The nature and scale of the problem
Depression is a mental disorder characterised by low mood, loss of interest or enjoyment, and reduced energy, leading to increased fatigue, reduced activity, and marked functional impairment (WHO, 1990). Other common symptoms are reduced concentration, reduced self-esteem, ideas of guilt or unworthiness, pessimistic views of the future, ideas or acts of self-harm or suicide, disturbed sleep, disturbed appetite and irritability. Depression is more severe than everyday fluctuations in mood, and leads to significant personal suffering and impairment in normal functioning.
Maternal depression is defined as depression experienced by a mother during pregnancy or the postnatal period (first 12 months of her baby’s life). The experience of maternal depression may vary substantially across cultures, with a variety of culture-specific idioms of distress. Examples include kufungisisa “thinking too much” in Zimbabwe (Patel et al, 1997), ukudakumba “being sad or unhappy” and ucingakakhulu “thinking too much” in South Africa (Davies et al, 2016), and yandimukuba “being struck by pressure” in Uganda (Nakku et al, forthcoming). These experiences are often accompanied by social isolation, withdrawal and stigma. Prevalence estimates for maternal depression vary. A recent systematic review reported that 16 per cent of pregnant women and 20 per cent of postnatal women experience depression in low- and middle-income countries (LMIC) (Fisher et al, 2012). This is higher than high-income countries, where 10 per cent of pregnant women and 13 per cent of postnatal women experience depression (O’hara and Swain, 1996).
Risk factors for maternal depression include poverty, unintended pregnancy, younger age, being unmarried, lacking intimate partner empathy and support, trauma (especially intimate partner violence), insufficient emotional and practical support, and HIV status (Fisher et al, 2012; Hartley et al, 2011). Conversely, protective factors include, social support, family involvement, planned pregnancy, partner involvement, and individual resilience factors such as optimism (Grote and Bledsoe, 2007).
Impact on the woman and her children
Maternal depression has a number of negative consequences for the woman herself. These include loss of functioning (inability to perform everyday tasks or social roles), loss of interest in self-care and child care, behaviour that affects other health conditions (for example, poor adherence to antiretroviral treatment for HIV), and risk of suicide or self-harm. A global systematic review reports that between 5 per cent and 14 per cent of women report suicide ideation during pregnancy or the postnatal period (Lindahl, Pearson and Colpe, 2005). Most suicides happen in the postnatal period (Gentile, 2011) and the presence of perinatal depression predicts suicide (Lindahl, Pearson and Colpe, 2005). Suicide now surpasses maternal mortality as the leading cause of death in girls aged 15-19 years, globally (Petroni, Patel and Patton, 2015).
Recent research from LMIC has revealed a number of negative consequences of maternal depression for the child. These include effects on children’s general health, development and behaviour (Wachs, Black and Engle, 2009; Hayes and Sharif, 2009), diarrhoeal episodes (Ross et al, 2011), malnutrition (Anoop et al, 2004; Patel, De Souza and Rodrígues, 2002), impaired physical development including significantly reduced height and weight and impaired mental development (Patel, De Souza and Rodrígues, 2002; Hadley et al, 2008), as well as poor mother-infant attachment and impaired mother-child relationships (Tomlinson, Cooper and Murray, 2005; Cooper et al, 1999).
Given the effect of maternal depression on infant and child developmental trajectories, maternal depression may play a key role in maintaining inter-generational cycles of poverty. However, the longitudinal data to support this hypothesis is not yet available in LMIC. Atif Rahman and colleagues in Pakistan are conducting long-term follow-up of children of maternally depressed women and are investigating this area in an ongoing way (Maselko et al, 2015).
Screening and diagnostic tools for maternal depression in low-income settings
A variety of screening tools have been used in low-income settings, including the Edinburgh Postnatal Depression Scale (EPDS) (Cox, Holden and Sagovsky, 1987), which has been validated in many settings (De Bruin et al, 2004) and other general depression screening tools such as the Patient Health Questionnaire (PHQ) (Kroenke and Spitzer, 2002), the Centre for Epidemiological Studies Depression Scale (CESD) (Radloff, 1977) and the Self Reporting Questionnaire (SRQ20) (Beusenberg and Orley, 1994). The benefits of screening tools are that they can facilitate a relatively quick and cheap assessment of potential depression and facilitate access to community-based care. General health practitioners such as nurses or community health workers can be trained to administer screening tools. The risks are that such tools may lack local cultural validity: with inadequate sensitivity they may miss real cases of depression and with inadequate specificity they may overburden services with ‘false positive’ cases (Kagee et al, 2013). A further risk is that if adequate resources are not in place in the health system, the system may be flooded by new referrals whose needs cannot be met. Careful consideration of the broader health system requirements of introducing routine screening is therefore essential.
A more rigorous but also more costly alternative is a diagnostic assessment by a mental health professional (for example using the WHO ICD10) (WHO, 1990), or the use of diagnostic assessment instruments such as the Mini International Neuropsychiatric Interview (Sheehan et al, 1998) or the Composite International Diagnostic Interview (CIDI) (Kessler and Ustun, 2004). The latter instruments take longer to administer than screening tools, require more skilled personnel and are therefore more costly. They may also suffer from similar problems of inadequate local cultural validity if they have not been properly adapted and translated into the local language.
A third alternative (and relatively recent innovation) is the use of idioms of distress to generate vignette based detection tools such as the Community Informant Detection Tool in Nepal (Jordans et al, 2015). This approach marks a step forward in identifying culturally valid experiences of depression, although substantial adaptation may be required for local cultural settings.
When should one screen? Some researchers have argued that the perinatal period is a time of high risk for women and their infants, and that routine antenatal screening for mental health, particularly in communities where high prevalence has been reported, should be mandatory (Honikman et al, 2012). Recently, the US Prevention Task Force published findings in the Journal of the American Medical Association (JAMA) recommending routine screening for depression, especially for pregnant and postpartum women (Siu et al, 2016). The final decision on whether to introduce routine antenatal or postnatal depression screening should depend on a number of considerations, including the prevalence of maternal depression in the local setting, the local validity of screening tools, and the availability of resources for detection and treatment.
What is good practice? Interventions in low resource settings
There is good emerging evidence for the cost-effectiveness of adapted psychological interventions, such as cognitive behaviour therapy (CBT), delivered by community health workers or lay counsellors, using a task shifting or task sharing approach (Chowdhary et al, 2014). For example, a large randomised controlled trial using Lady Health Workers to deliver a Thinking Healthy intervention in Pakistan demonstrated a significant improvement in depression outcomes (Rahman et al, 2008). As a result, the WHO has endorsed this approach and published a Thinking Healthy manual for maternal depression (WHO, 2015). Other trials are underway currently, for example, using peer counsellors in India and Pakistan (Sikander et al, 2015), and community health workers in South Africa (Lund et al, 2014).
How can maternal depression interventions be integrated into general maternal health programmes?
Integration is possible and there are several best practice examples, for example, the Perinatal Mental Health Project in Cape Town, South Africa (Honikman et al, 2012). Steps for integrating maternal depression interventions into wider maternal health programmes include the following:
- Select a suitable locally relevant screening or detection tool. Examples of screening tools include the EPDS or PHQ9 (see above) and clinical algorithms include the WHO mhGAP Intervention Guide (WHO 2010).
- Adapt and translate the screening tool if necessary.
- Conduct a needs assessment: administer the screening tool to all antenatal and postnatal mothers over a specified period of time to determine prevalence.
- Based on the identified need, design a stepped care approach, appropriate to the local setting:
- Step 1: routine or selected antenatal and postnatal screening
- Step 2: screen positives referred for evidence-based counselling
- Step 3: referral of mothers who are not responsive to counselling for assessment by a medical doctor or a suitably qualified prescribing practitioner for potential anti-depressant medication
- Five-day training (for example, using the WHO Thinking Healthy manual) (WHO, 2015), plus ongoing supervision of counsellors is essential. Appropriately selected lay counsellors or community health workers within the existing health system may be able to take on this role, although careful attention should be paid to potential counsellors’ personal capacity, motivation and skills (Honikman et al, 2012). Counsellors can include psychological counsellors and community health workers such as the Lady Health Workers in Pakistan (Rahman et al, 2008). Currently trials are under way in Pakistan and India to assess the effectiveness and cost-effectiveness of peer counsellors for perinatal depression (Sikander et al, 2015). The time required for counsellors to provide counseling will depend on the caseload, whether group or individual sessions are conducted and the number of sessions attended by each woman detected with depression.
- It is also important that the broader health system is strengthened to cope with the possible additional demand. This should include appropriately trained medical personnel and the supply of appropriate anti-depressant medication for mothers who do not respond to psychological interventions. See other models, such as the Perinatal Mental Health Project (PMHP) for an indication of possible demand for medical personnel and medication – in the case of the PMHP only 2 per cent of women who received counseling were referred and seen by a psychiatrist (Honikman et al, 2012), but needs are likely to vary substantially based on a variety of contextual factors.
- Costs to the health system are likely to vary substantially depending on demand, coverage and local health system costs (including personnel, medication and facilities). Estimates of the costs of integrating maternal mental healthcare into general primary care systems in LMIC are the subject of ongoing studies, such as the PRogramme for Improving Mental health carE (PRIME) study, which generated estimates of between US$5.05 in Ethiopia and US$14.48 in India per perinatally depressed woman treated with psychosocial care (Chisholm et al, 2016).
Some research and innovation groups working in maternal mental health in LMIC are:
- Atif Rahman, Vikram Patel and colleagues at the University of Liverpool, working in Pakistan and India
- Simone Honikman and colleagues at the Perinatal Mental Health Project in Cape Town, South Africa
- Jane Fisher and colleagues at Monash University, Australia
- Ricardo Araya and colleagues at the Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, United Kingdom, with projects in Brazil and Chile
- Juliet Nakku and colleagues at Makerere University, Kampala, Uganda
- Charlotte Hanlon and colleagues at Addis Ababa University, Ethiopia
Funders who have supported research in this area include the Wellcome Trust, Grand Challenges Canada, the National Institute of Mental Health and the Department for International Development (DFID).
For more on global mental health innovations, see the Mental Health Innovation Network: http://mhinnovation.net
Reading 1: Fisher J, Mello MCd, Patel V, et al. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. Bull World Health Organ 2012; 90(2): 139-49. https://www.heart-resources.org/doc_lib/prevalence-determinants-common-perinatal-mental-disorders-women-low-lower-middle-income-countries-systematic-review/
Reading 2: Patel V, De Souza N, Rodrígues M. Postnatal depression and infant growth and development in low income countries: a cohort study from Goa, India. Arch Dis Child 2002; 87: 1-4. https://www.heart-resources.org/doc_lib/postnatal-depression-infant-growth-development-low-income-countries-cohort-study-goa-india/
Reading 3: Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised control trial. Lancet 2008; 372: 902-9. https://www.heart-resources.org/doc_lib/cognitive-behaviour-therapy-based-intervention-community-health-workers-mothers-depression-infants-rural-pakistan-cluster-randomised-controlled-trial/
Reading 4: Honikman S, van Heyningen T, Field S, Baron E, Tomlinson M. Stepped care for maternal mental health: a case study of the perinatal mental health project in South Africa. PLoS Med 2012; 9(5): e1001222. https://www.heart-resources.org/doc_lib/stepped-care-maternal-mental-health-case-study-perinatal-mental-health-project-south-africa/
Reading 5: WHO (2015). Thinking Healthy: A manual for psychological management of perinatal depression. Geneva: WHO. https://www.heart-resources.org/doc_lib/thinking-healthy-manual-psychosocial-management-perinatal-depression/
Reading 6: Kagee A, Tsai AC, Lund C, Tomlinson M. Screening for common mental disorders in low resource settings: reasons for caution and a way forward. International Health 2013; 5(1): 11-4. https://www.heart-resources.org/doc_lib/screening-common-mental-disorders-low-resource-settings-reasons-caution-way-forward/
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Questions to guide reading
- What are best practice models for integrating mental health into maternal healthcare?
- What are the risks and benefits of using screening tools for maternal depression?
- How could services be set up to treat maternal depression in your context?
- What additional resources would you need, beyond those that are currently available, to get the service up and running?
- What tools can you use to persuade the government or other service funders about the need for the service in your local setting?