Maternal Mental Health: Overview of
the HEART Reading Pack
Prof Crick Lund
Department of Psychiatry and Mental Health
University of Cape Town
Email: crick.lund@uct.ac.za

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

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

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

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

Risk Factors

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)

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.

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

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