Tackling postnatal depression

2 February, 2002

Cheryll Adams, BSc (Hons), MSc, RN, RHV, DMS.

Professional Officer, Research and Practice Development, Community Practitioners' and Health Visitors' Association, London

Research confirms that maternal depression in the first year of a child's life can have significant consequences on the child's future cognitive and social development, and can also affect the stability of the family unit.

Potential outcomes of postnatal depression are:

- A breakdown in the mother's relationship with her baby, her husband and other children (Holden, 1994; Milgrom and McCloud, 1996; Murray and Cooper, 1997; Beck, 1996)

- Delays in the child's cognitive and social development (Coghill et al, 1986; Murray and Cooper, 1996; Hay et al, 2001)

- Children of mothers with postnatal depression are more likely to have behavioural problems and to be abused (Sheppard, 1994; Murray, 2000; Boath et al, 1998; Buist, 1998).

Impact of depression
The 1994-96 report Why Mothers Die (Department of Health, 1998a) found that suicide was four times more likely to occur in the nine months after childbirth than during pregnancy.

There is also research evidence (Evans et al, 2001) that antenatal depression may be as common as postnatal depression, which affects 10-15% of mothers perinatally (O'Hara and Swain, 1996). Anecdotal evidence suggests the incidence in some areas may be much higher.

Health visitors and midwives are often the first health professionals to suspect that a woman has postnatal depression, and are in an ideal position to recognise women who may be at most risk of developing the condition.

Support services
Effective identification and appropriate intervention can ameliorate the effects of postnatal depression (Murray and Cooper, 1997). However, there is no equity in the provision of training or standardised guidelines to support this area of work.

Several government reports have highlighted the need for the development of equitable, evidence-based health services (DoH, 1997; 1998b; 1999a). Furthermore, these reports highlight the key role health visitors have in promoting mental health by working through a public health, family-centred model of practice (DoH, 1998c; DoH, 1999b, DoH, 1999c).

The model is not only expected to help prevent emotional and cognitive harm to children and reduce referrals to secondary services such as child and family therapy but also, in the longer term, to have an impact on adolescent crime rates and the incidence of family breakdown (Sheppard, 1996).

The National Service Framework for Mental Health (1999a) recommends that within the primary health-care team, health visitors, with training, should use their routine contacts with new mothers to identify postnatal depression and treat its milder forms.

The framework also states: 'Primary care groups should work with primary care teams and specialist services to agree and implement assessment and management protocols across the primary care group ... protocols should be implemented for postnatal depression.'

National network
The Community Practitioners' and Health Visitors' Association (CPHVA) has established a Postnatal Depression and Maternal Mental Health Network to promote service development in this key area of its health visitor members' work.

As well as giving members the chance to share good practice, the network has been able to contribute expertise to national initiatives that are looking into this area of practice, and has held a number of educational events.

The network was formally launched on June 22 last year with a national conference held in London.

The event provided an overview of key research and practice issues for professionals who worked with mothers with depression and who wanted to update their practice. It was attended by midwives, health visitors, community psychiatric nurses, doctors and a number of representatives from voluntary organisations.

The conference proceedings have now been published as a book, to enable a wider audience to be reached. The proceedings (CPHVA, 2001) contain all the papers, as well as questions to speakers with their answers, and will prove invaluable to anyone wanting to develop and update their practice in this area.

The document is also a very helpful tool for primary care trusts, providing the research basis and a model for service development as they respond to the recommendations of the National Service Framework for Mental Health (DoH, 1999a).

- Postnatal Depression and Maternal Mental Health is available (£5 CPHVA members; £7.50 non-members) from: McMillan Scott, 6 Bourne Enterprise Centre, Wrotham Road, Borough Green, Kent TN15 8DG. Tel:01732-884023.

Beck, C. (1996) A meta-analysis of the relationship between postpartum depression and infant temperament. Nursing Research 45: 4, 225-230.

Boath, E.H., Pryce, A.J., Cox, J.L. (1998) Postnatal depression: the impact on the family. Journal of Reproductive and Infant Psychology 16: 2/3, 199-213.

Buist, A. (1998) Childhood abuse, postpartum depression and parenting difficulties: a literature review of associations. Australian and New Zealand Journal of Psychiatry 32: 3, 370-378.

Coghill, S., Caplan, H., Alexandra, H. et al. (1986) Impact of maternal postnatal depression on cognitive development of young children. British Medical Journal 292: 1165-1167.

Community Practitioners' and Health Visitors' Association. (2001) Postnatal Depression and Maternal Mental Health: A public health priority (conference proceedings). London: CPHVA.

Department of Health. (1997) The New NHS: Modern, dependable. London: The Stationery Office.

Department of Health. (1998a) Why Mothers Die: Report on confidential enquiry into maternal deaths in the United Kingdom, 1994-1996. London: The Stationery Office.

Department of Health. (1998b) A First-Class Service. London: The Stationery Office.

Department of Health. (1998c) Supporting Families. London: The Stationery Office.

Department of Health. (1999a) National Service Framework for Mental Health. London: The Stationery Office.

Department of Health. (1999b) Saving Lives: Our healthier nation. London: The Stationery Office.

Department of Health. (1999c) Making a Difference. London: The Stationery Office.

Evans, J., Heron, J., Francomb, H. et al. (2001) Cohort study of depressed mood during pregnancy and after childbirth. British Medical Journal 323: 257-260.

Hay, D.F., Pawlby, S., Sharp, D. et al. (2001) Intellectual problems shown by 11-year-old children whose mothers had postnatal depression. Journal of Child Psychology and Psychiatry 42: 7, 871-889.

Holden, J. (1994) Can non-psychotic depression be prevented? In: Cox, J., Holden, J. (eds). Perinatal Psychiatry. London: Gaskell and Royal College of Psychiatrists.

Milgrom, J., McCloud, P. (1996) Parenting stress and postnatal depression. Stress Medicine 12: 13, 177-186.

Murray, L., Cooper, P. (1996) The impact of postpartum depression on child development. International Review of Psychiatry 8: 1, 55-63.

Murray, L., Cooper, P. (1997) Postpartum Depression and Child Development. New York, NY: Guilford Press.

Murray, L. (2000) Postnatal Depression, the Mother-infant Relationship and Child Outcome. Manchester: Marce Conference Proceedings.

O'Hara, M., Swain, A. (1996) Rates of postpartum depression. International Review of Psychiatry 8: 1, 37-54.

Sheppard, M. (1996) Depression in the work of British health visitors: clinical facets. Social Science Medicine 43: 11, 1637-1648.

Sheppard, M. (1994) Postnatal depression, childcare and social support: a review of findings and their implications for practice. Social Work and Social Sciences Review 5: 1, 24-46.