Maternal depression from pregnancy to 4 years postpartum
36 National Institute for Health and Clinical Excellence. Antenatal and postnatal mental health: clinical management and service guidance (NICE Clinical Guideline 45). Report. London: NICE, 2007. 37 Department of Education and Early Childhood Development. Maternal and Child Health Service: Practice Guidelines. Melbourne: Victorian State Government, 2009.
38 Rahman A, Surkan PJ, Cayetano CE, Rwagatare P, Dickson KE. Grand challenges: integrating maternal mental health into maternal and child health programmes. PLoS Med 2013;10:e1001442.
It is time to focus on maternal mental health: optimising maternal and child health outcomes S Meltzer-Brody, A Brandon Department of Psychiatry, University of North Carolina, Chapel Hill, NC, USA Linked article: This article is a mini commentary on H Woolhouse et al., pp. 312–21 in this issue. To view this article visit http://dx.doi.org/10.1111/1471-0528.12837. Published Online 21 May 2014. With maternal mental health so clearly and consistently associated with child health outcomes, it is imperative that science and society prioritise support for mothers of young children. In this issue of BJOG, Woolhouse et al. provide just such a welcome call to arms by documenting the prevalence and chronicity of depressive symptoms in women not just in the first postpartum year, but throughout the first 4 years of motherhood. Expanding our focus beyond the perinatal period is critical to ensure optimal health outcomes for both mother and child. Only within the last year one group of investigators reported that 61% of the children of chronically depressed mothers met criteria for Axis I disorders (compared with 15% of those with nondepressed mothers), and also identified neurobiological mechanisms associated with depressed families (Apter-Levy et al. Am J Psychiatry 2013;170:1161–8). Further, data from the STAR*-D cohort study of adult depression confirmed that not only do the children (ages 7–18 years) of chronically depressed mothers have significantly worse outcomes, but the treatment and remission of maternal depression had positive effects on both mothers and their children
(Weissman et al. J Am Med Assoc 2006;295:1389–98). Given this body of knowledge, it is highly troubling that so little attention has been paid to the recognition or systematic intervention of maternal depression outside the acute perinatal period. Woolhouse et al. recruited 1507 Australian nulliparous women during the first trimester of pregnancy, collecting data at five postpartum timepoints (3, 6, 12, 18 months and 4 years). The investigators found a disturbingly high prevalence of maternal depressive symptoms, with one in three mothers reporting symptoms at some point during the course of the study and one in seven (14.5%) still reporting symptoms at the 4-year follow-up period. Robust associations were reported between depressive symptoms and co-occurring intimate partner violence, psychosocial adverse events and chronicity of the symptoms. Although an association between intimate partner violence and maternal depression has been previously documented (Meltzer-Brody et al. Arch Womens Ment Health 2013;16:465–73; Silverman et al. Arch Womens Ment Health 2010;13:411–15), more than a quarter (28.4%) of the Australian cohort had a history of intimate partner violence. In other words, the most
ª 2014 Royal College of Obstetricians and Gynaecologists
vulnerable women (those with past and current trauma histories and persistent mental illness) remained the most depressed over time. These figures highlight an epidemic mandating our response as scientists, clinicians and members of society. One of the most important ways in which we can address the neglect of maternal mental health is by examining the delivery of our healthcare services to children and families and finding ways to incorporate psychosocial and mental health assessment and intervention across mother–child units. It is extremely naive to believe that mothers can provide optimal care for their children without having adequate support and treatment for the widely prevalent societal and mental health concerns that challenge women during their reproductive years. Second, if we are to mitigate the intergenerational consequences of violence against women, we must take an active stance against intimate partner violence. Across healthcare settings, we can only optimise mother and child outcomes through tireless advocacy, careful assessment and immediate intervention.
Disclosure of interest The authors report no conflict of interest. &
321
Copyright of BJOG: An International Journal of Obstetrics & Gynaecology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
36 National Institute for Health and Clinical Excellence. Antenatal and postnatal mental health: clinical management and service guidance (NICE Clinical Guideline 45). Report. London: NICE, 2007. 37 Department of Education and Early Childhood Development. Maternal and Child Health Service: Practice Guidelines. Melbourne: Victorian State Government, 2009.
38 Rahman A, Surkan PJ, Cayetano CE, Rwagatare P, Dickson KE. Grand challenges: integrating maternal mental health into maternal and child health programmes. PLoS Med 2013;10:e1001442.
It is time to focus on maternal mental health: optimising maternal and child health outcomes S Meltzer-Brody, A Brandon Department of Psychiatry, University of North Carolina, Chapel Hill, NC, USA Linked article: This article is a mini commentary on H Woolhouse et al., pp. 312–21 in this issue. To view this article visit http://dx.doi.org/10.1111/1471-0528.12837. Published Online 21 May 2014. With maternal mental health so clearly and consistently associated with child health outcomes, it is imperative that science and society prioritise support for mothers of young children. In this issue of BJOG, Woolhouse et al. provide just such a welcome call to arms by documenting the prevalence and chronicity of depressive symptoms in women not just in the first postpartum year, but throughout the first 4 years of motherhood. Expanding our focus beyond the perinatal period is critical to ensure optimal health outcomes for both mother and child. Only within the last year one group of investigators reported that 61% of the children of chronically depressed mothers met criteria for Axis I disorders (compared with 15% of those with nondepressed mothers), and also identified neurobiological mechanisms associated with depressed families (Apter-Levy et al. Am J Psychiatry 2013;170:1161–8). Further, data from the STAR*-D cohort study of adult depression confirmed that not only do the children (ages 7–18 years) of chronically depressed mothers have significantly worse outcomes, but the treatment and remission of maternal depression had positive effects on both mothers and their children
(Weissman et al. J Am Med Assoc 2006;295:1389–98). Given this body of knowledge, it is highly troubling that so little attention has been paid to the recognition or systematic intervention of maternal depression outside the acute perinatal period. Woolhouse et al. recruited 1507 Australian nulliparous women during the first trimester of pregnancy, collecting data at five postpartum timepoints (3, 6, 12, 18 months and 4 years). The investigators found a disturbingly high prevalence of maternal depressive symptoms, with one in three mothers reporting symptoms at some point during the course of the study and one in seven (14.5%) still reporting symptoms at the 4-year follow-up period. Robust associations were reported between depressive symptoms and co-occurring intimate partner violence, psychosocial adverse events and chronicity of the symptoms. Although an association between intimate partner violence and maternal depression has been previously documented (Meltzer-Brody et al. Arch Womens Ment Health 2013;16:465–73; Silverman et al. Arch Womens Ment Health 2010;13:411–15), more than a quarter (28.4%) of the Australian cohort had a history of intimate partner violence. In other words, the most
ª 2014 Royal College of Obstetricians and Gynaecologists
vulnerable women (those with past and current trauma histories and persistent mental illness) remained the most depressed over time. These figures highlight an epidemic mandating our response as scientists, clinicians and members of society. One of the most important ways in which we can address the neglect of maternal mental health is by examining the delivery of our healthcare services to children and families and finding ways to incorporate psychosocial and mental health assessment and intervention across mother–child units. It is extremely naive to believe that mothers can provide optimal care for their children without having adequate support and treatment for the widely prevalent societal and mental health concerns that challenge women during their reproductive years. Second, if we are to mitigate the intergenerational consequences of violence against women, we must take an active stance against intimate partner violence. Across healthcare settings, we can only optimise mother and child outcomes through tireless advocacy, careful assessment and immediate intervention.
Disclosure of interest The authors report no conflict of interest. &
321
Copyright of BJOG: An International Journal of Obstetrics & Gynaecology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
