Preventing and treating postnatal depression

Two linked studies assess different approaches for preventing and treating postnatal depression.1 2 This condition is a common form of maternal morbidity that affects about one in eight women from diverse cultures.3 It is also a leading cause of maternal mortality. The UK Confidential Enquiry into maternal deaths found that psychiatric disorders contributed to 12% of all maternal deaths, with suicide being identified as the leading cause of maternal mortality in the United Kingdom.4 Postnatal depression can also have serious consequences for the health and wellbeing of the family. Infants and children are particularly vulnerable—impaired maternal-infant interactions can affect their cognitive, emotional, social, and behavioural development. Clearly, postnatal depression is a substantial public health problem that requires attention.

Given the diversity in causes and severity of symptoms, researchers have evaluated various treatments. Although antidepressants are effective many women are reluctant to take medication, especially when breast feeding. A recent systematic review indicates that psychosocial and psychological interventions may provide an alternative to pharmacological treatment.5 In the linked randomised controlled trial (doi:10.1136/bmj.a3045), Morrell and colleagues assessed the importance of these non-pharmacological interventions. They found that cognitive behavioural therapy and non-directive counselling provided in the home by health visitors were effective in treating depressive symptoms at six and 12 months postpartum. This methodologically robust trial provides good evidence that health visitors can be trained to identify women with depression and offer effective treatment.

The evaluation of preventive interventions has been another high priority. The second linked study (doi:10.1136/bmj.a3064) is our multisite randomised controlled trial that evaluated the effectiveness of telephone based peer (mother to mother) support to prevent postnatal depression in high risk women. After web based screening of more than 21 000 women by public health nurses in the first two weeks after birth, 701 eligible mothers participated in the trial. Women who received the peer support intervention had half the risk of developing postnatal depression at 12 weeks postpartum than those in the control group (13.5% v 24.8%; relative risk reduction 0.46, 95% confidence interval 0.24 to 0.62; number needed to treat 8.8, 5.9 to 19.6). The results are consistent with a large systematic review, which found that interventions to prevent postnatal depression are more likely to succeed if they are individually based, initiated postnatally, and targeted at high risk women.6

These trials add to the growing evidence that postnatal depression can be effectively treated and possibly prevented. Despite this research, postnatal depression is still undetected or untreated in many women. Why is this?

Firstly, there are substantial barriers to identifying and treating postnatal depression.7 Women often lack knowledge about postnatal depression, with many denying or minimising their symptoms. Some women assume that the struggles they are experiencing are common in new mothers and are a reasonable response to adversity. Conversely, some women do recognise their depressive symptoms but are unaware of treatment options. Other women are unwilling to disclose emotional difficulties, especially depression, because of fear about being labelled mentally ill, having their children taken away, or being perceived as not fulfilling their maternal role. A systematic review found that health professionals can be barriers to care if they minimise symptoms or offer treatment that is not convenient, accessible, or timely.7 The results suggest that women and family members should be educated about postnatal depression, not only to destigmatise the condition, but also to help them identify it in themselves and seek assistance. Treatment also needs to be provided in a way that fits in with a new mother’s lifestyle. Home based and proactive telephone based programmes are convenient and accessible for new mothers. To improve adherence to treatment, it is important to ask women why they feel depressed and to match treatment with perceived cause.

Secondly, although new mothers typically encounter a variety of health professionals—midwives, doctors, nurses, and health visitors—all of whom are capable of screening for postnatal depression, coordinated multidisciplinary efforts rarely occur. Screening programmes for postnatal depression have not been widely implemented, even though they meet many of the necessary criteria for implementation, such as there being a good understanding of the condition, a validated screening test with appropriate cut-off values, and the availability of effective treatment for those who screen positive.8 All health professionals who interact with new mothers should proactively screen for postnatal depression. To enhance the accuracy of identification, health professionals need to understand the traditional postpartum rituals and practices seen in diverse cultures9 and the different cultural perceptions of depression.

Finally, the effective delivery of high quality clinical care requires a specialist multidisciplinary perinatal service provided by primary, secondary, and tertiary care.10 This perinatal service can be established in each locality to provide direct services, consultation, and advice to maternity, mental health, and community services. Clear referral and management protocols for services across all levels of a stepped care framework for depression11 are needed to ensure effective transfer of information and continuity of care.10 Care pathways with defined roles and competencies for all professional groups are also required. A systematic review found that care pathways can improve the effectiveness of treatment for depression compared with usual care for people with mild to moderate depression for up to 12 months.12 These care pathways included interdisciplinary collaboration, intensive patient education, case management, and telephone support. Only by overcoming the barriers to treatment, providing comprehensive screening programmes, and ensuring the delivery of appropriate and timely care will we effectively prevent and treat postnatal depression.