Intended for healthcare professionals


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

BMJ 2009; 338 doi: (Published 16 January 2009) Cite this as: BMJ 2009;338:a3045
  1. C Jane Morrell, senior research fellow 1,
  2. Pauline Slade, professor of clinical psychology2,
  3. Rachel Warner, consultant psychiatrist3,
  4. Graham Paley, nurse research fellow and psychotherapist4,
  5. Simon Dixon, senior lecturer in health economics1,
  6. Stephen J Walters, senior lecturer in medical statistics1,
  7. Traolach Brugha, professor of psychiatry5,
  8. Michael Barkham, director6,
  9. Gareth J Parry, assistant professor7,
  10. Jon Nicholl, director of medical care research unit1
  1. 1School of Health and Related Research (ScHARR), University of Sheffield, Sheffield S1 4DA
  2. 2Clinical Psychology Unit, Department of Psychology, University of Sheffield, Western Bank, Sheffield S10 2UR
  3. 3Adult Mental Health Services, Sheffield S11 9AR
  4. 4Leeds Mental Health Trust Specialist Psychotherapy Service, Leeds LS2 9PJ
  5. 5Department of Health Sciences, University of Leicester, Leicester General Hospital, Leicester LE5 4PW
  6. 6Centre for Psychological Services Research, Department of Psychology, University of Sheffield, Sheffield S10 2TP
  7. 7Department of Pediatrics, Harvard Medical School, Children’s Hospital Boston, 300 Longwood Avenue, MA 02115
  1. 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}
  • Accepted 14 October 2008


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.


  • We thank the women, health visitors, general practitioners, and primary care trusts for supporting the trial; the trial advisory group; Trent MREC, David Shapiro, and the training reference group; Mike Campbell and the data monitoring and ethics committee; Tom Ricketts, Keith Tudor, and Chris Williams for their training input; Robin Smith, GIS Analyst; and Mind Garden Inc for permission to use the STAI and Psychological Assessment Resources for permission to use the PSI-SF.

  • Contributors: CJM prepared the proposal, designed and supervised the conduct of the study, prepared the manuscript, and is guarantor. PS prepared the proposal, advised on design and provided supervision for the local coordinators. RW prepared the proposal and designed and advised on the conduct of the study. GP advised on design and analysed the intervention process monitoring. SD advised on design and participated in the economic analysis and the reporting. SJW provided statistical advice on the proposal at trial advisory group meetings and revised the statistical analysis plan, analysed the data, contributed to the writing. TB prepared the proposal and advised on design. MB advised on design and chaired the trial advisory group. GJP advised on design and planned the statistical analysis. JN contributed to the development of the proposal, advised on design, and assisted with the preparation of the manuscript. All contributors reviewed the manuscript.

  • Funding and sponsor: The trial was commissioned, funded, and sponsored by the NHS research and development health technology assessment programme.

  • Competing interests: None declared.

  • Ethical approval: Trent multicentre research ethics committee.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

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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