Epidemiology Assignment: Antenatal Depression and Gestational Diabetes

This assignment presents a critical appraisal of three articles investigating the association between antenatal depression and gestational diabetes (GDM). The methodology involved a comprehensive search of MEDLINE and CINAHL using relevant search terms, followed by the application of inclusion and exclusion criteria to refine the search results. The articles selected for appraisal included a systematic review, a cross-sectional study, and an epidemiological study. The appraisal employed the Critical Appraisal Skills Programme (CASP) to assess the value, trustworthiness, and relevance of the findings. The systematic review by Byrn and Penckofer (2013) found a link between GDM and increased depression scores. Byrn and Penckofer (2015)'s cross-sectional study revealed that women with GDM had a higher likelihood of antenatal depression, with perceived stress and trait anxiety as predictive factors. Laurent and Ramos (2017)'s epidemiological study also indicated a strong association between GDM and depression. The discussion section critically evaluates the strengths and limitations of each study design, including the use of appropriate methods, potential biases, and the generalizability of the findings. Strategies to improve the reliability of the systematic review and the limitations of the sampling methods are discussed, along with implications for clinical practice and future research. The findings of all three studies support a correlation between GDM and antenatal depression. The report concludes with recommendations for healthcare providers to screen for depression in pregnant women with GDM and suggests future research directions.

Running head: NURSING
PUBH6005: Epidemiology
Name of the Student
Name of the University
Author Note

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Introduction- According to Jarde et al. (2016) also referred to as prenatal depression,
antenatal depression refers to a type of clinical depression that creates an impact on a female,
at the time of pregnancy. This condition is generally considered as a precursor to postpartum
depression, when left untreated. Time and again it has been found any type of prenatal stress
sensed by the mother creates significant negative consequences on numerous facets of foetal
development, which in turn result in harm to the child and mother (Rice, Langley, Woodford,
Smith & Thapar, 2018). Such antenatal depression is found to occur due to several aspects
that are related to the personal life of the mother, socioeconomic condition, family issues and
relationship status (Castro, Glover, Ehlert & O'Connor, 2017). Following birth, an infant who
is born from a stressed or depressed mother is usually subjected to the repercussions, such
that the child becomes less active, and also experiences emotive distress. In contrast,
gestational diabetes (GDM) refers to the condition when a female demonstrated elevated
levels of blood glucose, usually during pregnancy (Koivusalo et al., 2016). This often
increases the risks of depression, besides augmenting susceptibility to pre-eclampsia and
often the child require caesarean section during delivery. Research evidences have also
established strong correlation between postpartum depression and antenatal depression
(Doyle, 2017). It has often been established by researchers that pregnant women diagnosed
with gestational diabetes, when subjected to a range of lifestyle interventions demonstrated
reduced signs and symptoms of postpartum depression (Lim et al., 2019). This assignment
will therefore contain a critical appraisal of three articles that determine the association
between antenatal depression and gestational diabetes.
Methodology- The extraction of articles was based on formulation of a causal research
question that generally helps in determining whether one or more variables affect or cause
one or more outcomes. The research question used for this assignment is given below:
What is the association between GDM and antenatal depression?

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Two electronic databases namely, MEDLINE and CINAHL were comprehensively
searched for recovering scholarly evidences with the use of definite search terms that were
relevant to the aforementioned question. The terms that were given as an input in the
databases were namely, “gestational diabetes mellitus”, “gdm”, “diabetes in pregnancy”,
“gestational diabetes”, “association”, “relationship”, “correlation”, “antenatal depression”,
“perinatal depression”, and “depression in pregnancy”. A manual search was also conducted
in the bibliography of the obtained articles to retrieve additional evidences that were pertinent
to the research question. The search terms were combined using boolean operators ‘AND’
and ‘OR’ (McGowan et al. 2016). A definite inclusion and exclusion criteria was also
developed for refining the search results. The table given below contains the eligibility
criteria developed for article extraction:
Inclusion criteria Exclusion criteria
Articles published in English Articles published in foreign languages
Articles published on or after 2013 Articles published prior to 2013
Based on link between GDM and antenatal
depression
Articles that focus on other metabolic
syndrome
Primary and secondary research articles Clinical guideline, case study
Table 1- Inclusion and exclusion criteria
Following extraction of three articles that were considered most relevant to the
research question, a critical appraisal was performed for systematically and carefully
examining the outcome of the selected evidences. This helped in judging the value,
trustworthiness, and relevance of the findings in the particular context. The Critical Appraisal
Skills Programme (CASP) was used for the critical evaluation (CASP UK, 2018).

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Results- The tables provided below contains answers to individual checklists for each
type of study that had been selected:
Byrn and Penckofer (2013)
Questions Answers Justification
1 Yes There is lack of evidence for the correlation between
antenatal depression and gestational diabetes.
2 Yes The researchers explored the causal association by collating
and summarising six research evidences that addressed the
phenomenon under investigation
3 Yes Till 2013, there were only six articles that had addressed
link between the two variables
4 Can’t tell There was lack of information on critical analysis of the
included articles
5 Yes Clear display and collation of the six articles suggested that
pregnant females with antenatal depression and GDM are at
an increased risk for negative health outcomes (Skelly,
Dettori & Brodt, 2012)
6 There exist a link between females with GDM and greater
depression scores paralleled to females without diabetes
throughout pregnancy
7 95% CI was reported by two studies included in the review
thus suggesting 95% certainty about obtaining similar
association in the target population
8 Yes There is not much difference in the local setting for

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pregnant women diagnosed with gestational diabetes
9 Yes Prevalence of depression, as evidenced by using depression
scale was measured in all studies included in the review
10 Yes There are no potential risks associated with early screening
of antenatal depression among GDM affected pregnant
women
Table 2- CASP checklist for systematic review
Byrn and Penckofer (2015)
Questions Answers Justification
1 Yes The researchers tried to determine the susceptibility of
pregnant women with GDM towards development of
antenatal depression and the predictive factors.
2 Yes The cohort comprised of 135 pregnant women of whom
GDM was prevalent in 65 women. They used convenience
sampling technique for recruiting participants based on their
proximity.
3 Can’t tell Apart from confirmed diagnosis of GDM, the patients were
not subjected to any other factors
4 Yes They used the Edinburgh Postnatal Depression Screen
(EPDS) for diagnosing the presence of antenatal depression.
This scale has been established and validated as an effective
tool for determining signs of clinical depression.
5a No No information was provided on the external influences that
might have created an impact on the independent and

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dependent variables (Skelly, Dettori & Brodt, 2012)
5b Yes The researchers conducted multiple regression, and logistic
regression analysis for determining if GDM affected women
had greater depression symptoms
6a No No follow-up was conducted amid the participants
6b No No follow-up was conducted amid the participants
7 Antenatal depression found among 21% GDM women and
13% healthy women. GDM women demonstrated 3.79
times increased likelihood of depression history. Perceived
stress and trait anxiety were the major predictive factors.
8 Link between GDM and depression was supported by 95%
confidence interval, thus suggesting that there was 95%
conviction of obtaining similar result on re-conducting the
study.
9 Can’t tell Use of convenience sampling reduced representativeness of
the results. Obtaining responses from self-reported EPDS
for diagnosing depression was not equivalent to clinical
diagnosis of depression.
10 Yes Similar cohort of pregnant women suffering from GDM can
be selected from the local population in order to determine
the prevalence of depression
11 Yes The findings are consistent with different research findings
that have established a clear correlation between depression
and GDM.
12 Yes Care providers should contemplate screening females with a

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depression history, during initial stages of pregnancy for
diagnosing GDM
Table 3- CASP checklist for cross-sectional study
Laurent and Ramos (2017)
Questions Answers Justification
1 Yes Depression is more prevalent in females aged between 15-
44 years, which includes the childbearing age as well, thus
increasing risks for pregnancy-associated physical
manifestations.
2 Yes Participants were selected from a pilot study that comprised
of 354 GDM women and 350 healthy subjects.
3 Yes GDM diagnostic rest was performed during 24-28th
pregnancy week. Those with ≥5.3 mmol/L glucose levels
were diagnosed with GDM.
4 Yes Montogomery and Asberg Depression Rating Scale
(MADRS) was used for determining depressive symptoms.
This scale is widely used by psychiatrists for detecting
depressive episode severity.
5a Yes 3 days of regular physical activity and unrestricted diet was
ensured to prevent any impact on blood glucose levels.
5b Yes Researchers performed logistic regression for adjusting the
confounding factors (Skelly, Dettori & Brodt, 2012)
6a No The researchers did not conduct a follow-up to determine
the increase or decrease in depression severity among the

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patients
6b No No follow-up was conducted by the researchers
7 General prevalence of depression was roughly 18.32 %, and
more among GDM women (25.92 %), in contrast to
without-GDM women (10.38 %) having a mean age of
28.34 and 27.17 years respectively. There existed strong
association of depression with GDM history and dwelling
place.
8 No information provided about confidence interval
9 Can’t tell It established a strong correlation between GDM,
depression, and its risk factors
10 Yes High prevalence of GDM and antenatal depression confirm
the implementation of the results to the local population
11 Yes Prevalence of depression among GDM affected women was
consistent with findings from other research evidences.
12 Yes The findings might pave the way for formulation of new
policies and programs for the prevention and management
of both health ailments
Table 4- CASP checklist for epidemiological study
Discussion- Conduction of a systematic review was a correct approach by Byrn and
Penckofer (2013) owing to the fact that this type of secondary research focuses on collection,
analysis and synthesis of data in either a quantitative or qualitative manner, thus adding to the
body of evidence. It must be taken into consideration that the systematic review comprised of
already published, valid primary articles, thus establishing reliability of the findings (Boland,
Cherry & Dickson, 2017). This research was based on the concept that women having GDM

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often report signs and symptoms of depression during their pregnancy (Ruohomäki et al.,
2018). It has often been established that formulating an appropriate inclusion and exclusion
criteria help in extraction of articles that are most pertinent to the research phenomenon being
investigated (). Thus, inclusion of all six articles that had been published till the review was
accurate. Critical analysis is mandatory in a systematic review since it helps in evaluating the
reliability of the findings that have been included. Nonetheless, lack of any such analysis
might have led to bias in the results. It is imperative for researchers to include studies in a
review that have high precision such that on performing identical research in the target
population, similar results are obtained. However, presence of 95% CI in two of the six
included studies reduced reliability of the findings (Greenland et al., 2016).
The findings can be easily applied to the local population since GDM is common
among 12% and 14% of pregnant Australian women. Thus, they can be selected from the
primary care centres, followed by determination of the incidence and prevalence of antenatal
depression. Use of depression scale ensured that all outcomes were considered in the
individual studies since they comprise of questionnaire that provide an indication for the
severity of different depressive symptoms like suicide ideation, agitation, weight loss,
somatic symptoms, low mood, and insomnia (Howard et al., 2018). Few strategies that could
have been adopted to increase reliability of the systematic review are namely, (i) involving
two or more committee experts who will independently select and appraise the articles to
prevent bias, (ii) development of a review protocol for data collection and appraisal, and (iii)
conducting a meta-analysis that will combine results from the quantitative studies and
compare them to recognise the common effect (Rychetnik, Frommer, Hawe & Shiell, 2002).
The second research by Byrn and Penckofer (2015) was based on a cross-sectional
design, which can be cited as correct owing to the fact that it allowed assessment of a range
of variables within a definite time, and also facilitated routine collection of data at little or no

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expense (Parahoo, 2014). Evidences illustrate that assessment of exposure with great
specificity is imperative for minimalizing bias, owing to measurement error. The researchers
classified the study subjects into two groups, based on GDM diagnosis, thus ensuring that
there was no bias in the group allocation. However, use of convenience sampling was a major
limitation since the sample was not representative of the entire population, thus leading to
systematic bias (Emerson, 2015). This could be addressed if purposive sampling procedure
had been followed. Use of EPDS scale proved effective since the 10-item questionnaire
specifically addresses females with postnatal depression. Though the authors conducted
multiple regression, and logistic regression for confounding variable adjustment, clear
information was not provided on the range of variables.
Owing to the fact that confounding variables alter the impact of independent and
dependent variables, the researchers must have addressed the extraneous influence on the
outcomes, to prevent threat to internal validity (Halperin, Pyne & Martin, 2015). Follow-up
steps form an essential component of all investigation and are generally conducted in order to
ascertain the long-term health outcomes of the target population. Thus, the researchers should
have observed whether the symptoms of depression persisted throughout and after pregnancy.
Questions must have been formulated that assess the occupation, lifestyle and other
exposures, thereby categorising the stud subjects. In addition, recall bias must have been
prevented by using high-quality questionnaire and blinding the researchers to the participants
such that they will not be aware of the GDM status of study subjects (Rychetnik, Frommer,
Hawe & Shiell, 2002).
Laurent and Ramos (2017) conducted an epidemiological study for determining the
prevalence of depression among pregnant females, with or without GDM. This was a correct
research design since epidemiology encompasses the study of prevalence or incidence of
diseases in a particular population, besides determining the protective and risk factors

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(Parahoo, 2014). They selected participants from a pilot study. Pilot study refers to a
preliminary trial that is usually conducted for determining duration, feasibility and adverse
events of a project (Patten & Newhart, 2017). Although use of the MADRS helped in
obtaining self-reports of depression symptoms, it was imperative to conduct a clinical
diagnosis based on DSM-V criteria for diagnosing antenatal depression. Owing to the impact
that confounding variables create on the research outcomes, adjusting these variables using
logistic regression ensured that there was no external influence on the link between
dependent and independent variables (Greenland et al. 2016). Follow-up was also not
conducted, thus leading to failure in determining the long-term causal association. Steps that
could have improved this research are namely, (i) disclosing the foreknowledge of outcome,
(ii) gaining a sound understanding of key data and its inherent variability, and (iii)
incorporating detailed exposure characterisation (Rychetnik, Frommer, Hawe & Shiell,
2002).
Conclusion- Thus, it can be concluded that antenatal depression is prevalent among
pregnant females and the condition is generally manifested in the form of unusual worry,
apprehensions, chronic anxiety, and emotional detachment. This condition is most prevalent
among females who have been diagnosed with GDM, which refers to an increase in blood
glucose levels. On conducting a critical appraisal of the three selected articles, it was found
that all three of them established a clear association between GDM and antenatal depression,
thus calling for the need of conducting health screening, in order to facilitate early diagnosis.
Early detection of the condition would prevent health deterioration, and enhance the physical
and mental wellbeing of pregnant females.
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