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 factorsBoyce, 2003

• History of depression• Lack of confiding relationships• Socio-economic adversity• Social isolation

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• Early social contacts Mothers less responsive and sensitive, more intrusive or withdrawn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

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

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))

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

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)

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

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

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

Additional considerations

• Chronicity of depression and associated family difficulties

• Motivation

• Professionals identify needs

• Cultural values

Additional considerations: chronicity of depression

Women with PND have further episodes of depression outside the postnatal period: Cambridge study

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

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)

Treatment trial in South Africa: Rates of insecure attachment at 18 months

0

5

10

15

20

25

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35

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intervention

control

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

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

Future directions

• Role of fathers

• Role of other carers

• Effects of antenatal depression and effects of anxiety