Improving infant sleep and maternal mental health: a cluster randomised trial

Objectives: To determine whether a community-delivered intervention targeting infant sleep problems improves infant sleep and maternal well-being and to report the costs of this approach to the healthcare system.

Design: Cluster randomised trial.

Setting: 49 Maternal and Child Health (MCH) centres (clusters) in Melbourne, Australia.

Participants: 328 mothers reporting an infant sleep problem at 7 months recruited during October–November 2003.

Intervention: Behavioural strategies delivered over individual structured MCH consultations versus usual care.

Main outcome measures: Maternal report of infant sleep problem, depression symptoms (Edinburgh Postnatal Depression Scale (EPDS)), and SF-12 mental and physical health scores when infants were 10 and 12 months old. Costs included MCH sleep consultations, other healthcare services and intervention costs.

Results: Prevalence of infant sleep problems was lower in the intervention than control group at 10 months (56% vs 68%; adjusted OR 0.58 (95% CI: 0.36 to 0.94)) and 12 months (39% vs 55%; adjusted OR 0.50 (0.31 to 0.80)). EPDS scores indicated less depression at 10 months (adjusted mean difference –1.4 (–2.3 to –0.4) and 12 months (–1.7 (–2.6 to –0.7)). SF-12 mental health scores indicated better health at 10 months (adjusted mean difference 3.7 (1.5 to 5.8)) and 12 months (3.9 (1.8 to 6.1)). Total mean costs including intervention design, delivery and use of non-MCH nurse services were £96.93 and £116.79 per intervention and control family, respectively.

Conclusions: Implementing this sleep intervention may lead to health gains for infants and mothers and resource savings for the healthcare system.

The influence of maternal mental health, attachment and hormonal factors on a mother’s attachment to her fetus during pregnancy

 The thesis investigated the role of maternal mental health, maternal attachment and hormones in the development of maternal-fetal attachment during pregnancy. The study found that oxytocin and cortisol were associated with maternal-fetal attachment throughout pregnancy. The study also found that maternal mental health, particularly anxiety, stress and depression during the prenatal period impacted on the development of maternal-fetal attachment across pregnancy. The findings have clinical and research implications with regard to early intervention for attachment and maternal well-being.

Predictors of postnatal mother-infant bonding: the role of antenatal bonding, maternal substance use and mental health

The emotional bond that a mother feels towards her baby is critical to social, emotional and cognitive development. Maternal health and wellbeing through pregnancy and antenatal bonding also play a key role in determining bonding postnatally, but the extent to which these relationships may be disrupted by poor mental health or substance use is unclear. This study aimed to examine the extent to which mother-fetal bonding, substance use and mental health through pregnancy predicted postnatal mother-infant bonding at 8 weeks. Participants were 372 women recruited from three metropolitan hospitals in Australia. Data was collected during trimesters one, two and three of pregnancy and 8 weeks postnatal using the Maternal Antenatal Attachment Scale (MAAS), Maternal Postnatal Attachment Scale (MPAS), the Edinburgh Antenatal and Postnatal Depression Scale (EPDS), the Depression and Anxiety Scales (DASS-21), frequency and quantity of substance use (caffeine, alcohol and tobacco) as well as a range of demographic and postnatal information. Higher antenatal bonding predicted higher postnatal bonding at all pregnancy time-points in a fully adjusted regression model. Maternal depressive symptoms in trimesters two and three and stress in trimester two were inversely related to poorer mother-infant bonding 8 weeks postnatally. This study extends previous work on the mother’s felt bond to her developing child by drawing on a large sample of women and documenting the pattern of this bond at three time points in pregnancy and at 8 weeks postnatally. Utilising multiple antenatal waves allowed precision in isolating the relationships in pregnancy and at key intervention points. Investigating methods to enhance bonding and intervene in pregnancy is needed. It is also important to assess maternal mental health through pregnancy.

The association between diet quality and mental health during the perinatal period. A systematic review

BACKGROUND: While maternal nutrition during pregnancy is known to play a critical role in the health of both mother and offspring, the magnitude of this association has only recently been realized. Novel, epigenetic data suggest that maternal dietary intake has permanent phenotypic consequences for offspring, highlighting the potency of antenatal diet. To date, the relationship between poor antenatal diet and maternal mental health specifically, remains poorly understood. Therefore, we aimed to systematically review evidence that has examined associations between antenatal diet quality and the experience of depressive, anxiety and stress symptoms during the perinatal period.

METHODS: A search for peer-reviewed papers was conducted using Medline Complete, PsycINFO, CINAHL, Academic Search Premiere and Psychology and Behavioral Science Collection.

RESULTS: Nine studies (cohort = 4, cross-sectional = 5) published between 2005 and 2013 were eligible for inclusion in this review. A synthesis of findings revealed positive associations between poor quality and unhealthy diets and antenatal depressive and stress symptoms. Healthy diets were inversely associated with antenatal depressive and anxiety symptoms. Postnatal depressive symptoms demonstrated inconsistent results.

CONCLUSIONS: Given the paucity of research examining diet quality and mental health in women during the perinatal period, further sufficiently powered studies are urgently required to examine this association.

Maternal mental well-being during pregnancy and glucocorticoid receptor gene promoter methylation in the neonate

Maternal mental health during pregnancy has been linked to health outcomes in progeny. Mounting evidence implicates fetal “programming” in this process, possibly via epigenetic disruption. Maternal mental health has been associated with glucocorticoid receptor methylation (nuclear receptor subfamily 3, group C, member 1 [NR3C1]) in the neonate; however, most studies have been small (n < 100) and have failed to control for multiple testing in the statistical analysis. The Barwon Infant Study is a population-derived birth cohort with antenatal recruitment. Maternal depression and anxiety were assessed using the Edinburgh Postnatal Depression Scale and psychological distress using the Perceived Stress Scale. NR3C1 cord blood methylation levels were determined using Sequenom MassArray for 481 participants. Maternal psychological distress and anxiety were associated with a small increase in neonate NR3C1 methylation at specific CpG sites, thus replicating some previous findings. However, associations were only nominally significant and did not remain after correction for the number of CpG sites and exposures investigated. As the largest study to explore the relationship between maternal well-being and offspring NR3C1 cord blood methylation, our results highlight the need for caution when interpreting previous findings in this area. Future studies must ensure they are adequately powered to detect the likely small effect sizes while controlling for multiple testing.

Maternal and early postnatal nutrition and mental health of offspring by age 5 years: a prospective cohort study clinical guidance

Objective
Diet quality is related to the risk for depression and anxiety in adults and adolescents; however, the possible impact of maternal and early postnatal nutritional exposures on children’s subsequent mental health is unexplored.

Method
The large prospective Norwegian Mother and Child Cohort Study recruited pregnant women between 1999 and 2008. Data were collected from mothers during pregnancy and when children were 6 months and 1.5, 3, and 5 years of age. Latent growth curve models were used to model linear development in children’s internalizing and externalizing problems from 1.5 to 5 years of age as a function of diet quality during pregnancy and at 1.5 and 3 years. Diet quality was evaluated by dietary pattern extraction and characterized as “healthy” or “unhealthy.” The sample comprised 23,020 eligible women and their children. Adjustments were made for variables including sex of the child, maternal depression, maternal and paternal age, maternal educational attainment, household income, maternal smoking before and during pregnancy, mothers’ parental locus of control, and marital status.

Results
Higher intakes of unhealthy foods during pregnancy predicted externalizing problems among children, independently of other potential confounding factors and childhood diet. Children with a high level of unhealthy diet postnatally had higher levels of both internalizing and externalizing problems. Moreover, children with a low level of postnatal healthy diet also had higher levels of both internalizing and externalizing problems.

Conclusion
Among this large cohort of mothers and children, early nutritional exposures were independently related to the risk for behavioral and emotional problems in children.

Maternal prenatal mental health and placental 11β-HSD2 gene expression: initial findings from the mercy pregnancy and emotional wellbeing study

High intrauterine cortisol exposure can inhibit fetal growth and have programming effects for the child's subsequent stress reactivity. Placental 11beta-hydroxysteroid dehydrogenase (11β-HSD2) limits the amount of maternal cortisol transferred to the fetus. However, the relationship between maternal psychopathology and 11β-HSD2 remains poorly defined. This study examined the effect of maternal depressive disorder, antidepressant use and symptoms of depression and anxiety in pregnancy on placental 11β-HSD2 gene (HSD11B2) expression. Drawing on data from the Mercy Pregnancy and Emotional Wellbeing Study, placental HSD11B2 expression was compared among 33 pregnant women, who were selected based on membership of three groups; depressed (untreated), taking antidepressants and controls. Furthermore, associations between placental HSD11B2 and scores on the State-Trait Anxiety Inventory (STAI) and Edinburgh Postnatal Depression Scale (EPDS) during 12-18 and 28-34 weeks gestation were examined. Findings revealed negative correlations between HSD11B2 and both the EPDS and STAI (r = -0.11 to -0.28), with associations being particularly prominent during late gestation. Depressed and antidepressant exposed groups also displayed markedly lower placental HSD11B2 expression levels than controls. These findings suggest that maternal depression and anxiety may impact on fetal programming by down-regulating HSD11B2, and antidepressant treatment alone is unlikely to protect against this effect.

Young maternal age at first birth and mental health later in life: does the association vary by birth cohort?

BACKGROUND: It is well established that maternal age at childbirth has implications for women's mental health in the short term, however there has been little research regarding longer term implications and whether this association has changed over time. We investigated longer term mental health consequences for young mothers in Australia and contrasted the effects between three birth cohorts. METHODS: Using thirteen waves of data from 4262 women aged 40 years or above participating in the Household, Income and Labour Dynamics in Australia Survey, we compared the mental health of women who had their first child aged 15-19 years, 20-24 years, and 25 years and older. Mental health was measured using the mental health component summary score of the SF-36. We used random-effects linear regression models to generate estimates of the association between age at first birth and mental health, adjusted for early life socioeconomic characteristics (country of birth, parents' employment status and occupation) and later life socioeconomic characteristics (education, employment, income, housing tenure, relationship status and social support). We examined whether the association changed over time, testing for effect modification across three successive birth cohorts. RESULTS: In models adjusted for early life and later life socioeconomic characteristics, there was strong evidence of an association between teenage births and poor mental health, with mental health scores on average 2.76 to 3.96 points lower for mothers aged younger than 20 years than for mothers aged 25 years and older (Late Baby Boom (born 1936-1945): -3.96, 95% CI -5.38, -2.54; Early Baby Boom (born 1946-1955): -3.01, 95% CI -4.32, -1.69; Lucky Few (born 1956-1965): -2.76, 95% CI -4.34, -1.18), and evidence of an association for mothers aged 20-24 years compared to mothers aged 25 years and older in the most recent birth cohort only (-1.09, 95% CI -2.01, -0.17). There was some indication (though weak) that the association increased in more recent cohorts. CONCLUSION: This study highlights that young mothers, and particularly teenage mothers, are a vulnerable group at high risk of poor mental health outcomes compared to mothers aged 25 years and above, and there was some suggestion (though weak) that the health disparities increased over time.

Preventing mental health problems in children : the families in mind population-based cluster randomised controlled trial.

Background

Externalising and internalising problems affect one in seven school-aged children and are the single strongest predictor of mental health problems into early adolescence. As the burden of mental health problems persists globally, childhood prevention of mental health problems is paramount. Prevention can be offered to all children (universal) or to children at risk of developing mental health problems (targeted). The relative effectiveness and costs of a targeted only versus combined universal and targeted approach are unknown. This study aims to the effectiveness, costs and uptake of two approaches to early childhood prevention of mental health problems ie: a Combined universal-targeted approach, versus a Targeted only approach, in comparison to current primary care services (Usual care).
Design

Three armed, population-level cluster randomised trial (2010-2014) within the universal, well child Maternal Child Health system, attended by more than 80% of families in Victoria, Australia at infant age eight months. Participants: Families of eight month old children from nine participating local government areas. Randomised to one of three groups: Combined, Targeted or Usual care. Intervention: (a) the Combined universal and targeted program where all families are offered the universal Toddlers Without Tears group parenting program followed by the targeted Family Check-Up one-on-one program or (b) the Targeted Family Check-Up program. The Family Check-Up program is only offered to children at risk of behavioural problems. Analysis: Participants will be analysed according to the trial arm to which they were randomised, using logistic and linear regression models to compare primary and secondary outcomes. An economic evaluation (cost consequences analysis) will compare incremental costs to all incremental outcomes from a societal perspective.
Discussion

This trial will inform public health policy by making recommendations about the effectiveness and cost-effectiveness of these early prevention programs. If effective prevention programs can be implemented at the population level, the growing burden of mental health problems could be curbed.

Preventing mental health problems in offspring by targeting dietary intake of pregnant women

The concept of 'early life programming' considers the importance of very early environmental exposures throughout the gestational period on the subsequent health outcomes of offspring. The role of maternal dietary intake, specifically, has been highlighted after recent studies have shown maternal diet quality to predict mental health problems in offspring. Even in the pre-conception period, maternal nutrition can have permanent and sustained phenotypic consequences for offspring.

`This was a great project!`: reflections on a `successful` mental health promotion project in a remote Indigenous school

Issue addressed: The complexities encountered in an Indigenous community when a white project support team assisted a school (Bwgcolman on Palm Island, Queensland) to implement MindMatters, a centralised, national project aiming to promote the psychosocial health of young Australians through the development of a comprehensive, school- based mental health promotion program. Approach: The MindMatters consortium offered pilot schools curriculum materials, professional development for staff, funding and ongoing support at a local level in return for their participation in the project. The support team flew to the island on two occasions to provide support. Conclusion: Whether or not MindMatters constituted a community project at Bwgcolman is debatable. Nevertheless, the project at Bwgcolman was considered a 'success' by key players since initial aims identified by the school were tangible (eg, professional development, curriculum development) and met in a way that the school could take ownership of. Additionally, behavioural management policy was implemented in a manner that was cognisant of a history of coercive relations with Indigenous communities. So what?: It is important in the telling of the success story at Bwgcolman that even though MindMatters endeavoured to be culturally sensitive, it was nevertheless a centralist mental health promotion program. Future mental health promotion initiatives need to be aware that the approach of the support team in attempting to hand back some community control at the local level may have played a role in the school succeeding.

Towards critical social work practice in mental health: a review

Progressive social work perspectives that draw on both critical theories and postmodern thought, provide highly relevant and appropriate frameworks to inform social work practice in the mental health field. Despite this, the literature overviewed indicates that the majority of social work practice conducted in mental health settings reflects an uncritical embrace of the medical model of psychiatric illness, and therefore largely neglects social work approaches which utilize critical principles. The following article explores the possibilities for applying a critical model of social work practice to the mental health field, and argues the necessity for social workers to actively engage with critical practice, even in medically dominated settings, to effectively work towards the espoused social justice ethics and mission of the social work profession.

The impact of caring on caregivers' mental health : a review of the literature

This paper provides a brief overview of the literature on the impact of caring on the mental health of informal caregivers in the areas of aged care, disability and mental health. Factors discussed that may impact on caregivers' mental health include the relationship between the caregiver and care recipient, the nature of the care recipient's disability and the stage of the caregiving process. Several moderators of the impact of caring on mental health are described, including socio-economic factors, social support and coping strategies. This information provides a context within which to examine the type of interventions appropriate to assist caregivers in various situations.