be taken away. Actually your GP, health visitor and midwife will want to help you get better. This will mean that you can enjoy and care for your baby at home. They can provide you with support and information so you can do this.

Having a baby is a time of huge change. It is common to feel many different emotions. Not everyone gets a depressive illness.

Over half of new mothers will experience the 'Baby Blues'. ⁴ This usually starts 3 to 4 days after birth. You may have mood swings. You may burst into tears easily. You can feel irritable, low and anxious at times. You may also over-react to things. It usually stops by the time your baby is about 10 days old. Women with baby blues do not need treatment. If it continues for more than 2 weeks, tell your health visitor or GP. They can check whether you have PND.

Depression and are the most common mental health problems in pregnancy. They affect 10-15 in every 100 women.1,5 Depression in pregnancy can be helped in much the same way as postnatal depression. Women also experience a range of other mental health problems during pregnancy, just like at other times. See our page onmental health in pregnancy.

Postpartum (puerperal) psychosis
This is the most severe type of mental illness that happens after having a baby. It affects around 1 in 1000 women ⁶ and starts within days or weeks of childbirth. It can develop in a few hours and can be life-threatening, so needs urgent treatment.

There are many symptoms that may occur. Your mood may be high or low and there are often rapid mood swings. Women often experience psychotic symptoms. They may believe things that are not true (delusions) or see or hear things that are not there (hallucinations).

This illness always needs medical help and support. You may have to go into hospital. Ideally, this should be to a specialist mother and baby unit where your baby can go with you.

Women who have had previous episodes of severe mental illness, particularly bipolar disorder, are at a high risk of postpartum psychosis. You also have a high risk if you have had Postpartum Psychosis before. Let your doctor or midwife know about this. You can discuss with them ways to increase the chances of you staying well. Although postpartum psychosis is a serious condition, women usually recover completely. For more information see our page onPostpartum Psychosis.

Perinatal Obsessive Compulsive Disorder affects 2-3 in every 100 women after having a baby. ⁷ Women have anxious thoughts or images which keep coming into their mind (obsessions). These thoughts often focus on the possibility of the baby being harmed. The thoughts cause anxiety. Women may also keep repeating thoughts or actions in an attempt to reduce this anxiety (compulsions). Treatment is with Cognitive Behaviour Therapy and/or medication. For more information see our page onPerinatal OCD.

Other mental health problems after childbirth

You may have had a mental illness before pregnancy. Your symptoms may get worse or return after your baby is born. Just as at other times, women can experience many types of mental health problems. If you are worried about any type of mental illness, discuss this with your GP. They can make sure you get the help and support you need.

Many possible causes for PND have been suggested. There is probably no single reason, but a number of different stresses may add up to cause it.

You are more likely to have PND if you have ²:

Previous mental health problems, including depression

Depression or anxiety during pregnancy

Poor support from partner, family or friends - or marital difficulties

A recent stressful event - e.g. death of someone close to you, relationship ending, losing a job.

Experienced domestic violence or previous abuse

Arrived in a developed country as a refugee or to seek asylum

There may be a physical cause for your depression, such as an underactive thyroid or low levels of vitamin B12. These can be easily treated.

PND can start for no obvious reason, without any of these causes. Also having these problems does not mean that you will definitely have PND.

Several interventions have been shown to prevent Postnatal Depression. These include:

Telephone support from other women who have had Postnatal Depression⁸

Home visits by health professionals⁸

Interpersonal Psychotherapy⁸

Cognitive Behaviour Therapy⁹

Not enough research has been done to make it clear whether antidepressants prevent depression. ¹⁰

The following are suggestions that may help to keep you well.

Don't try to be 'superwoman'. Try to do less and make sure that you don't get over-tired.

Do make friends with other women who are pregnant or have just had a baby. It may be more difficult to make new friends if you get PND.

Do find someone you can talk to. If you don't have a close friend you can turn to, you can find support through one of the organisations at the end of this page.

Do go to antenatal classes. If you have a partner, take them with you. If not take a friend or relative.

Don't stop antidepressant medication during pregnancy without advice. You are more likely to relapse if you have had severe depression¹¹, several episodes or a recent episode.¹² You need to discuss the risks and benefits of continuing treatment in pregnancy and breastfeeding with your GP or psychiatrist.

Do keep in touch with your GP and your health visitor if you have had depression before. Any signs of depression in pregnancy or PND can be recognised early.

Do make sure that you have treatment for depression in pregnancy. This may be a talking therapy or medication.

Do accept offers of help from friends and family.

Do tell others how you are feeling. You may be surprised how many people feel or have felt the same way.

Do make a Wellbeing Plan - this helps you to start thinking about the support you might need in your pregnancy and after the birth. You can download a Wellbeing Plan template from the Tommy's charity website (www.tommys.org/pregnancy-information/health-professionals/free-pregnancy-resources/wellbeing-plan)

The first thing is to recognise you have had a depressive illness. Don't dismiss it as the 'baby blues'. Don't assume it's normal to feel like this when coping with a baby.

There are lots of reasons why women delay seeking help. You may:

not realise what is wrong

worry about what other people think

feel ashamed to admit that you are not enjoying being a mother.

Some women worry that their baby will be taken away. In fact, you are doing what is best for your baby and for yourself by getting help for your PND. Doctors and health visitors want to get the care you need so you can look after your baby.

People are now more aware of depression in general. This means PND shouldn't be missed so often.

Doctors, midwives and health visitors usually ask new mothers about their mental health. They may ask you to fill in a questionnaire or ask the following questions:

During the last month, have you been bothered by feeling down, depressed or hopeless?

During the last month, have you been bothered by having little interest in pleasure or in doing things?

Is this something you feel you need or want help with?

It is important to answer these questions honestly so that you can be offered help if you need it. If your answers suggest you might have PND, you should see your GP. Your GP will need to ask more questions to confirm the diagnosis.

The help and treatment you need depends on how severe your PND is. Your GP and health visitor can help you decide what kind of help you need. If you don't get the help you think you need straight away, you can ask for a second opinion or you could see a different GP.

Try some of the self-help suggestions below. If this is not enough, you might find a talking therapy helpful. For more severe depression, you may need medication, with or without talking therapy. Your GP can advise you about these treatments.

A small number of women will need help from mental health services. Your GP can refer you to a perinatal mental health service - a specialist service for pregnant women or women with a baby under a year old. Otherwise you can be referred to a Community Mental Health Team. These are usually only needed for women with more severe illnesses.

Only a few women will need to go into hospital for treatment of PND. In that case, you should usually be admitted with your baby to a specialist Mother and Baby Unit.

If you cannot look after yourself or your baby, or if you have plans to harm yourself, you should be seen urgently by:

your GP

a mental health service - your GP can arrange this. You may already have a crisis number to call

your local Emergency Department - open 24 hours.

Don't be frightened by the diagnosis. Many women have postnatal depression and you will get better in time. Your partner, friends or family can be more helpful and understanding if they know what the problem is.

Do tell someone about how you feel. It can be a huge relief to talk to someone understanding. This may be your partner, a relative or friend. If you can't talk to your family or friends, talk to your health visitor or GP. They will know that these feelings are common and will be able to help.

Do take every opportunity to get some sleep or rest during the day or night. If you have a helpful partner, relative or friend, ask them to feed the baby at night sometimes. You can use your own expressed breast milk, or formula milk for this. If you are on your own, try and rest when the baby sleeps. Even if you cannot sleep, take some time to rest and relax.

Do try to eat regularly, even if you don't feel like eating. Eat healthy food.

Do find time to do things you enjoy or help you relax - e.g. go for a walk, read a magazine, listen to music.

If you have a partner, do try to enjoy some time together. If you are a single mother, try to do something enjoyable with a friend or family member.

Do go to local groups for new mothers or postnatal support groups. Your health visitor can tell you about groups in your area. You may not feel like going to these groups if you are depressed. See if someone can go with you. You may find the support of other new mothers helpful. You may find some women who feel the same way as you do.

Do let others help you with housework, shopping and looking after other children.

Do some exercise. Ask your health visitor if there are any mother and baby exercise classes in your area. Walking with your baby in the pram is good exercise. Regular exercise can boost your mood.

Do use self-help books and websites.

Do contact organisations that support women with Postnatal Depression.

Don't blame yourself, your partner or close friends or relatives. Life is tough at this time, and tiredness and irritability can lead to quarrels. 'Having a go' at your partner can weaken your relationship when it needs to be at its strongest. The same can happen with other close family or friends who are trying to support you.

Don't use alcohol or drugs. They may make you feel better for a short time, but it doesn't last. Alcohol and drugs can make depression worse. They are also bad for your physical health.

Don't be shocked or disappointed if your partner, friend or relative says she has postnatal depression. It is common and can be effectively helped.

Make sure that you understand what postnatal depression is. Ask the health visitor or GP if you need more information.

It's helpful just to spend time with someone who is depressed. It is important to listen and to offer encouragement and support. Reassure her that she will get better.

Be mindful of language you use - this is an illness, not something someone can 'snap out of', 'get on with' or cure by 'thinking positively'.

Take your partner, relative or friend seriously if she talks about not wanting to live or about harming herself. Make sure she seeks help urgently (see section above on Urgent Help).

Encourage your partner, relative and friend to get the help and treatment she needs. If you have any worries about treatment, discuss these with the doctor.

Do all you can to help with the practical things. This includes feeding and changing the baby, shopping, cooking or housework.

If you are the mother's partner, make sure that you have some support yourself.

If this is a first baby, you may feel pushed to one side, both by the baby and by your partner's needs. Try not to feel resentful. Your partner needs your help and support.

Ensure you are a good role model and take care of yourself.

Fathers can also get depressed after the birth of a baby. This may be more likely if the mother also has postnatal depression. If you are a father and think you may have depression, talk to your GP. It is important for you and your family that you get the help you need.

Most women will get better without any treatment within 3 to 6 months. 1 in 4 mothers with PND are still depressed when their child is one-year-old. ¹³ However, this can mean a lot of suffering. PND can spoil the experience of new motherhood. It can strain your relationship with your baby and partner. You may not look after your baby, or yourself, as well as you would when you are well. PND can affect your child's development and behaviour even after the depression has ended. ¹⁴ So the shorter it lasts, the better.

The treatment you need depends on how unwell you are. You should be told about all the likely benefits and risks of treatment so you can make the best choice for you.

Treatment includes: ¹⁵

Talking about your feelings can be helpful, however depressed you are. Sometimes, it's hard to express your feeling to someone close to you. Talking to a trained counsellor or therapist can be easier. It can be a relief to tell someone how you feel. It can also help you to understand and make sense of your difficulties.

Trained health visitors can offer counselling at home in some areas. There are also more specialised psychological treatments.

Cognitive Behavioural Therapy can help you to see how some of your ways of thinking and behaving may be making you depressed. You can learn to change these thoughts which has a positive effect on other symptoms. Other psychotherapies can help you to understand the depression in terms of your relationships or what has happened to you in the past.

Improving Access to Psychological Therapies (IAPT) services offers short-term talking therapies. The types of therapy offered will vary depending on your local IAPT service. These may include guided self-help sessions with a therapist, cognitive behaviour therapy, couples therapy and counselling. IAPT services offer individual and group therapies. Women who are pregnant or have recently had a baby are usually given priority. You can often bring your baby to appointments. Some IAPT services also have groups just for women who are pregnant or for new mums. You can self-refer to your local IAPT service. Your GP, midwife or health visitor can also make a referral for you.

Talking treatments are usually very safe, but they can have unwanted effects. Talking about things may bring up bad memories from the past. This can make you low or distressed. Psychotherapy can put a strain on relationships with people close to you.

Make sure that you can trust your therapist and that they have the necessary training.

Another problem with talking therapies is that they are still hard to get in some areas. National guidelines state that women with PND should be seen within a month. Sometimes there are long waiting lists. This means you may not get any treatment for quite a while.

If you have a more severe depression, or it has not improved with support or a talking therapy, an antidepressant will probably help. 15,16

There are several types of antidepressants. They all work equally well, but have different side-effects. They are not addictive. They can all be used in PND, but some are safer than others if you are breastfeeding. 2,16

Antidepressants take at least 2 weeks to start working. You will need to take them for around 6 months after your start to feel better.

Make sure that your doctor knows that you are breastfeeding. For many antidepressants, there is no evidence that they cause problems for breastfed babies, so breastfeeding is usually possible. If your baby is unwell or premature the advice may change. You can talk to the doctor looking after your baby about this.

The decision is an individual one for each woman. Some antidepressants have been used in breastfeeding for many years. There is less information about newer medications. Your doctor can provide up-to-date information and advice and can check with the UK Drugs in Lactation Advisory Service if needed.

To decide whether to breastfeed when taking an antidepressant, you need to think about:

how severe your illness is (or has been in the past)

treatments which have helped you before

side-effects

up-to-date information about the safety of medication in breastfeeding

the benefits of breastfeeding

whether your baby is very premature or has any health problems

the impact of the untreated illness on your baby.

Breastfeeding has many health benefits for mother and baby. However, fully breastfeeding a baby can be very tiring. Some women find it easier to combine breast and bottle feeding. If a partner, friend or family member can do some of the feeds you will be able to get more rest.

Sometimes women feel guilty if they can't breastfeed. If you are unable to breastfeed you should not worry. It is more important for your baby that you are well. You will still develop a close bond with your baby if you bottle feed.

Hormones have been suggested as a treatment for PND. However, there is little evidence that they work, and they have their own dangers ², particularly if you have had thrombosis (blood clots in their veins).

St John's Wort is a herbal remedy available from chemists. There is evidence that it is effective in mild to moderate depression. It seems to work in much the same way as some antidepressants, but some people find that it has fewer side-effects.

One problem is that St John's Wort can interfere with the way other medications work. If you are taking other medication, you should discuss it with your doctor. This is very important if you are taking the oral contraceptive pill. St John's Wort might stop your pill working. This can lead to an unplanned pregnancy.

There is not enough information to say that it is definitely safe in breastfeeding. ¹⁷ Only small amounts get into breast milk, but do not assume that because it is 'herbal', it will be safe. Discuss the risks and benefits of treatment in breastfeeding with your doctor.

Telephone helpline and information leaflets for women with postnatal mental illness. Also a network of volunteers (telephone and postal) who have experienced postnatal mental illness. Email: info@apni.org Tel: 020 7386 0868

Free App with information in the form of video clips about many aspects of pregnancy and parenting, including mental health.

Information and support for women who have had a traumatic birth experience

Information and support about breastfeeding, including information about using medication when breastfeeding. Breastfeeding Helpline: 0300 100 0212

Advice and information on how to cope with a sleepless baby and/or a crying baby. Helpline: 08451 228669.

Support and practical help for families affected by mental health problems and other challenges such as substance misuse and domestic violence. Contact: T: 020 7254 6251. Email: info@family-action.org.uk

Support and practical help for families with at least one child under-5. Help offered to parents finding it hard to cope for many reasons. These include PND or other mental illness, isolation, bereavement, illness of parent or child.

Practical and emotional support in all areas of pregnancy, birth and early parenthood. Antenatal and postnatal courses. Local networks where you can meet other parents. Support line: 0300 330 0700

Help advice and support on a wide range of pregnancy and parenting issues, including mental health.

Support and advice for women with perinatal mental illness and their families. An organisation that helps individuals and their families with pre- and postnatal depression advice and support. Support line: 0843 2898401. Email: info@pandasfoundation.org.uk

Relationship support including couple and family counselling. Face-to-face, telephone or online counselling.

24-hour free helpline 116 123 ; Email: jo@samaritans.org.

Confidential emotional support for those in distress who are experiencing feelings of distress or despair, including suicidal thoughts.

Postnatal Depression Support packs. Mother and baby hampers for women with PND who are in considerable financial difficulty.

Further reading

Overcoming postnatal depression: a five areas approach by Christopher Williams, Roch Cantwell and Karen Robertson, Hodder Arnold (2012)

The Compassionate Mind Approach to Postnatal Depression: Using Compassion Focused therapy to Enhance Mood, Confidence and Bonding, by Michelle Cree, Robinson (2015)

Antenatal and Postnatal Depression by Siobhan Curran, Vermillion (2017)

Coping with postnatal depression by Dr Sandra Wheatley, Sheldon Press (2005)

Surviving postnatal depression by Cara Aitken, Jessica Kingsley Publishers (2000)

Feelings after birth: the NCT book of postnatal depression by Heather Welford, NCT Publishers (2002)

1. Woody CA, Ferrari A, Siskind D, Whiteford H, Harris M. A systematic review and meta-regression of the prevalence and incidence of perinatal depression. J Affect Disord. 2017; 219: 86-92.

2. Howard LM, Moylneaux E, Dennis C-L, Rochat T, Stein A, Milgrom J. Non-psychotic mental disorders in the perinatal period. The Lancet. 2014; 384;1775-1788.

3. Wisner K, Sit D, McShea M, Rizzo D, Zoretich R, Hughes C et al. Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry. 2013; 70: 490-498.

4. Henshaw C. Mood disturbance in the early puerperium: a review. Arch Womens Ment Health. 2003; 6: S33-42.

5. Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol. 2005; 106:1071-83.

6. VanderKruik R, Barreix M, Chou D, Allen T, Say L, Cohen LS. VanderKruik et al. The global prevalence of postpartum psychosis: a systematic review. BMC Psychiatry. 2017; 17:272.

7. Russell EJ, Fawcett JM, Mazmanian D. Risk of obsessive-compulsive disorder in pregnant and postpartum women: a meta-analysis. J Clin Psychiatry. 2013; 74:377-85.

8. Dennis CL, Dowswell T. Psychosocial and psychological interventions for preventing postpartum depression. Cochrane Database Syst Rev. 2013; 2: CD001134

9. Sockol LE.A systematic review of the efficacy of cognitive behavioral therapy for treating and preventing perinatal depression. J Affect Disord. 2015; 15:177:7-21.

10. Molyneaux E, Howard LM, McGeown HR, Karia AM, Trevillion K.Antidepressant treatment for postnatal depression. Cochrane Database Syst Rev. 2014;9:CD002018.

11. Cohen LS, Altshuler LL, Harlow BL, Nonacs R, Newport DJ, Viguera AC et al Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA. 2006; 295: 499-507.

12. Yonkers KA, Gotman N, Smith MV, Forray A, Belanger K, Brunetto WL etal. Does antidepressant use attenuate the risk of a major depressive episode in pregnancy? Epidemiology. 2011; 22: 848-854.

13. Goodman JH. Postpartum depression beyond the early postpartum period. J Obstet Gynecol Neonatal Nurs. 2004; 33:410-20.

14. Stein A, Pearson RM, Goodman SH, Rapa E, Rahman A, McCallum M et al. Effects of perinatal mental disorders on the fetus and child. Lancet. 2014;15;384:1800-19.

15. National Institute for Health and Clinical Excellence Antenatal and postnatal mental health: clinical management and service guidance. NICE Clinical Guideline 192: London 2014. www.nice.org.uk/ guidance/CG192

16. McAllister-Williams RH, Baldwin DS, Cantwell R, Easter A, Gilvarry E, Glover V et al. British Association for Psychopharmacology consensus guidance on the use of psychotropic medication preconception, in pregnancy and postpartum. J Psychopharmacol. 2017; 31: 519-552.

17. Budzynska K, Gardner ZE, Dugoua JJ, Low Dog T, Gardiner P. Systematic review of breastfeeding and herbs. Breastfeed Med. 2012; 7: 489-503.

Credits

Produced by the RCPsych Public Engagement Editorial Board

Author: Dr Lucinda Green
Service user and carer input: Members of Depression Alliance and Cocoon Family Support
Series Editor: Dr Phil Timms
Series Manager: Thomas Kennedy
© November 2018 Royal College of Psychiatrists

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Postnatal depression | Royal College of Psychiatrists

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This information is for anyone who wants to know more about postnatal depression (PND for short). We hope it will be helpful to: women who have, or think they might have postnatal depression pregnant women who are worried about getting postnatal depression partners, family and friends. This leaflet provides information, not advice.

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Statistics of the rise of alcohol in young adults in the UK
https://alcoholchange.org.uk/alcohol-facts/fact-sheets/alcohol-statistics

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Behavioural patterns of young adults who substance abuse

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Summary

A survey of drinking and drug behaviour of two samples of university students was conducted, one from Britain and one Zimbabwe. Quantities and frequencies of consumption, preferred beverages and frequencies of drinking in various contexts were elicited. Comparing the samples, Zimbabwean students drank less frequently than British students but become intoxicated more often. While smoking and illicit drug use were associated in both samples, drinking was a poor predictor of these behaviours. The case for there being a deviant sub‐group who engage in all three behaviours is not supported by these data.

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Behavioural Patterns of Alcohol Use Among Young Adults in Britain and Zimbabwe

# data[].attributes.attachment_link.description
A survey of drinking and drug behaviour of two samples of university students was conducted, one from Britain and one Zimbabwe. Quantities and frequencies of consumption, preferred beverages and frequencies of drinking in various contexts were elicited. Comparing the samples, Zimbabwean students drank less frequently than British students but become intoxicated more often.

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Economical effects of Caucasian young adults and substance abuse
https://academic.oup.com/eurpub/article/24/3/410/475353?login=true

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Substance abuse cause in young adults relating back to education

https://www.sciencedirect.com/science/article/abs/pii/S0277953610002650

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The risks of alcohol abuse including health risks and behavioural risks.
https://www.nidirect.gov.uk/articles/young-people-and-risks-alcohol