Part 2: Helping troubled mothers around childbirth

1. Part 2: Helping troubled mothers around childbirth

2. Helping mothers with postnatal depression, and those at risk • PND is common (14%) • Adverse effects on mother-infant relationship and child development

3. Postnatal depression: risk factorsBoyce, 2003 • History of depression • Lack of confiding relationships • Socio-economic adversity • Social isolation

4. 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more marked in high risk samples • Early social contacts Mothers less responsive and sensitive, more intrusive or withdrawn • Later mother-child relationships Attachments are more likely to be insecure

5. 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 problems mainly in high risk samples where depression is chronic, but also evidence of early effects, especially on internalising problems • Psychiatric disorder more limited evidence, but raised frequency of anxiety and depression

6. 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))

7. PsychotherapeuticTreatments for PND itself • Review: Dennis and Hodnett, 2007 CBT; interpersonal therapy; non-directive counselling- moderately effective, similarly beneficial • Meta-analysis: Cuijpers et al., 2008 CBT, 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

8. Pharmacological treatments Little evidence 1. 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., 2004 SSRI vs SSRI + CBT Similar improvements; small numbers, no control Need for more research. NB effects on breast milk (SRI)

9. What about infants/children? • Cooper et al., 2003/Murray et al., 2003 RCT counselling, CBT, psychotherapy vs routine care Short term benefits to mother-inf relationship, not sustained; no other benefits • Clark et al., 2003 Mother-infant therapy vs psychotherapy vs waiting list PND benefitted, but not mother-inf relationship, infant behaviour or cognitive development • Forman et al., 2007 Interpersonal psychotherapy vs waiting list vs non-depressed controls PND (and parenting stress) benefitted, but not mother-inf interactions, behaviour or attachment Same negative result for responders

10. Studies focusing on infant/child outcome (NB, not all mothers depressed) • Cicchetti et al., 1999; 2000 RCT mother-toddler psychotherapy for >1yr vs. no treatment, vs. non-depressed controls Benefit to child attachment; No decline in cognitive scores in treated group • Hart et al 1998 NBAS scale by experimenter and mothers vs no NBAS Improved infant NBAS-type behaviour • Horowitz et al., 2001 RCT interaction coaching vs home visits-coaching Increased mother-infant responsiveness • Onozawa et al., 2001;/Glover et al., 2002 RCT infant massage vs. support group Improved mother-infant interactions But, longer-term outcomes not assessed

11. 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

12. Additional considerations • Chronicity of depression and associated family difficulties • Motivation • Professionals identify needs • Cultural values

13. Additional considerations: chronicity of depression Women with PND have further episodes of depression outside the postnatal period: Cambridge study

14. 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

15. Treatment trial in peri-urban settlement in South AfricaCooper 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)

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

18. 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

19. 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

20. Future directions • Role of fathers • Role of other carers • Effects of antenatal depression and effects of anxiety