part 2: helping troubled mothers around childbirth
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Part 2: Helping troubled mothers around childbirth. Helping mothers with postnatal depression, and those at risk. PND is common (14%) Adverse effects on mother-infant relationship and child development. Postnatal depression: risk factors Boyce, 2003. History of depression - PowerPoint PPT PresentationTRANSCRIPT
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Part 2: Helping troubled mothers around childbirth
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Helping mothers with postnatal depression, and those at risk
• PND is common (14%)
• Adverse effects on mother-infant relationship and child development
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Postnatal depression: risk factorsBoyce, 2003
• History of depression• Lack of confiding relationships• Socio-economic adversity• Social isolation
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Effects of PND on mother-child relationship
• Effects more marked in high risk samples
• Early social contacts Mothers less responsive and sensitive, more intrusive or withdrawn
• Later mother-child relationshipsAttachments are more likely to be insecure
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Effects of PND on child development
• Reduced cognitive performance mainly in high risk samples; mainly where depression is chronic
or severe; mediated by low sensitive responsiveness
• Emotional/behavioural problemsmainly in high risk samples where depression is chronic, but also
evidence of early effects, especially on internalising problems
• Psychiatric disordermore limited evidence, but raised frequency of anxiety and
depression
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Detection of depression
• Edinburgh Postnatal Depression Scale (EPDS) 10 item screen
• In research settings (including postal/telephone admin) is acceptable, and has reasonable sensitivity, specificity, ppp- 81%, 91.5% and 65%, respectively (Shakespeare, 2001)
• Less known re. practice-based admin; in the UK not accepted by NSC as a screen- however, with no policy on roll out, detection poor (< 50% by GP’s/health visitors (Murray et al., 2004))
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PsychotherapeuticTreatments for PND itself
• Review: Dennis and Hodnett, 2007 CBT; interpersonal therapy; non-directive counselling-
moderately effective, similarly beneficial
• Meta-analysis: Cuijpers et al., 2008CBT, social support, interpersonal therapy, counselling, psychoanalytic therapy- moderately effective- e.g., 60% remit vs. 30%
But, mainly short term treatments, and short-term follow ups- little info re long term effects, though Cooper study showed subsequent depression common
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Pharmacological treatments
Little evidence1. Appleby et al., 1997 SSRI, counselling, or SSRI plus counselling, vs placebo or single session counselling. Single treatments similarly effective; no advantage of combination.NB v poor take up (< 50%)
2. Misri et al., 2004SSRI vs SSRI + CBTSimilar improvements; small numbers, no control
Need for more research. NB effects on breast milk (SRI)
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What about infants/children?• Cooper et al., 2003/Murray et al., 2003RCT counselling, CBT, psychotherapy vs routine careShort term benefits to mother-inf relationship, not sustained; no other benefits
• Clark et al., 2003 Mother-infant therapy vs psychotherapy vs waiting listPND benefitted, but not mother-inf relationship, infant behaviour or cognitive
development
• Forman et al., 2007Interpersonal psychotherapy vs waiting list vs non-depressed controlsPND (and parenting stress) benefitted, but not mother-inf interactions, behaviour or
attachmentSame negative result for responders
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Studies focusing on infant/child outcome (NB, not all mothers depressed)
• Cicchetti et al., 1999; 2000RCT mother-toddler psychotherapy for >1yr vs. no treatment, vs. non-depressed
controlsBenefit to child attachment; No decline in cognitive scores in treated group
• Hart et al 1998NBAS scale by experimenter and mothers vs no NBASImproved infant NBAS-type behaviour• Horowitz et al., 2001RCT interaction coaching vs home visits-coachingIncreased mother-infant responsiveness• Onozawa et al., 2001;/Glover et al., 2002RCT infant massage vs. support groupImproved mother-infant interactions
But, longer-term outcomes not assessed
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Psychological preventive interventions
• Dennis and Creedy, 2004 meta-analysis
15 studies included: conclude no benefit.
Only one study noted as promising (MacArthur, 2002) in fact had substantial post partum treatment (vs. preventive) element.
Some evidence that individual vs. group better
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Additional considerations
• Chronicity of depression and associated family difficulties
• Motivation
• Professionals identify needs
• Cultural values
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Additional considerations: chronicity of depression
Women with PND have further episodes of depression outside the postnatal period: Cambridge study
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Additional considerations: motivation and context
• Parents may not perceive the problems professionals perceive
• They may need to be convinced of longer-term benefits
• Cultural values may militate against intervention
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Treatment trial in peri-urban settlement in South Africa
Cooper et al., 2008• All pregnant women identified
• Random allocation to intervention/control groups
• Treatment delivered by trained community mothers
• Home visiting late pregnancy- 6m postpartum
• Support, plus ‘The Social Baby’ principles (Murray, 2000)
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Treatment trial in South Africa: Rates of insecure attachment at 18 months
0
5
10
15
20
25
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35
40
intervention
control
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Kyhaleitsha treatment continued
• Benefits in terms of maternal sensitivity and intrusiveness post treatment and at follow up at 18 months
• The same treatment in Reading, UK was highly acceptable (take up/ retention), but had no benefit in terms of mother-infant interactions or infant outcome; motivational difference striking
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Summary and Conclusions
• PND is generally effectively treated with psychotherapy; severe depression less likely to improve and may require anti-depressant medication.
• But mothers likely to experience further episodes• Effects do not generally extend to mother-infant
relationship and infant, especially in the longer term. More specific focus on mother-infant relationship, plus long term monitoring and support likely to be required
• Preventive treatments do not seem to work
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Future directions
• Role of fathers
• Role of other carers
• Effects of antenatal depression and effects of anxiety