Cost-effectiveness of a preventive counseling and support package for postnatal depression

Objectives: This study reports the cost-effectiveness of a preventive intervention, consisting of counseling and specific support for the mother-infant relationship, targeted at women at high risk of developing postnatal depression. Methods: A prospective economic evaluation was conducted alongside a pragmatic randomized controlled trial in which women considered at high risk of developing postnatal depression were allocated randomly to the preventive intervention (n = 74) or to routine primary care (n = 77). The primary outcome measure was the duration of postnatal depression experienced during the first 18 months postpartum. Data on health and social care use by women and their infants up to 18 months postpartum were collected, using a combination of prospective diaries and face-to-face interviews, and then were combined with unit costs ( pound, year 2000 prices) to obtain a net cost per mother-infant dyad. The nonparametric bootstrap method was used to present cost-effectiveness acceptability curves and net benefit statistics at alternative willingness to pay thresholds held by decision makers for preventing 1 month of postnatal depression. Results: Women in the preventive intervention group were depressed for an average of 2.21 months (9.57 weeks) during the study period, whereas women in the routine primary care group were depressed for an average of 2.70 months (11.71 weeks). The mean health and social care costs were estimated at 2,396.9 pound per mother-infant dyad in the preventive intervention group and 2,277.5 pound per mother-infant dyad in the routine primary care group, providing a mean cost difference of 119.5 pound (bootstrap 95 percent confidence interval [Cl], -535.4, 784.9). At a willingness to pay threshold of 1,000 pound per month of postnatal depression avoided, the probability that the preventive intervention is cost-effective is .71 and the mean net benefit is 383.4 pound (bootstrap 95 percent Cl, -863.3- pound 1,581.5) pound. Conclusions: The preventive intervention is likely to be cost-effective even at relatively low willingness to pay thresholds for preventing 1 month of postnatal depression during the first 18 months postpartum. Given the negative impact of postnatal depression on later child development, further research is required that investigates the longer-term cost-effectiveness of the preventive intervention in high risk women.

Self-exclusion from health care in women at high risk for postpartum depression

Background A significant proportion of women who are vulnerable to postnatal depression refuse to engage in treatment programmes. Little is known about them, other than some general demographic characteristics. In particular, their access to health care and their own and their infants' health outcomes are uncharted. Methods We conducted a nested cohort case-control study, using data from computerized health systems, and general practitioner (GP) and maternity records, to identify the characteristics, health service contacts, and maternal and infant health outcomes for primiparous antenatal clinic attenders at high risk for postnatal depression who either refused (self-exclusion group) or else agreed (take-up group) to receive additional Health Visiting support in pregnancy and the first 2 months postpartum. Results Women excluding themselves from Health Visitor support were younger and less highly educated than women willing to take up the support. They were less likely to attend midwifery, GP and routine Health Visitor appointments, but were more likely to book in late and to attend accident and emergency department (A&E). Their infants had poorer outcome in terms of gestation, birthweight and breastfeeding. Differences between the groups still obtained when age and education were taken into account for midwifery contacts, A&E attendance and gestation;the difference in the initiation of breast feeding was attenuated, but not wholly explained, by age and education. Conclusion A subgroup of psychologically vulnerable childbearing women are at particular risk for poor access to health care and adverse infant outcome. Barriers to take-up of services need to be understood in order better to deliver care.

Socioemotional development in adolescents at risk for depression: the role of maternal depression and attachment style

We examined the impact on adolescent socioemotional functioning of maternal postnatal depression (PND) and attachment style. We also investigated the role of earlier aspects of the child's development-attachment in infancy, and 5-year representations of family relationships. Ninety-one mother-child pairs, recruited in the postnatal period, were followed tip at 13 years. Adolescents were interviewed about their friendships, and their level of emotional sensitivity and maturity were rated. Emotional sensitivity was heightened in girls whose mothers experienced PND; notably, its occurrence was also linked to insecure attachment in infancy and raised awareness of emotional components of family relationships at 5 years. High emotional sensitivity was also associated with adolescent depressed mood. Raised social maturity was predicted by a secure maternal attachment style and, for girls, by exposure to maternal PND. Precursors of adolescent social maturity were evident in the narrative coherence of 5-year family representations. Higher social maturity in the friendship interview was also associated with overall good adjustment.

Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression 2. Impact on the mother-child relationship and child outcome

Background: Postnatal depression is associated with adverse child cognitive and socio-emotional outcome. It is not known whether psychological treatment affects the quality of the mother-child relationship and child outcome. Aims: To evaluate the effect of three psychological treatments on the mother-child relationship and child outcome. Method: Women with post-partum depression (n=193) were assigned randomly to routine primary care, non-directive counselling, cognitive-behavioural therapy or psychodynamic therapy The women and their children, were assessed at 43, [8 and 60 months post-partum. Results: Indications of a positive benefit were limited. All three treatments had a significant benefit on maternal reports of early difficulties in relationships with the infants, counselling gave better infant emotional and behaviour ratings at 18 months and more sensitive early mother-infant interactions. The treatments had no significant impact on maternal management of early infant behaviour problems, security of infant-mother attachment. Infant cognitive development or any child outcome at 5 years. Conclusions: Early intervention was of short-term benefit to the mother-child relationship and infant behaviour problems. More-prolonged intervention may be needed. Health visitors could deliver this.

The effects of maternal depression and parental conflict on children's peer play

Background Little is known about the relative effects of exposure to postnatal depression and parental conflict on the social functioning of school-aged children. This is, in part, because of a lack of specificity in the measurement of child and parental behaviour and a reliance on children's reports of their hypothetical responses to conflict in play. Methods In the course of a prospective longitudinal study of children of postnatally depressed and well women, 5-year-old children were videotaped at home with a friend in a naturalistic dressing-up play setting. As well as examining possible associations between the occurrence of postnatal depression and the quality of the children's interactions, we investigated the influence of parental conflict and co-operation, and the continuity of maternal depression. The quality of the current mother-child relationship was considered as a possible mediating factor. Results Exposure to postnatal depression was associated with increased likelihood, among boys, of displaying physical aggression in play with their friend. However, parental conflict mediated the effects of postnatal depression on active aggression during play, and was also associated with displays of autonomy and intense conflict. While there were no gender effects in terms of the degree or intensity of aggressive behaviours, girls were more likely to express aggression verbally using denigration and gloating whereas boys were more likely to display physical aggression via interpersonal and object struggles. Conclusions The study provided evidence for the specificity of effects, with strong links between parental and child peer conflict. These effects appear to arise from direct exposure to parental conflict, rather than indirectly, through mother-child interactions.

The dynamics of threat, fear and intentionality in the conduct disorders: longitudinal findings in the children of women with post-natal depression

This paper considers how environmental threat may contribute to the child's use of avoidant strategies to regulate negative emotions, and how this may interact with high emotional reactivity to create vulnerability to conduct disorder symptoms. We report a study based on the hypothesis that interpreting others' behaviours in terms of their motives and emotions - using the intentional stance - promotes effective social action, but may lead to fear in threatful situations, and that inhibiting the intentional stance may reduce fear but promote conduct disorder symptoms. We assessed 5-year-olds' use of the intentional stance with an intentionality scale, contrasting high and low threat doll play scenarios. In a sample of 47 children of mothers with post-natal depression ( PND) and 35 controls, children rated as securely attached with their mothers at the age of 18 months were better able to preserve the intentional stance than insecure children in high threat scenarios, but not in low threat scenarios. Girls had higher intentionality scores than boys across all scenarios. Only intentionality in the high threat scenario was associated with teacher-rated conduct disorder symptoms, and only in the children of women with PND. Intentionality mediated the associations between attachment security and gender and conduct disorder symptoms in the PND group.

Maternal depression and psychiatric outcomes in adolescent offspring: a13-year longitudinal study

Background: Maternal postnatal depression (PND) has been associated with adverse outcomes in young children, but an association with longer-term psychiatric disorder has not been demonstrated. We present the preliminary findings of a 13-year longitudinal study. Methods: In the course of a prospective longitudinal study, we examined DSM-IV Axis I disorders in 13-year-old adolescents who had (n=53) or had not (n=41) been exposed to maternal PND. We also detailed the occurrence of depression in mothers throughout the 13-year follow-up period. Results: Maternal PND was associated with higher rates of affective disorders in adolescent offspring. However, mothers who developed PND were also substantially more likely than those who did not to experience depression subsequently, a fact that contributed to the development of depressive disorder in offspring. Maternal PND was associated with increased risk for depression in adolescent offspring only if there had also been later episodes of maternal depression. In contrast, anxiety disorders in offspring were elevated in the maternal PND group regardless of the occurrence of subsequent maternal depression. Limitations: Due to the modest sample size and consequently limited power, findings must be regarded as preliminary. Conclusions: The particular association between early maternal depression and anxiety disorders in offspring was consistent with theories that emphasise the primacy of early environmental exposures. This position was not supported with respect to offspring depressive disorder, where overall duration of maternal depression was a significant factor. PND was associated with recurrent episodes of depression in the majority of cases, underlining the need for monitoring of this population beyond the postnatal period. (c) 2006 Elsevier B.V. All rights reserved.

Exposure to postnatal depression predicts elevated cortisol in adolescent offspring

Background. Animal research shows that early adverse experience results in altered glucocorticoid levels in adulthood, either raised basal levels or accentuated responses to stress. If a similar phenomenon operates in humans, this suggests a biological mechanism whereby early adversity might transmit risk for major depression, glucocorticoid elevations being associated with the development of this disorder. Methods. We measured salivary cortisol at 8:00 Am and 8:00 Pm over 10 days in 13-year-old adolescents who had (n = 48) or bad not (n = 39) been exposed to postnatal maternal depression. Results: Maternal postnatal depression was associated with higher, more variable morning cortisol in offspring, a pattern previously found to predict major depression. Conclusions. Early adverse experiences might alter later steroid levels in humans. Because maternal depression confers added risk for depression to children, these alterations might provide a link between early events and later psychopathology.

Disturbances in morning cortisol secretion in association with maternal postnatal depression predict subsequent depressive symptomatology in adolescents

Background: We have previously reported higher and more variable salivary morning cortisol in 13-year-old adolescents whose mothers were depressed in the postnatal period, compared with control group adolescents whose mothers did not develop postnatal depression (PND). This observation suggested a biological mechanism by which intrafamilial risk for depressive disorder may be transmitted. In the current article, we examined whether the cortisol disturbances observed at 13 years could predict depressive symptornatology in adolescents at 16 years of age. Methods: We measured self-reported depressive symptoms in 16-year-old adolescents who had (n = 48) or had not (n = 39) been exposed to postnatal maternal depression and examined their prediction by morning and evening cortisol indices obtained via 10 days of salivary collections at 13 years. Results: Elevated morning cortisol secretion at 13 years, and particularly the maximum level recorded over 10 days of collection, predicted elevated depressive symptoms at 16 years over and above 13-year depressive symptom levels and other possible confounding factors. Morning cortisol secretion mediated an association between maternal PND and symptornatology in 16-year-old offspring. Conclusions: Alterations in steroid secretion observed in association with maternal PND may provide a mechanism by which risk for depression is transmitted from mother to offspring.

Depression, confidence, and decision: evidence against depressive realism

This research examined how retrospective self-assessments of performance are affected by major depression. To test the validity of the depressive realism versus the selective processing hypotheses, aggregate posttest performance estimates (PTPEs) were obtained from clinically depressed patients and an age-matched comparison group across 4 decision tasks (object recognition, general knowledge, social judgment, and line-length judgment). As expected on the basis of previous findings, both groups were underconfident in their PTPEs, consistently underestimating the percentage of questions they had answered correctly. Contrary to depressive realism, and in partial support of the selective processing account, this underconfidence effect was not reduced but modestly exacerbated in the depressed patients. Further, whereas the PTPEs of the comparison group exceeded that expected on the basis of chance alone those of the depressed individuals did not. The results provide no support for the depressive realism account and suggest that negative biases contribute to metacognitive information processing in major depression.

The factor structure of the Edinburgh postnatal depression scale in a South African peri-urban settlement

The factor structure of the Edinburgh Postnatal Depression scale (EPDS) and similar instruments have received little attention in the literature. The researchers set out to investigate the construct validity and reliability of the EPDS amongst impoverished South African women. The EPDS was translated into isiXhosa (using Brislin's back translation method) and administered by trained interviewers to 147 women in Khayelitsha, South Africa. Responses were subjected to maximum likelihood confirmatory factor analysis. A single factor structure was found, consistent with the theory on which the EPDS was based. Internal consistency was satisfactory (a = 0.89).

Mothers' attributions following their child's diagnosis of autistic spectrum disorder: exploring links with maternal levels of stress, depression and expectations about their child's future

Although the impact of autism spectrum disorders (ASDs) on the family is well recognized, the way mothers attempt to make sense of the diagnosis is largely unexplored. However, in other disabilities, attributions have been shown to predict a variety of outcomes including maternal wellbeing and engagement in treatment. Using Weiner's (198S) three-dimensional model, 16 mothers were interviewed to examine the nature and impact of their beliefs about their child's ASD using semi-structured interviews and measures of depression, parenting stress and expectations for their child's future. The findings suggested that mothers made a diverse and complex range of attributions that were consistent with Weiner's dimensions of locus of cause, stability and controllability. The nature of their attributions reflected particular difficulties associated with ASDs, such as uncertainties regarding cause and prognosis. Taking account of mothers' search for meaning will better enable professionals to support families following diagnosis.

Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression - 1. Impact on maternal mood!

Background: Psychological interventions for postnatal depression can be beneficial in the short term but their longer-term impact is unknown, Aims To evaluate the long-term effect on maternal mood of three psychological treatments in relation to routine primary care. Method: Women with post-partum depression (n=193)were assigned randomly to one of four conditions: routine primary care, non-directive counselling, cognitive-behavioural therapy or psychodynamic therapy. They were assessed immediately after the treatment phase (at 4.5 months) and at 18 and 60 months post-partum. Results: Compared with the control, ail three treatments had a significant impact at 4.5 months on maternal mood (Edinburgh Postnatal Depression Scale, EPDS). Only psychodynamic therapy produced a rate of reduction in depression (Structured Clinical interview for DSM III-R) significantly superior to that of the control. The benefit of treatment was no longer apparent by 9 months postpartum, treatment did not reduce subsequent episodes of post-partum depression. Conclusions: Psychological intervention for post-partum depression improves maternal mood (EPDS) in the short term. However, this benefit is not superior to spontaneous remission in the long term.