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Maternal depression HEART Reading Pack

  1. Maternal Mental Health: Overview of the HEART Reading Pack Prof Crick Lund Department of Psychiatry and Mental Health University of Cape Town Email:
  2. What is depression?1 Core requirements: • Depressed mood (feels sad, empty or hopeless) • Loss of interest and enjoyment/pleasure • Reduced energy leading to increased fatigue and diminished activity. Plus 3 or more of the following: significant weight gain/loss; insomnia/hypersomnia; psychomotor agitation/retardation; feeling excessively worthless/guilty; diminished ability to think/concentrate; recurrent thoughts of death/suicide Note: • Symptoms must cause clinically significant distress or impairment in social, occupational or other important areas of functioning • Symptoms must persist for at least a 2 week period (major depressive episode) 1. DSM-5, American Psychiatric Association, 2013; ICD-10, WHO, 2010
  3. What is maternal depression? • 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, and is expressed in various idioms of distress, e.g.: – kufungisisa “thinking too much” in Zimbabwe – ukudakumba “being sad or unhappy” and ucingakakhulu “thinking too much” in South Africa – yandimukuba “being struck by pressure” in Uganda
  4. Why should we treat maternal depression? The burden of Common perinatal mental disorders (depression and anxiety) is high: – High income countries: 13% (antenatal); 10% (postnatal) – Low and middle-income countries: 16% (antenatal) ; 20% (postnatal) Fisher et al 2012 Photo: Alexia Beckerling
  5. Why should we treat maternal depression? Prevention: intergenerational impact Antenatal distress Postnatal distress • Chronic mental illness • Drugs / alcohol • Suicide/Infanticide Child Infancy • Emotional problems • Cognitive problems • Poor growth • Diarrhoeal disease • Malnutrition Childhood / Adolescence • Mental health problems • Impaired mother-child relationships Mother Poor bonding Dysfunction may influence the next generation Trans-placental
  6. Risk Factors
  7. Why should we integrate? The good news • Unique opportunities for health system contact with mothers – Antenatal Care – Postnatal Care • Evidence for effective treatment – Low resource settings (India, Pakistan, Chile) – WHO Thinking Healthy Manual – The Perinatal Mental Health Project model (South Africa) • Efficient investment for child outcomes (Heckman’s model)
  8. Investment hypothesis Investing in Early Human Development: Timing and Economic Efficiency Orla Doyle, Colm P. Harmon, James J. Heckman,and Richard E. Tremblay Econ Hum Biol. 2009 March; 7(1): 1–6.
  9. Steps to integrating mental health care into routine maternal health care • Select a suitable locally relevant screening or detection tool. • Adapt and translate the screening tool if necessary. • Conduct a needs assessment. • Based on the identified need, design a stepped care approach, appropriate to local setting: – Step 1: Routine or selected antenatal and postnatal screening – Step 2: Screen positives referred for evidence- based counseling – Step 3: Referral of mothers who are not responsive to counseling for assessment by medical doctor for potential anti-depressant medication. Photo: PMHP
  10. Cautionary notes • Consider options for screening tools carefully. • 5-day training using the WHO Thinking Healthy manual • Ongoing supervision of counselors is essential! • Select counselors carefully based on: – Personal capacity for empathy – Motivation – Skills

Editor's Notes

  1. Systemic reviews of prevalence data from high income countries show prevalence rates of 13% for antenatal mental disorders (Hendrick, Altshuler, Cohen, & Stowe, 1998) and of 10% in the postnatal period (O’Hara & Swain, 1996).