Treatment of maternal perinatal depression in a low-income setting does not lead to improved outcomes for children

ABSTRACT FROM: Maselko J, Sikander S, Bhalotra S, et al. Effect of an early perinatal depression intervention on long-term child development outcomes: follow-up of the Thinking Healthy Programme randomised controlled trial. Lancet Psychiatry 2015;2:609–17.

What is already known on this topic

Perinatal depression is common; in high-income countries the point prevalence is approximately 13%, with higher rates estimated in low-income and middle-income countries.¹ Furthermore, perinatal depression is associated with an increased risk of adverse child outcomes, including behavioural, emotional and cognitive difficulties,² which persist into late childhood and adolescence. However, there is as yet only limited evidence to convincingly establish this association as being causal, with few studies evaluating the effects of intervening in the perinatal period on child development outcomes.

Methods of the study

Study participants were mother-child dyads who had been screened as part of the Thinking Healthy Programme (THP) randomised controlled trial.³ Of 705 participating mother–child dyads interviewed at the end of the THP study, 584 (83%) dyads were enrolled. Participants with depression were randomised in two groups (intervention arm n=289; control arm n=295) and a reference non-depressed group (n=300) was also included in this follow-up. Married women aged 16–45 years, in their third trimester of pregnancy were screened for depression; those who met Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) criteria for a major depressive episode were invited into the THP randomised trial, whereas those in the reference group were sampled from the population without antenatal depression. Women were excluded if they had a diagnosed serious medical condition requiring inpatient or outpatient treatment, pregnancy-related illness, substantial physical or learning disability or psychosis. The THP is a home-based intervention delivered by community health workers. It is based on cognitive behavioural therapy and consists of 16 sessions, starting in the last month of pregnancy and continuing until 10 months postpartum. Those in the control group received ‘enhanced routine care whereby a community health worker who had not been trained in the THP intervention made 16 home visits. This study investigated cognitive, socioemotional and physical outcomes in children, assessed at approximately 7 years of age. Data were collected in Pakistan between March 2013 and January 2014. The primary cognitive outcome was the Wechsler Preschool and Primary Scale of Intelligence, primary socioemotional outcomes were measured using the Strengths and Difficulties Questionnaire and the Spence Children's Anxiety Scale and primary physical outcomes were height-for-age, weight-for-age and body-mass-index-for-age Z scores. Assessors were blind to prenatal depression status and random assignment.

What does this paper add

• This is one of the first studies to investigate the effects of an intervention for perinatal depression on long-term child outcomes, and one of the few in a low or middle income country.

• Overall, cognitive, socioemotional or physical development outcomes did not differ in the intervention or control groups. When compared with the reference group of children whose mothers did not have prenatal depression, the THP trial children had worse socioemotional outcomes.

• This paper suggests that treating maternal depression alone might not be sufficient to improve outcomes for the child; in fact for one outcome (child anxiety) the outcome was worse.

• This may be because of limitations with the treatment or the research study, or it may be that treating maternal depression (alone) is not sufficient to reduce the impact on the child.

Limitations

• The study focused on maternal depression alone and no other carers, despite 44% of families living with a grandmother, who may have been providing a proportion of the care.

• Many measures were by maternal report questionnaires, which may have been influenced by factors related to maternal mental health, although current maternal depression was controlled for.

What next in research

This study joins others which have found no effect on children when maternal perinatal depression is treated. Potential shortcomings in the interventions need to be considered, including the possibility that depression needs to be treated earlier in pregnancy for there to be a strong benefit for offspring. Intervention may also need to be targeted more broadly than just treating maternal depression. Maternal depression may be a marker for other factors that are causal, such as family relationship difficulties, difficulties in the parent–child relationship and wider family and social factors.

Do these results change your practices and why?

Not yet. We need to be more cautious and critical when considering evidence from observational studies of maternal depression and child outcome, which consistently point to associations. There may be a need to begin considering broader approaches for maternal perinatal depression if one of the aims is to improve outcomes for children. Interventions incorporating wider family involvement and possibly supporting improved parent–child interactions and relationships may prove more beneficial, than just treating depression in isolation (important though treating depression is).