Effective treatment of postnatal depression is associated with normal child development
Authors: Louise M Howard, Fiona Challacombe
Journal: The Lancet Psychiatry (2018)

Postnatal depression is known to be one of the most common complications of child bearing, and is often associated with adverse outcomes for the woman as well as an increased risk of adverse child outcomes, including cognitive, behavioural, and emotional problems, and insecure attachment.1Catalao R Howard LM Jones I McDonald E Chapter 7: perinatal mental health.in: Annual report of the Chief Medical Officer, 2014. The health of the 51%: women. Department of Health, London2014Google Scholar Initiatives are underway internationally to improve the identification and treatment of postnatal depression and other perinatal mental disorders (ie, disorders in pregnancy and post partum), which are hoped to improve maternal and child mental health. In England, an investment of £365 million has been planned over 2016–21 by NHS England into perinatal mental health services. These new services are focused on addressing maternal mental disorders in the perinatal period, rather than parenting and mother–infant interactions, although these are key mediators of adverse child outcomes. However, some commentators have argued that parenting interventions should be integrated into treatment for postnatal depression.2Goodman SH Garber J Evidence-based interventions for depressed mothers and their young children.Child Dev. 2017; 88: 368-377Crossref PubMed Scopus (98) Google Scholar There remains inconsistent evidence on whether additional interventions to address mother–infant interactions are required to ameliorate the potential effect on child outcomes from postnatal depression.3Letourneau NL Dennis CL Cosic N Linder J The effect of perinatal depression treatment for mothers on parenting and child development: a systematic review.Depress Anxiety. 2017; 34: 928-966Crossref PubMed Scopus (83) Google Scholar The trial by Alan Stein and colleagues4Stein A Netsi E Lawrence PJ et al.Mitigating the effect of persistent postnatal depression on child outcomes through an intervention to treat depression and improve parenting: a randomised controlled trial.Lancet Psychiatry. 2018; (published online Jan 15.)http://dx.doi.org/10.1016/S2215-0366(18)30006-3Summary Full Text Full Text PDF Scopus (65) Google Scholar in this issue of The Lancet Psychiatry addressed this question by randomly allocating women with persistent postnatal depression of at least 3 months' duration to receive video-feedback therapy (VFT; an evidence-based intervention known to improve deficits in mother–infant interactions) or progressive muscle relaxation (PMR), while treating women in both groups with optimally delivered cognitive behavioural therapy (CBT). There was no added benefit of the VFT on child cognitive, language, behavioural, or attachment outcomes, which were all in the normal range, and no significant differences in parenting behaviours at 2 years, thus suggesting that the additional intervention was not necessary. The authors examined the potential moderating effect of comorbid disorders (generalised anxiety disorder [GAD] and post-traumatic stress disorder) and other key moderators but no effects were found (although this might have been due to limited statistical power). It is striking how effective the psychological intervention was in producing sustained remission from depression, even at 2 years post partum (>80%), and it seems likely that the flexible delivery of an effective intervention in women's homes by highly trained therapists was key in producing such positive outcomes. However, this type of intervention is not routinely available anywhere internationally. The trial used highly skilled, well trained, and well supervised clinical psychologists delivering a tailored intervention of long (1·5 h) sessions, with sustained input comprising weekly then fortnightly sessions, with boosters into the second postnatal year (beyond the usual perinatal period of specialist services). The CBT was perinatally tailored, involving issues such as sleep, routines, and self-care. This unique model of tapered, ongoing intervention, delivered as mothers navigated several key infant developmental stages, might have been particularly effective. The finding of good maternal and child outcomes shows that excellent results are possible in the context of high quality service provision. Home-based psychological intervention is not often available from clinical psychologists because of the expense of travel time and consequent pressure on service provision. However, women favour tailored and, crucially, accessible interventions in the perinatal period.5Millet L Taylor BL Howard LM Bick D Stanley N Johnson S Experiences of Improving Access to Psychological Therapy services for perinatal mental health difficulties: a qualitative study of women's and therapist's views.Behav Cogn Psychother. 2017; 30: 1-16Crossref Scopus (20) Google Scholar There are important caveats to highlight before drawing firm conclusions from this study. The women in this trial were of relatively high income, around half had a university degree, many self-referred, and they were highly adherent to therapy with almost all attending at least nine sessions; these women are therefore not representative of the general population of women with persistent postnatal depression. Although ongoing for a minimum of 3 postnatal months, it is unclear how long the woman's current episode of depression was and whether it had started in pregnancy; antenatal depression also confers increased risks on children.6O'Donnell KJ Glover V Barker ED O'Connor TG The persisting effect of maternal mood in pregnancy on childhood psychopathology.Dev Psychopathol. 2014; 26: 393-403Crossref PubMed Scopus (260) Google Scholar The high levels of maternal education might have also buffered some of the known effects of depression on children.7Pearson RM Evans J Kounali D et al.Maternal depression during pregnancy and the postnatal period: risks and possible mechanisms for offspring depression at age 18 years.JAMA Psychiatry. 2013; 70: 1312-1319Crossref PubMed Scopus (398) Google Scholar The authors suggest that both additional interventions could have influenced parenting interactions, and it is noticeable that the levels of GAD were higher in the VFT group (40%) than in the PMR group (26%), although the study did not find evidence of significant moderation effects by the presence of comorbid GAD for any of the primary outcomes. The tailored CBT itself might also have indirectly influenced parenting and child outcomes by targeting processes such as maternal avoidance. Thus, the trial leaves us unclear as to whether an additional parenting intervention is indicated for some mothers with postnatal depression (or other perinatal mental disorders), even when their disorder is in remission. Robust means of identifying these women within the first postnatal year are needed alongside a better understanding of whether and for whom parenting interventions are required in addition to effective treatment of maternal symptoms. Important moderators should be examined in future trials, including not only comorbid anxiety disorders but also factors such as maternal personality dysfunction, which is known to be associated with poor childhood mental health independent of depression,8Pearson RM Campbell A Howard LM et al.Impact of dysfunctional maternal personality traits on risk of offspring mental health problems at age 18 years: a population-based longitudinal study.Psychol Med. 2017; 6: 1-11Google Scholar and poverty, which is a key moderator.9Stein A Pearson RM Goodman SH et al.Impact of perinatal mental disorders on the foetus and child.Lancet. 2014; 384: 1800-1819Summary Full Text Full Text PDF PubMed Scopus (1145) Google Scholar Nevertheless, it is encouraging that high intensity and high quality psychological treatment can be so effective for mothers with postnatal depression and, as a result, is associated with normal infant development. LMH was the chair of the NICE guideline development group for CG192 (Antenatal and Postnatal Mental Health) and has collaborated with some of the authors of the paper linked to this Comment, including co-editing The Lancet Perinatal Mental Health Series with Alan Stein. FC worked with Alan Stein on a maternal eating disorders trial in 2000–02. LMH and FC are both supported through an NIHR Research Professorship to LMH (NIHR-RP-R3-12-011). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research, or the Department of Health. Mitigating the effect of persistent postnatal depression on child outcomes through an intervention to treat depression and improve parenting: a randomised controlled trialThe effect of persistent postnatal depression on children is a major public health issue. For both treatment groups there was sustained remission from depression, and child development outcomes were in the normal range. The precise mechanisms accounting for the observed positive child outcomes cannot be ascertained from this study. Full-Text PDF Open Access