Auseinetter - Issue 8
Guest Editorial
Stephen Matthey
Early Intervention and Perinatal Mental Health
Intervention and Home Visits
Considerable efforts are being made to provide the best possible start to a family's life by intervening early where there is risk of the mother experiencing significant distress in the perinatal period. Early on, work focused on detecting mothers with anxiety or depression and providing a home visiting intervention. Barnett and Parker (1985) demonstrated the effectiveness of a year-long support program on anxious mothers' distress levels using professional or lay people to do home visits (professionals resulted in superior improvement over lay people). Holden et al., (1989) also provided depressed women with a home visitation service over 13 weeks, and demonstrated that non-directive counselling was effective in alleviating their distress. This study has been replicated by Wickberg & Hwang (1996), with similar encouraging results.
Both of these programs illustrate that not only can such interventions be effective but that, by offering such assistance to women who are experiencing difficulty in the early postpartum weeks, many accept such help. However, it would be a mistake to think that simply sending people to visit women with postpartum depression or anxiety (PNDD) will solve their difficulties. All three studies had extensive training for the home visitors, both prior to the commencement of the programs, and with ongoing supervision. Simply sending visitors to a new mother is not sufficient if we are to make an impact on her, and the family's, psychosocial adjustment. For many years all new parents have had a Health Visitor in Britain, with visits lasting up to a year. However, even with this service the rate of maternal depression in British studies was never lower than in countries where the new mother did not receive such home visiting. Thus careful consideration must be given to the aims of the visit, the skill of the visitor, the model of intervention to be provided, and the training and back-up support that is given. Indeed, Families First, a program commencing in New South Wales in the near future, which aims to visit all new parents, augurs well for families providing that these issues are adequately addressed. It is all too easy to assume that programs which provide `home visiting' must be beneficial - but as with any intervention, the content and process issues must be routinely monitored and adjusted if we are to ensure that what looks good on paper is actually good in practice, and demonstrated to be so (or not) by proper evaluation.
The success of such programs, together with the increased acknowledgment of the extent of difficulties faced by new parents, has lead to the recommendation in NSW that all new mothers be given the Edinburgh Postnatal Depression Scale at their initial visits to the Early Childhood Clinics (PND Services Review, 1994). This is a self-report instrument used as a screen, and sensitive for postnatal depression, which is brief and has high acceptability to the women. Thus the move is towards the health services taking a proactive role in detecting women with PNDD.
Screening & Prediction
There is also now a move towards attempting to predict which parents will become depressed or anxious, and thereby either provide them with a service in their pregnancy, or provide extra support, if needed, in the early postpartum weeks. Initiatives in this area include those by Appleby et al (1994), Beck (1995), Cooper et al., (1996), and more locally by ourselves and colleagues in South West Sydney (`MINET' project) and also in South East Sydney.
The benefits of trying to predict who will become depressed are in one sense obvious. If we are `correct' in our predictions, then considerable effort and expense can be spared by knowing who to target once the baby is born. Information can be transferred to Early Childhood services so that at a mother's (or father's / couples') first few visits with the baby, sensitive inquiring about how she is managing can be undertaken with the knowledge of the risk factors identified in her pregnancy (such as lack of support or feeling depressed). Appropriate intervention can then be offered, and the family's adjustment can be monitored, so as to maximise the opportunity for a good beginning for the family.
But what if we are not `correct' in our predictions? To date these studies, utilising many risk factors for PNDD, have not shown high accuracy in predicting antenatally those women who will develop PNDD. A consideration of some factors could provide an explanation for this low hit rate.
Around half of women with PNDD have experienced depression either during their pregnancy, or have had a history of depression in their life. Whether screening measures, such as those discussed above, will have differential accuracy at predicting these two categories of PNDD, known as `Recurrent' or `De Novo' (Cooper & Murray, 1995), is yet to be tested. It may be that if studies determine the accuracy of prediction instruments for each of these two groups, then the success rate of the instrument (adjudged by its receiver operating characteristics) may be found to be good for at least one of them.
Another consideration is whether different stressors associated with PNDD are more predictive than others. Thus while it is easy to read the research into risk factors, build up a picture of what seems to `cause' PNDD (which should more correctly be read as being `associated' with), and conclude, for example, that complications in delivery will not `result' in PNDD (as the majority of studies show little association between this and PNDD), such an interpretation is clearly incorrect when one moves from the overall descriptive statistics of quantitative research, to the individual stories of women themselves. Thus for most women, having a caesarean will not be associated with feeling depressed. However, but there are instances where having a natural birth is valued so highly by a woman that not having this, in conjunction with other factors, will result in a high level of postpartum distress. Because of these idiosyncrasies in human behaviour and emotions, screening based upon a simple presence/absence of certain risk factors cannot be expected to be 100% accurate. The prediction formula may well have to be considerably more sophisticated than a simple algorithm which sums different risk factors. It may need to weight different stressors, or combinations of stressors, if it is to be useful. But if such predictive instruments remain poor in predictive power, should such screening be abandoned, at least in the antenatal period?
The argument for screening antenatally or postnatally if we can't develop a highly predictive instrument is, I would argue, strong. We are not just interested in the woman's wellbeing after the birth. Antenatal care is just that - care for all aspects of the woman's health during the antenatal period. Screening therefore has the dual purpose of predicting and providing a clinical service at the same time. Asking not just about possible risk factors, but also about how she is feeling now, will be of enormous benefit for her and her family. A woman who is struggling emotionally during her pregnancy needs support, in whatever form, at this point. By providing this some mothers may adjust better, and better utilise services and supports before and after the birth - thereby reducing the accuracy of our predictions in the best possible way.
There are also other benefits to such early screening. By inquiring of all mothers in their pregnancy on such issues as likely support after the birth, whether or not there has been a history of anxiety or depressive conditions previously, and current mood and feelings towards the pregnancy, we are showing that we care about not just the infant, nor just about her physical wellbeing, but also about a mother's psychosocial adjustment to her situation. There are a significant number of women who experience postnatal depression without any of the risk factors during their pregnancy. For these women, similar follow-up questions at the Early Childhood Clinic will remind the mother of our interest in her wellbeing. It is possible that this will result in these `de novo' depressed or anxious women being more willing to seek appropriate support at this time.
Another consideration, if our screening instruments are not particularly successful at prediction, are those women who are predicted as being of low risk of becoming postnatally depressed. The temptation would be not to offer these women a screening service in the postnatal period, and to assume that because they were `low-risk' in pregnancy they do not need the resources in comparison to `high-risk' women. This is a risky strategy. Women's circumstances change - while there may have been support during the pregnancy with no major stressors, for a fair number of women other issues will have arisen since the pregnancy that now would put them at risk of having difficulty coping. The birth may not have gone according to plan, close relationships may have changed, or other major life events could have occurred. Thus screening all women postpartum is necessary to ensure such women are quickly detected and offered help if required.
Of course, and this is a personal (and I'm sure some would say male!) view, if the screening is used to subtly make a woman feel guilty if she has any thoughts of not breastfeeding then it will have the effect of driving women away from health services. I have spent the last three years interviewing many new mothers and fathers, and understand the effects of the hospital 'baby friendly' policy on some of these parents. The stress that they report at the inability of health services to respect their informed decision to bottle feed is substantial. As one father said to me, having expressed his anger at the intolerance of many staff at their decision not to breastfeed: "Are we actually allowed to bottle feed our baby?".
Interventions for `at-risk' women
This move towards identifying high-risk women in the antenatal period has lead to studies examining the effectiveness of providing support to those considered to be `at-risk' in their pregnancy. Several investigators have examined the efficacy of running groups or individual counselling at this time, and sometimes extending these to continue into the postpartum period (e.g., Elliott et al, 1988; Stamp et al, 1995). Some studies show benefits, while others do not. Of interest in such work in one sense is the assumption that one intervention should be effective for all at-risk women. Undoubtedly we shall soon move in the direction of attempting to compare different early interventions for different types of women - whether the types differ in their risk factors, or in their personality or coping styles, are just some of the considerations that may be worthwhile to pursue. For some women, interventions that provide non-directive support may be most beneficial while, for others, practical ways that increase the sense of competence at caring for an infant may be more appropriate. Our own research (Matthey et al., in preparation) in providing interventions antenatally to couples suggests that a woman's self-esteem is an important variable that plays a part in how effective certain interventions are in the antenatal period, and this finding ties in well with the evidence of the role of self-esteem in the aetiology of depression (cf. Brown et al., 1990). Another consideration, which is again being explored in our research, is the role of the woman's partner. It is likely that interventions will differ in their effectiveness (for both the woman and man) depending upon the quality of the couple's relationship. Thus when and how to include the partner in antenatal or postnatal interventions, or screening interviews, needs to be empirically determined. Up to now such considerations appear to be based more upon practical considerations than well-supported theory.
Conclusions
In the next few years I expect that we shall see continued advances in the use of screening instruments antenatally and postnatally for women, and an advance in our thinking of the overall benefits of such screening. Research is likely to inform us further as to the matching of interventions to different types of difficulties or aspects of the parents in the perinatal period. Increasingly the role of men in all of these aspects will be explored.
References
Appleby, L., Gregoire, A., Platz, C., et al. (1994). Screening women for high risk of postnatal depression. Journal of Psychosomatic Research, 38, 539-545.
Barnett, B. & Parker, G. (1985). Professional and non-professional intervention for highly anxious primiparous mothers. British Journal of Psychiatry, 146, 287-293.
Beck, C. T. (1995). Screening methods for postpartum depression. Journal of Obstetric, Gynaecological and Neonatal Nursing. 24, 308-312.
Brown., G. W., Bifulco, A., Veiel, H. O. F. et al. (1990). Self-esteem and depression. Social Psychiatry and Psychiatric Epidemiology, 25, 225-234.
Cooper, P.J. & Murray, L. (1995) Course and recurrence of postnatal depression: Evidence for the specificity of the diagnostic concepts. British Journal of Psychiatry 166, 191-195.
Cooper, P. J., Murray, L., Hooper, R., & West, A. (1996). The development and validation of a predictive index for postpartum depression. Psychological Medicine, 26, 627-634.
Elliott, S. A., Sanjack, M., & Leverton, T. J. (1988). Parenting groups in pregnancy: a preventive intervention for postnatal depression? In B. H. Gottlieb (Ed.), Marshalling Social Support. pp 87-110. Newbury Park: Sage.
Holden, J. M., Sagovsky, R., & Cox, J. L. (1989). Counselling in a general practice setting: controlled study of health visitor intervention in treatment of postnatal depression. British Medical Journal, 298, 223-226.
Postnatal Depression Services Review (1994). NSW Health Department. State Health Publication No. (PA) 94-131.
Stamp, G. E., Williams, A. S., & Crowther, C. A. (1995). Evaluation of antenatal and postnatal support to overcome postnatal depression: a randomised, controlled trial. Birth, 22, 138-143.
Wickberg, B. & Hwang, C. P. (1996). Counselling of postnatal depression: a controlled study on a population based Swedish sample. Journal of Affective Disorders, 39, 209-216.
For further information contact Stephen Matthey, Senior Clinical Psychologist & Research Director, South Western Sydney Area Health Service, Park House (Paediatric Mental Health Service), 13 Elizabeth Street, Liverpool 2170.
ph; (02) 9827 8011; fax: (02) 9827 8010; email: pmhs@unsw.edu.au