Published 15 January 2009, doi:10.1136/bmj.a3045
Cite this as: BMJ 2009;338:a3045

Research

Clinical effectiveness of health visitor training in psychologically informed approaches for depression in postnatal women: pragmatic cluster randomised trial in primary care

C Jane Morrell, senior research fellow 1, Pauline Slade, professor of clinical psychology2, Rachel Warner, consultant psychiatrist3, Graham Paley, nurse research fellow and psychotherapist4, Simon Dixon, senior lecturer in health economics1, Stephen J Walters, senior lecturer in medical statistics1, Traolach Brugha, professor of psychiatry5, Michael Barkham, director6, Gareth J Parry, assistant professor7, Jon Nicholl, director of medical care research unit1

1 School of Health and Related Research (ScHARR), University of Sheffield, Sheffield S1 4DA, 2 Clinical Psychology Unit, Department of Psychology, University of Sheffield, Western Bank, Sheffield S10 2UR, 3 Adult Mental Health Services, Sheffield S11 9AR, 4 Leeds Mental Health Trust Specialist Psychotherapy Service, Leeds LS2 9PJ, 5 Department of Health Sciences, University of Leicester, Leicester General Hospital, Leicester LE5 4PW, 6 Centre for Psychological Services Research, Department of Psychology, University of Sheffield, Sheffield S10 2TP, 7 Department of Pediatrics, Harvard Medical School, Children’s Hospital Boston, 300 Longwood Avenue, MA 02115

Correspondence to: C J Morrell, Centre for Health and Social Care Research, Human and Health Sciences, University of Huddersfield, Queensgate, Huddersfield HD1 3DH j.morrell{at}hud.ac.uk

Objective To evaluate benefits for postnatal women of two psychologically informed interventions by health visitors.

Design Prospective cluster trial randomised by general practice, with 18 month follow-up.

Setting 101 general practices in Trent, England.

Participants 2749 women allocated to intervention, 1335 to control.

Intervention Health visitors (n=89 63 clusters) were trained to identify depressive symptoms at six to eight weeks postnatally using the Edinburgh postnatal depression scale (EPDS) and clinical assessment and also trained in providing psychologically informed sessions based on cognitive behavioural or person centred principles for an hour a week for eight weeks. Health visitors in the control group (n=49 38 clusters) provided usual care.

Main outcome measures Score ≥12 on the Edinburgh postnatal depression scale at six months. Secondary outcomes were mean Edinburgh postnatal depression scale, clinical outcomes in routine evaluation-outcome measure (CORE-OM), state-trait anxiety inventory (STAI), SF-12, and parenting stress index short form (PSI-SF) scores at six, 12, 18 months.

Results 4084 eligible women consented and 595 women had a six week EPDS score ≥12. Of these, 418 had EPDS scores available at six weeks and six months. At six months, 34% women (93/271) in the intervention group and 46% (67/147) in the control group had an EPDS score ≥12. The odds ratio for score ≥12 at six months was 0.62 (95% confidence interval 0.40 to 0.97, P=0.036) for women in the intervention group compared with women in the control group. After adjustment for covariates, the odds ratio was 0.60 (0.38 to 0.95, P=0.028). At six months, 12.4% (234/1880) of all women in the intervention group and 16.7% (166/995) of all women in the control group had scores ≥12 (0.67, 0.51 to 0.87, P=0.003). Benefit for women in the intervention group with a six week EPDS score ≥12 and for all women was maintained at 12 months postnatally. There was no differential benefit for either psychological approach over the other.

Conclusion Training health visitors to assess women, identify symptoms of postnatal depression, and deliver psychologically informed sessions was clinically effective at six and 12 months postnatally compared with usual care.

Trial registration ISRCTN92195776 [controlled-trials.com] .

© Morrell et al 2009
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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