The effects of a social support group on depression, maternal attitudes and behavior in new mothers

The role of lack of grandparental support in perinatal depression

BACKGROUND

Low social support has been identified as a risk factor for perinatal mental health problems. However, previous studies mainly focused on partner support or general social support and neglected the roles of grandparents. Here, we examine whether a lack of grandparental support is related to increased risk of a diagnosis of perinatal depression. In addition, we examine whether poor grandparental support is related to more depressive symptoms in mothers with and without previously diagnosed perinatal depression and whether perceived grandparental support buffers against parenting difficulties in mothers with perinatal depression.

METHODS

The sample was drawn from an Australian pregnancy cohort study and consisted of 725 women, including 230 women who met criteria for Major Depression. At 12 months postpartum, women reported on grandparental geographical proximity and hours of grandparental childcare support. Perceived grandparental support was assessed with the Postpartum Social Support Questionnaire and parenting difficulties and depressive symptoms with the Parenting Stress Index and the Edinburgh Postnatal Depression Scale.

RESULTS

Perceived grandparental support was related to fewer depressive symptoms among mothers with perinatal depression. In addition, higher levels of perceived grandparental support were related to lower parenting stress in mothers with and without perinatal depression.

LIMITATIONS

Intergenerational conflicts and quality of grandparenting were not assessed.

CONCLUSIONS

Our findings indicate that supportive grandparents may prevent the development of more severe perinatal depression in mothers experiencing perinatal mental health problems. Future studies should examine whether involving grandparents in treatment may add to the effectiveness of existing perinatal mental health interventions.

Grandparental Support and Maternal Postpartum Mental Health : A Review and Meta-Analysis

Support from grandparents plays a role in mothers' perinatal mental health. However, previous research on maternal mental health has mainly focused on influences of partner support or general social support and neglected the roles of grandparents. In this narrative review and meta-analysis, the scientific evidence on the association between grandparental support and maternal perinatal mental health is reviewed. Searches in PubMed, EMBASE, MEDLINE, Scopus, and PsycINFO yielded 11 empirical studies on N = 3381 participants, reporting on 35 effect sizes. A multilevel approach to meta-analysis was applied to test the association between grandparental support and maternal mental health. The results showed a small, statistically significant association (r = .16; 95% CI: 0.09-0.25). A moderator test indicated that the association was stronger for studies reporting on support from the maternal grandmother in particular (r = .23; 95% CI: 0.06-0.29). Our findings suggest that involved grandparents, in particular mother's own mother, constitute a protective factor for the development of maternal postpartum mental health problems. These findings have clear implications for interventions. Future studies should examine whether stimulating high-quality support from grandparents is a fruitful avenue for enhancing maternal postpartum mental health.

Intergenerational transmission of adverse childhood experiences via maternal depression and anxiety and moderation by child sex

Adverse childhood experiences (ACEs) of parents are associated with a variety of negative health outcomes in offspring. Little is known about the mechanisms by which ACEs are transmitted to the next generation. Given that maternal depression and anxiety are related to ACEs and negatively affect children's behaviour, these exposures may be pathways between maternal ACEs and child psychopathology. Child sex may modify these associations. Our objectives were to determine: (1) the association between ACEs and children's behaviour, (2) whether maternal symptoms of prenatal and postnatal depression and anxiety mediate the relationship between maternal ACEs and children's behaviour, and (3) whether these relationships are moderated by child sex. Pearson correlations and latent path analyses were undertaken using data from 907 children and their mothers enrolled the Alberta Pregnancy Outcomes and Nutrition study. Overall, maternal ACEs were associated with symptoms of anxiety and depression during the perinatal period, and externalizing problems in children. Furthermore, we observed indirect associations between maternal ACEs and children's internalizing and externalizing problems via maternal anxiety and depression. Sex differences were observed, with boys demonstrating greater vulnerability to the indirect effects of maternal ACEs via both anxiety and depression. Findings suggest that maternal mental health may be a mechanism by which maternal early life adversity is transmitted to children, especially boys. Further research is needed to determine if targeted interventions with women who have both high ACEs and mental health problems can prevent or ameliorate the effects of ACEs on children's behavioural psychopathology.

Mother-infant separation among mothers with mental illness: An exploratory observational study in Japan

Mother-infant separation may influence child development and behavior problems. We reviewed charts for 3639 female patients to investigate rates, reasons, and predictors for mothers with mental illness being separated from their infants during the first year after childbirth in Japan. Of 77 patients with childbirth, 26 cases (34%) presented with maternal separation. The most common reason was psychiatric hospitalization. Diagnoses of schizophrenia spectrum disorders or mood disorders were independent contributors for maternal separation. Clinicians should pay particular attention to relapse or onset of psychotic or mood disorders during the perinatal period.

Association between maternal depression and maternal sensitivity from birth to 12 months: a meta-analysis

Maternal sensitivity plays a central role in shaping children's development across a number of domains, and may be disrupted by depression. The current meta-analysis quantified the magnitude of the association between depression and maternal sensitivity, defined broadly as timely, contingent, and appropriate responding to infants' cues, from birth to 12 months. Across k = 48 studies and n = 4,934 mother-infant dyads, the aggregate effect size between depression and maternal sensitivity was r = -.16, p < .0001, indicating that mothers with higher depression levels were less sensitive than mothers with lower depression levels. Studies that compared a depressed group with a nondepressed/control group had larger effect sizes (r = -.35, p < .0001) than studies that examined depression within a single sample of either unselected cases or clinical-only cases (r = -.11, p < .001), suggesting that clinical levels of depression may pose a particular threat to sensitive parenting. Clinical implications (e.g. screening, prevention) are discussed.

Affective changes during the postpartum period: Influences of genetic and experiential factors

This article is part of a Special Issue "Parental Care". The postpartum period involves some truly transformational changes in females' socioemotional behaviors. For most female laboratory rodents and women, these changes include an improvement in their affective state, which has positive consequences for their ability to sensitively care for their offspring. There is heterogeneity among females in the likelihood of this positive affective change, though, and some women experience elevated anxiety or depression (or in rodents anxiety- or depression-related behaviors) after giving birth. We aim to contribute to the understanding of this heterogeneity in maternal affectivity by reviewing selected components of the scientific literatures on laboratory rodents and humans examining how mothers' physical contact with her infants, genetics, history of anxiety and depression and early-life and recent-life experiences contribute to individual differences in postpartum affective states. These studies together indicate that multiple biological and environmental factors beyond female maternal state shape affective responses during the postpartum period, and probably do so in an interactive manner. Furthermore, the similar capacity of some of these factors to modulate anxiety and depression in human and rodent mothers suggests cross-species conservation of mechanisms regulating postpartum affectivity.

Emotional Rejection of the Infant: Status of the Concept

Emotional rejection of the infant is a morbid, clinical phenomenon, central to mother-infant psychiatry. It occurs in about 1% of births in the general population, but much more often in mothers referred to specialist services. It has severe consequences for children, but responds well to treatment. It is now better recognized, but research is required, especially cohort studies and neuroscientific investigations.

Perinatal Risks and Childhood Premorbid Indicators of Later Psychosis: Next Steps for Early Psychosocial Interventions

Schizophrenia and affective psychoses are debilitating disorders that together affect 2%-3% of the adult population. Approximately 50%-70% of the offspring of parents with schizophrenia manifest a range of observable difficulties including socioemotional, cognitive, neuromotor, speech-language problems, and psychopathology, and roughly 10% will develop psychosis. Despite the voluminous work on premorbid vulnerabilities to psychosis, especially on schizophrenia, the work on premorbid intervention approaches is scarce. While later interventions during the clinical high-risk (CHR) phase of psychosis, characterized primarily by attenuated positive symptoms, are promising, the CHR period is a relatively late phase of developmental derailment. This article reviews and proposes potential targets for psychosocial interventions during the premorbid period, complementing biological interventions described by others in this Special Theme issue. Beginning with pregnancy, parents with psychoses may benefit from enhanced prenatal care, social support, parenting skills, reduction of symptoms, and programs that are family-centered. For children at risk, we propose preemptive early intervention and cognitive remediation. Empirical research is needed to evaluate these interventions for parents and determine whether interventions for parents and children positively influence the developmental course of the offspring.

Psychological treatments for perinatal depression

Perinatal depression is prevalent and greatly affects the mother and infant. Fortunately, empirically validated psychological treatments are available for postpartum depression and depression during pregnancy. Primary among these are interpersonal psychotherapy and cognitive-behavioural therapy, which have been shown to be effective for perinatal women across the spectrum from mild to severe depression. At present, interpersonal psychotherapy is better validated than antidepressant medication for perinatal depression, and should be considered as a first-line treatment option, especially for pregnant and breast-feeding women who are depressed. More studies are needed to evaluate further the relative efficacy of psychotherapy and medication, and more thoroughly test other psychological treatments.

Stories of women involved in a postpartum depression peer support group

Living through postpartum depression (PPD) might lead women to seek a variety of support to re-establish their well-being, including a hybrid of traditional and non-traditional services. Within this mix, some women participate in peer groups; however, there is a paucity of research regarding their subjective experiences of engaging in this type of support. The purpose of this study was to describe how women talked about living through PPD in the context of a peer support group. This focused ethnography was a component of a larger participatory action study in northern Ontario, Canada. The seven members of a 5-week peer support group described their postpartum experiences through written, visual, and spoken stories. Using structural narrative analysis, stories about recovery were identified across the data. Three groups of recovery stories were labelled as illness, mothering wisdom, and mobilizing. The findings suggested that women actively sought and established a therapeutic space for PPD recovery with peers. As such, health-care providers are encouraged to acknowledge the merits and advocate for the multiple and diverse alliances women might require to actualize recovery.

The developmental psychopathology of perinatal depression: implications for psychosocial treatment development and delivery in pregnancy

Taking a developmental psychopathology perspective, our objective was to identify ways in which psychosocial treatment of depression during pregnancy may be enhanced. We first consider the state of evidence on psychosocial interventions for antenatal depression, next define key developmental psychopathology concepts that are relevant to antenatal depression, and finally discuss implications for clinical practice and research. We found a limited, but promising, evidence base for effective psychosocial interventions for depression during pregnancy. Examining antenatal depression from a developmental psychopathology perspective revealed suggestions for improving treatment. A developmental psychopathology perspective suggests that treatment of depression during pregnancy may be improved by attention to the continuum of depression, from subclinical to severe major depressive disorder; personalized care based on individual women's pattern of risk and resilience factors and correlated risks; consideration of the potential benefits of treating the couple's relationship, the mother's qualities of parenting, and infants' and children's mental health needs; and, including a detailed understanding of the developmental pathways to antenatal depression for each patient in treatment planning.

Postpartum Doula and Peer Telephone Support for Postpartum Depression

Objectives: This research provides the first test of feasibility of recruiting postpartum doulas and depressed mothers for a peer support intervention study and begins to evaluate the benefit of postpartum doula support and peer telephone support for at-risk mothers. Methods: The authors recruited postpartum doulas from national doula organizations, peer telephone supporters from nursing referrals, and mothers with depressive symptoms from 3 local hospitals, local medical practices, Web sites, and community organizations. Participating mothers were randomized to 3 groups—postpartum doula, peer telephone support, and control group. Surveys were completed at 0, 3, and 6 months postenrollment. Results: Thirty-nine mothers with depressive symptoms, 6 postpartum doulas, and 6 peer telephone supporters participated. The postpartum doula group, compared with the other 2 groups, had a higher proportion of women with a previous history of depression, and similarly, a higher proportion of women who were depressed and receiving depression treatment at the 6-month follow-up. Satisfaction with study-sponsored support was greater in the postpartum doula group than in the telephone support group. Conclusions: It is feasible to recruit postpartum doulas, peer telephone supporters, and mothers with depressive symptoms for a peer support intervention trial. Mothers were more satisfied with postpartum doulas than peer telephone support. The authors recommend further research to assess the benefit of postpartum doula support for postpartum depression as adjunctive or alternative therapy.

Group treatment for postpartum depression: a systematic review

Postpartum depression (PPD) is a serious public health problem affecting 10% to 15% of women during the first year after delivery with negative consequences for both mother and infant. There is a need for evidence-based interventions to treat this disorder. Thus, the purpose of this study was to systematically review the literature regarding group treatment for PPD to determine the current state of knowledge regarding the efficacy of this treatment modality for reducing depressive symptoms in postpartum women. A systematic search of published and unpublished literature using the electronic databases Medline, CINAHL, PsycINFO, Cochrane Database, Cochrane Central Register of Controlled Trials, Current Controlled Trials, and Dissertation Abstracts through March 2011, supplemented by hand searches, identified 11 studies which met inclusion criteria: six were randomized controlled trials and five were non-randomized trials which utilized non-equivalent control or comparison groups. All but one study showed statistically significant improvement in depression scores from pretreatment to post-treatment, suggesting that group treatment is effective in reducing PPD symptoms. The review provides initial support for the role of group therapy in the treatment of PPD; however, caution is advised in making generalized interpretations of the findings as there was considerable heterogeneity of the studies included and the quality of the studies was mixed. Overall, the review reveals significant gaps in the current evidence base for group treatment for PPD and recommendations for further research is discussed.

Attitudes and adjustment to the parental role in mothers following treatment for postnatal depression

BACKGROUND

Few intervention studies of postnatal depression (PND) have evaluated accompanying changes in parenting, in spite of mounting evidence that exposure to chronic depression is detrimental to infant development. This study examined maternal attitudes and adjustment over the first postnatal year within a treatment trial. The aim was to examine whether maternal adjustment improved with earlier remission, and with combined medical and psychological treatment.

METHODS

As part of a multicentre pragmatic randomised controlled trial of treatment for PND, mothers completed a measure of maternal adjustment and attitudes and the Edinburgh Postnatal Depression Scale at an initial home visit (week 0) and three follow-ups (weeks 4, 18 and 44).

RESULTS

Maternal attitudes and adjustment improved with PND remission; earlier remission conferred no additional benefit by 44-week follow-up. In line with previous studies, no particular treatment modality (antidepressant or health-visitor delivered non-directive counselling), or combination of treatments, was more effective for improving adjustment to parenthood. However, the earlier start of antidepressant treatment provided a short-term advantage for improving attitudes and reducing perceived stress.

LIMITATIONS

As a result of the study's pragmatic trial design, there was high treatment non-compliance and no 'pure' control group. More depressed mothers may have been less likely to complete the maternal adjustment and attitudes measure.

CONCLUSIONS

Effective treatment of PND is important not only for the mother's wellbeing but also for healthy adjustment to parenthood. Provision of treatment choice and early antidepressant treatment are suggested for optimising maternal attitudes and adjustment.

Mums 4 Mums: structured telephone peer-support for women experiencing postnatal depression. Pilot and exploratory RCT of its clinical and cost effectiveness

Background

Postnatal depression (PND) can be experienced by 13% of women who give birth, and such women often exhibit disabling symptoms, which can have a negative effect on the mother and infant relationship, with significant consequences in terms of the child's later capacity for affect regulation. Research has shown that providing support to mothers experiencing PND can help reduce their depressive symptoms and improve their coping strategies. The Mums4Mums study aims to evaluate the impact of telephone peer-support for women experiencing PND.

Methods/Design

The study design adopts the MRC framework for the development and evaluation of complex interventions. Health visitors in Warwickshire and Coventry Primary Care Trusts are screening potential participants at the 8-week postnatal check using either the Edinburgh Postnatal Depression Scale (EPDS > = 10) or the three Whooley questions recommended by NICE (http://guidance.nice.org.uk/CG45). The Mums4Mums telephone support intervention is being delivered by trained peer-supporters over a period of four months. The primary outcome is depressive symptomatology as measured by the Edinburgh Postnatal Depression Scale. Secondary outcomes include mother-child interaction, dyadic adjustment, parenting sense of competence scale, and self-efficacy. Maternal perceptions of the telephone peer-support are being assessed using semi-structured interviews following the completion of the intervention.

Discussion

The proposed study will develop current innovative work in peer-led support interventions and telecare by applying existing expertise to a new domain (i.e. PND), testing the feasibility of a peer-led telephone intervention for mothers living with PND, and developing the relationship between the lay and clinical communities. The intervention will potentially benefit a significant number of patients and support a future application for a larger study to undertake a full evaluation of the clinical and cost effectiveness of telephone based peer-support for PND.

Trial registration

ISRCTN: ISRCTN91450073. The study has received a major funding grant from National Institute for Health Research (NIHR) (UK) - Research for Patient Benefit (RfPB) programme (ref: PB-PG-0407-13232).

Efficacy of peer support interventions for depression: a meta-analysis

OBJECTIVE

To assess the efficacy of peer support for reducing symptoms of depression.

METHODS

Medline, PsycINFO, CINAHL and CENTRAL databases were searched for clinical trials published as of April 2010 using Medical Subject Headings and free text terms related to depression and peer support. Two independent reviewers selected randomized controlled trials (RCTs) that compared a peer support intervention for depression to usual care or a psychotherapy control condition. Meta-analyses were conducted to generate pooled standardized mean differences (SMD) in the change in depressive symptoms between study conditions.

RESULTS

Seven RCTs of peer support vs. usual care for depression involving 869 participants were identified. Peer support interventions were superior to usual care in reducing depressive symptoms, with a pooled SMD of -0.59 (95% CI, -0.98 to -0.21; P=.002). Seven RCTs with 301 total participants compared peer support to group cognitive behavioral therapy (CBT). There was no statistically significant difference between group CBT and peer interventions, with a pooled SMD of 0.10 (95% CI, -0.20 to 0.39, P=.53).

CONCLUSION

Based on the available evidence, peer support interventions help reduce symptoms of depression. Additional studies are needed to determine effectiveness in primary care and other settings with limited mental health resources.

Maternal rejection of the young child: present status of the clinical syndrome

This article reviews severe disorders of the mother-infant relationship involving emotional rejection of the infant in the first year of its life. Infants exposed to their mother's hatred and rage may suffer far-ranging and long-term disadvantages, and are at risk of maltreatment. Diagnosis, therapy and research have been hampered by the lack of recognition of this clinical syndrome in the classifications. The imminent revision of these classificatory systems must include them.

Telephone-based mutual peer support for depression: a pilot study

OBJECTIVES

To evaluate the acceptability, feasibility and depression-related outcomes of a telephone-based mutual peer support intervention for individuals with continued depressive symptoms in specialty mental health treatment.

METHODS

Participants were depressed patients with continued symptoms or functional impairment treated at one of the three outpatient mental health clinics. Participants were partnered with another patient, provided with basic communication skills training, and asked to call their partner at least once a week using a telephone platform that recorded call initiation, frequency and duration. Depression symptoms, quality of life, disability, self-efficacy, overall mental and physical health and qualitative feedback were collected at enrolment, 6 weeks and 12 weeks.

RESULTS

Fifty-four participants enroled in the 12-week intervention and 32 participants (59.3%) completed the intervention. Participants completing the study averaged 10.3 calls, with a mean call length of 26.8 min. The mean change in BDI-II score from baseline to study completion was -4.2 (95% CI: -7.6, -0.8; p<0.02). Measures of disability, quality of life and psychological health also improved. Qualitative assessments indicated that participants found meaning and support through interactions with their partners.

DISCUSSION

Telephone-based mutual peer support is a feasible and acceptable adjunct to specialty depression care. Larger trials are needed to determine efficacy and effectiveness of this intervention.

A randomised control trial for the effectiveness of group Interpersonal Psychotherapy for postnatal depression

This study is a randomised controlled trial comparing outcomes from an 8-week Interpersonal Psychotherapy group (IPT-G) for postnatal depression with 'treatment as usual' (TAU), conducted in a routine community setting in the Australian Capital Territory (ACT). Eligible women were recruited and randomly assigned to either IPT-G or TAU conditions. This study compared outcomes on such variables as depressive symptoms, marital adjustment, social support and mother-infant bond at baseline, mid-treatment, end-of-treatment and 3 months follow-up. Participants were also independently assessed using the Hamilton Depression Rating Scale (HAM-D). 50 women completed baseline assessments and were included in the analysis. Comparisons of treatment conditions showed that by end of treatment both the TAU and IPT-G groups significantly improved in terms of mean depression scores, however, the IPT-G women improved significantly more and had continued improvements at 3 months post therapy. Furthermore, women who received IPT-G displayed significant improvement in terms of marital functioning and perceptions of the mother-infant relationship compared to TAU participants. These findings highlight the potential benefits of an interpersonally based treatment, which not only improves outcomes for the mother but also potentially for the couple and the infant when compared to usual care.

Nonpharmacologic intervention and prevention strategies for depression during pregnancy and the postpartum

Perinatal depression is a serious and disabling disorder that has enduring consequences for both women and their children. Although efficacious pharmacologic strategies are available, many perinatal women are reluctant to continue or start antidepressant medications because of the concern about impact on the fetus or, later, the nursing infant. Weighing the costs and benefits of pharmacologic strategies often requires complex-decision making on the part of obstetric providers and patients. Nonpharmacologic intervention and prevention strategies offer the potential of beneficial outcomes without substantial risk profiles. This paper reviews the evidence base for nonpharmacologic intervention and prevention strategies for depression during pregnancy and the postpartum. The evidence base suggests that efficacious nonpharmacologic options are available for women during pregnancy and postpartum; however, important research questions remain.

Postpartum Depression: An Update

Postpartum depression occurs in at least one in seven new mothers, usually within the first 6 months after delivery. By the time of onset of postpartum depression, the mother has usually long since been discharged from the maternity hospital. Early identification and treatment of these mothers reduces both maternal and infant suffering. Careful risk–benefit decision-making regarding various treatment options in the postpartum should be discussed with the mother. Risks of untreated depression include poor bonding with the infant, lack of self care, infant neglect and infanticide.

Advocacy for mothers with psychiatric illness: a clinical perspective

Motherhood is a challenging role and a life-changing experience. For women living with psychiatric illness, the challenge of motherhood is amplified. Psychiatric illness (including schizophrenia, affective and personality disorders) is associated with multiple adversities that can impair the capacity to parent. Social adversity, fluctuating symptoms, and medications and their related side-effects, can create difficulties for the new mother as she adjusts to her role. The risk for relapse among women who are unwell is heightened during the post-partum period. For many other women, the post-partum period is when psychiatric symptoms emerge for the first time. Equally important are the continuing concerns pertaining to infant well-being where maternal psychiatric illness is present. For mothers who exhibit symptoms at this time, a very real threat of protective removal exists. In the mother-infant setting, child protection legislation is biased towards the rights of the child. While there are cases for which this bias is clearly appropriate, there are less clear situations from which the infant is removed with little regard for the mother. Often mothers with psychiatric illness struggle to meet the cognitive, emotional, and financial demands of drawn-out custody proceedings. For these mothers, there is a paucity of appropriate support available, as will be evidenced throughout the present paper. There is an urgent need for professional advocacy to support women who are unwell in their transition to motherhood. The mental health nurse is able to fill a key advocating role in the perinatal psychiatric setting. Nurses in this role hold a unique position whereby social and community supports can be activated, while guidance is imparted from a ground-level standpoint. The nurse in this role has the capacity to liaise with authorities, negotiate service provision, and ensure that key parenting skills are acquired by the mother as she works to secure her role. Through the provision of proactive advocacy during this time, the nurse has the potential to ameliorate the outcomes of mothers who are unable to cope alone and the well-being of their infants.

A review of mother-child relational interventions and their usefulness for mothers with schizophrenia

This review evaluates empirical studies that have attempted to improve observed mother-infant relationships in order to inform a potential approach for mothers with schizophrenia, a growing group of vulnerable families where mothers are known to have relational difficulties. Parenting intervention studies in: (1) mothers with a mental disorder; (2) other vulnerable groups were reviewed. Only interventions that empirically evaluated observations of mother-child interaction or child attachment were included, and their potential usefulness for mothers with schizophrenia was examined. Nine studies involved mothers with mental disorder; none involved mothers with psychotic disorder specifically. Overall, approaches that emphasise the mother-child dyad, such as sensitivity-focused behavioural techniques and toddler-parent psychotherapy, were most efficacious for improving maternal sensitivity/child attachment. Although individual psychological therapies are the more conventional treatment, little current evidence suggests that mother-infant relations improve with symptom reduction. The usefulness of the available evidence for informing interventions with mothers with schizophrenia is discussed in the context of their clinical needs. Feasibility studies are needed, which provide a focus on enhancing maternal sensitivity directly within a multi-level support package.

Evidence-based recommendations for depressive symptoms in postpartum women

Postpartum depression is a serious health issue affecting 13% of women from diverse cultures. Despite the well-documented consequences of postpartum depression, it remains difficult to identify, and diverse practices relate to its prevention and treatment. Evidence-based interventions are essential to improve both maternal and infant health outcomes associated with pregnancy. This article describes the development process of an evidence-based practice guideline for postpartum depression and highlights the practice recommendations related to the confirmation, prevention, and treatment of depressive symptoms in postpartum mothers.

Psychosocial and psychological interventions for treating postpartum depression

BACKGROUND

Postpartum depression is a major health issue for many women from diverse cultures. While pharmacological interventions are an effective treatment for depression, mothers are often reluctant to take antidepressant medication due to concerns about breast milk transmission or potential side-effects. It is important that non-pharmacologic interventions be evaluated for use with postpartum women experiencing depressive symptomatology.

OBJECTIVES

Primary: to assess the effects of all psychosocial and psychological interventions compared with usual postpartum care in the reduction of depressive symptomatology.Secondary: to examine (1) the effectiveness of specific types of psychosocial interventions; (2) the effectiveness of specific types of psychological interventions; (3) the effectiveness of specific types of psychosocial interventions versus psychological interventions; (4) the effects of intervention mode (e.g., individual versus group-based interventions); and (5) the effects of sample selection criteria (e.g., targeting women with clinically diagnosed depression versus self-reported depressive symptomatology).

SEARCH STRATEGY

CCDANCTR-Studies and CCDANCTR-References were searched on 1/8/2007, the Cochrane Pregnancy and Childbirth Review Group trials register, CENTRAL, MEDLINE (1966 to 2006), EMBASE (1980 to 2006) and CINAHL (1982 to 2006) using various combinations of the terms 'postpartum/postnatal depression.' Secondary references and experts in the field were used to identify other published or unpublished trials.

SELECTION CRITERIA

All published, unpublished, and ongoing randomised controlled trials and quasi-randomised trials of psychosocial or psychological interventions where the primary or secondary aim was a reduction in depressive symptomatology.

DATA COLLECTION AND ANALYSIS

Both review authors participated in the evaluation of methodological quality and data extraction. Additional information was sought from several trial researchers. Results are presented using relative risk for categorical data and weighted mean difference for continuous data.

MAIN RESULTS

Ten trials met the inclusion criteria, of which nine trials reported outcomes for 956 women. Any psychosocial or psychological intervention, compared to usual postpartum care, was associated with a reduction in the likelihood of continued depression, however measured, at the final assessment within the first year postpartum. Both psychosocial and psychological interventions were effective in reducing depressive symptomatology. Trials selecting participants based on a clinical diagnosis of depression were just as effective in decreasing depressive symptomatology as those that enrolled women who met inclusion criteria based on self-reported depressive symptomatology.

AUTHORS' CONCLUSIONS

Although the methodological quality of the majority of trials was, in general, not strong, the meta-analysis results suggest that psychosocial and psychological interventions are an effective treatment option for women suffering from postpartum depression. The long-term effectiveness remains unclear.

Postpartum Depression

Postpartum depression is a crippling mood disorder, historically neglected in health care, leaving mothers to suffer in fear, confusion, and silence. Undiagnosed it can adversely affect the mother-infant relationship and lead to long-term emotional problems for the child. This article differentiates postpartum depression from other postpartum mood and anxiety disorders and addresses these aspects of postpartum depression: symptoms, prevalence, risk factors, interventions, and the effects on relationships and child development. Instruments available to screen for postpartum depression are also reviewed.

Intervening to reduce depression after birth: a systematic review of the randomized trials

A systematic review and meta-analysis of randomized trials of nonpharmaceutical and nonhormonal interventions to reduce postnatal depression was carried out to summarize the effectiveness of interventions grouped in terms of the nature and timing of the intervention and whether the trial population was universal, selective, or indicated.

A comparative evaluation of community treatments for post-partum depression: implications for treatment and management practices

OBJECTIVE

To compare existing community treatments for post-partum depression (PPD), treatment efficacy was evaluated for 146 women seeking treatment for PPD in the local community.

METHODS

Self-report questionnaires were designed to assess clinical depression and anxiety (psychological and physiological), risk factors, treatment satisfaction and the impact of social supports.

RESULTS

Comparison of treated subjects with those on a wait-list demonstrated that depression and the psychological component of anxiety decreased significantly after treatment. Psychological and pharmacological interventions produced similar clinical benefit in the treatment of psychological symptoms, and receiving both treatments in combination was of no added clinical benefit in the immediate or longer term. Individual treatment was associated with more rapid treatment gains initially than group treatment. However, the benefits of group treatment emerged during the 6 months following treatment, leading both interventions to be equally effective in the longer term. Cognitive behavioural therapy was not superior to the combination of non-specific counselling or behavioural strategies, either immediately following treatment or 6 months later.

CONCLUSIONS

Clinical efficacy together with other clinical and financial benefits strongly advocate the application of psychological treatment for PPD. Clear parallels between PPD and general depression support the application of knowledge about general depression to extend understanding of PPD and refine clinical management practices.

Postpartum psychiatric disorders

This review summarises the psychiatry of the puerperium, in the light of publications during the past 5 years. A wide variety of disorders are seen. Recognition of disorders of the mother-infant relationship is important, because these have pernicious long-term effects but generally respond to treatment. Psychoses complicate about one in 1000 deliveries. The most common is related to manic depression, in which neuroleptic drugs should be used with caution. Post-traumatic stress disorder, obsessions of child harm, and a range of anxiety disorders all require specific psychological treatments. Postpartum depression necessitates thorough exploration. Cessation of breastfeeding is not necessary, because most antidepressant drugs seem not to affect the infant. Controlled trials have shown the benefit of involving the child's father in therapy and of interventions promoting interaction between mother and infant. Owing to its complexity, multidisciplinary specialist teams have an important place in postpartum psychiatry.

PRISM (Program of Resources, Information and Support for Mothers) Protocol for a community-randomised trial [ISRCTN03464021]

BACKGROUND

In the year after birth one in six women has a depressive illness, and 30% are still depressed, or depressed again, when their child is 2 years old, 94% experience at least one major health problem (e.g. back pain, perineal pain, mastitis, urinary or faecal incontinence), 26% experience sexual problems and almost 20% have relationship problems with partners. Women with depression report less practical and emotional support from partners, less social support overall, more negative life events, and poorer physical health. Their perceptions of factors contributing to depression are lack of support, isolation, exhaustion and physical health problems. Fewer than one in three affected women seek help in primary care despite frequent contacts.

METHODS/DESIGN

PRISM aims to reduce depression and physical health problems of recent mothers through primary care strategies to increase practitioners' response to these issues, and through community-based strategies to develop broader family and community supports for recent mothers. Eligible local governments will be recruited and randomised to intervention or comparison arms, after stratification (urban/rural, size, birth numbers, extent of community activity), avoiding contiguous boundaries. Maternal depression and physical health will be measured six months after birth, in a one year cohort of mothers, in intervention and comparison communities. The sample size to detect a 20% relative reduction in depression, adjusting for cluster sampling, and estimating a population response fraction of 67% is 5740 x 2. Analysis of the physical and mental health outcomes, by intention to treat, will adjust for the correlated structure of the data.

Less is more: meta-analyses of sensitivity and attachment interventions in early childhood

Is early preventive intervention effective in enhancing parental sensitivity and infant attachment security, and if so, what type of intervention is most successful? Seventy studies were traced, producing 88 intervention effects on sensitivity (n = 7,636) and/or attachment (n = 1,503). Randomized interventions appeared rather effective in changing insensitive parenting (d = 0.33) and infant attachment insecurity (d = 0.20). The most effective interventions used a moderate number of sessions and a clear-cut behavioral focus in families with, as well as without, multiple problems. Interventions that were more effective in enhancing parental sensitivity were also more effective in enhancing attachment security, which supports the notion of a causal role of sensitivity in shaping attachment.

Video home training as a method of supporting family life control

The purpose of this study was to describe video home training as a method of early support in problems of family life control. Answers were sought to the following questions: how does a family counsellor use video home training to support families' own resources and family life control, and what are the uses and benefits of video home training from parents' perspective? The data consisted of the videotaped counselling sessions and family service plans for five families, and were analysed using the general method of analysing photographs and video material developed by anthropologist-photographers. Video home training as a method in supporting family life control consisted of goal-orientated reflection by parents on videotaped episodes of their everyday family life under the guidance of a family counsellor. The process of videotaping family life, in-depth analysis of the videotapes, recognition of instances of successful interaction, and search for new alternatives gave participants a feeling that it would be possible for them to make their everyday life fluent and functional. The findings show that video home training helped the families to gain better control over their family life.

Pharmacotherapy of postpartum depression

The postpartum period is an exceptionally high-risk time for the occurrence of episodes of depression in women with major depressive disorder or bipolar disorder. There is accumulating evidence that major depressive disorder with postpartum onset in some patients has a bipolar diathesis. This article reviews the pharmacological treatment of postpartum depression. Although the data are limited, studies have focused exclusively on the acute and prophylactic treatment of major depressive disorder. To date, there are no studies of bipolar depression with postpartum onset. A careful assessment of maternal and infant risks and benefits is required prior to initiation of pharmacological treatment. Strategies to reduce misdiagnosis of subtle forms of bipolar disorder are discussed and suggestions are made regarding possible treatment interventions. The urgent need to conduct further studies comparing the symptom patterns, response to treatment and illness course in women with major depressive disorders and bipolar depression with postpartum onset is highlighted.

Should postpartum depression be targeted to improve child mental health?

OBJECTIVE

To evaluate whether postpartum depression (PD) is an appropriate target to prevent poor child outcomes.

METHOD

Criteria are proposed for evaluating the appropriateness of targeting PD. The target factor should (1) be a causal factor for the negative outcome, (2) have high attributable risk for the negative outcome, (3) be alterable, and (4) be easily and accurately identified through screening. The associated intervention should (5) have characteristics to facilitate dissemination, (6) have low risk for adverse impact, and (7) be acceptable to key stakeholders.

RESULTS

PD is given a mixed endorsement as an appropriate target for a prevention intervention. Positive characteristics include that PD is moderately prevalent, it is linked with poor child outcomes, it requires inexpensive screening for detection, it is alterable through treatment interventions that may be realistically disseminated, and its treatment is likely to have popular and political support. However, efforts to detect syndromal depression may be costly, strength of the link between PD and poor child outcomes is undetermined, and risks associated with the intervention have not been investigated.

CONCLUSIONS

Further study is required to assess the appropriateness of PD as a prevention target for improving child outcomes. These provisional criteria may be useful for evaluating other proposed prevention targets.