Editorial

New developments in perinatal mental health

Perinatal mental health is a rapidly evolvingspecialty concerned with the mental health ofchildbearing women from conception throughpregnancy to the end of the first year afterdelivery (1). This discipline encompasses clinicaland research findings about the correlates anddeterminants of parental and infant mentalhealth and illness, includes classification anddiagnostic issues, methods for prevention, earlyintervention and treatment, impact, and outcomestudies. The pivotal role played by parentalmental health in the physical, emotional, cogni-tive, social and behavioural development ofinfants is widely acknowledged (2–4) and inter-national Public Health programmes are beingaimed increasingly at strategies that will reducecurrent high rates of mental health morbidity inthis population (5).

Broadening frames of reference

Many early studies of mental health amongstchildbearing women dealt exclusively with post-natal symptoms, especially postnatal depression(PND); however, rates of elevated scores (12–13cutoff) on the Edinburgh Postnatal DepressionScale (EPDS) (6) that have been shown tocorrelate with a formal diagnosis of clinicaldepression have been found to be similarduring pregnancy and after delivery. Up to40% of women have both antenatal and postna-tal symptoms, which suggests for many there is acontinuum of distress (1). The EPDS is alsosensitive to anxiety �the blues� and stress-relatedsymptoms, thus high scores indicate the need forfurther assessment to establish the correct diag-nosis. Anxiety disorders are being increasinglydocumented with recent studies suggesting thatperinatal anxiety may be as common as perinataldepression (1). Studies highlight the presenceof considerable comorbidity, the confoundingeffects of drug and alcohol abuse, eating disor-ders, and personality, upon perinatal mentalhealth (7) and one recent British report citessuicide as the leading cause of maternal deathpostpartum in association with severe psychiatricillness (8).

Impact of disorders

Impact of antenatal maternal distress upon foetal and infantbehaviour

Evidence is emerging concerning the impact ofantenatal maternal distress upon foetal and infantbehaviours and indicates the possible role of thehypothalamic pituitary adrenal axis in the trans-mission of maternal distress to the offspring inutero (9). Research that has previously addressedthe impact of PND on infants may be significantlyconfounded by the in utero influence of antenatalmaternal anxiety and depression (9, 10). Theinfluences of antenatal and postnatal mood andanxiety disorders need to be more clearly differen-tiated, as do environmental and genetic factors.

Impact of postnatal maternal distress upon infants

The majority of impact studies have demonstratedthat PND is associated with adverse cognitive,emotional and behavioural outcomes in infants andproblematic parenting behaviours. �Suboptimal�parenting behaviours are not confined to parentswith depressive disorders and adverse outcomes forinfants may persist beyond the duration of theinitial parental episode of mental illness (1, 2, 11).Links between PND and reduced infant growthrates in Asia have recently been demonstrated incombination with high rates of PND leading tospeculation that depressed women in Third Worldcountries may have difficulty attending to their ownphysical and emotional health care needs as well asthose of their infants (5).

Strategies for screening, prevention, early intervention andtreatment

Antenatal and postnatal psychosocial screening

The identification of antenatal risk factors associ-ated with PND has failed to produce risk indicesthat have adequate sensitivity or specificity for theprediction of PND. This has led to recommenda-tions that antenatal psychosocial screening pro-grammes focus on early identification, preventiveand early intervention strategies rather than pre-diction of PND (1). Screening during pregnancy is

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important in its own right given that many womenshow symptoms that are amenable to interventionsto reduce maternal distress and risks for the infantin utero (12). Universal antenatal psychosocialscreening programmes are being trialed in anumber of centres using combined approachesthat include scores on self-report measures ofsymptoms and psychosocial risk factors (1, 11,12). Postnatal psychosocial screening indices arebeing evaluated to aid in early postnatal identifi-cation of women �at risk� (13). Given that mostwomen seek health care services around pregnancy,delivery and the early postpartum, psychosocialscreening fits well into a primary preventionframework provided adequately trained staff areavailable to screen and provide follow-up servicesto those identified as being �at risk� (1, 13).

Antenatal and postnatal prevention, early intervention andtreatment programmes

Randomized controlled trials evaluating antenatalgroup interventions for �selected� populations,aimed at prevention of PND have had methodo-logical shortcomings and variable outcomes (14).Some psychological interventions targeting womenwith high postnatal EPDS scores have led toimproved maternal mood in the short term but nodemonstrable improvements in mother–infant rela-tionship, cognitive development or other childoutcomes nor was any reduction in rates ofmaternal depression at 5-year review (3, 4). Arecent study using cognitive behavioural therapywith women meeting DSM-IV criteria for diagno-sis of depression showed sustained improvementsin maternal mood and adjustment at 1 year afterdelivery (15). Further knowledge is required on thesafety of psychotropes in the perinatal period, andclinicians need to carefully discuss and documentthe risk–benefit ratio of pharmacological treatmentand prophylaxis with all prospective parents (16).

Future directions

There are major challenges still to be overcome at aglobal level in relation to measures, diagnosis,impact of disorders, psychosocial screening, pre-vention, early intervention, treatment, and out-comes if perinatal mental health morbidity andmortality are to be reduced.

Acta Psychiatrica ScandinavicaMarie-Paule Austin and Susan Priest

Invited Guest Editors

References

1. Austin M-P. Antenatal screening and early intervention for��perinatal�� distress, depression and anxiety: where to fromhere (Editorial)? Arch Women’s Ment Health 2004;7:1–6.

2. Murray L, Cooper PJ. The impact of postpartum depres-sion on child development. In: Goodyer I, ed. Aetiologicalmechanisms in developmental psychopathology. Oxford:Oxford University Press, 2004.

3. Cooper PJ, Murray L, Wilson A, Romaniuk H. Controlledtrial of the short- and long-term effect of psychologicaltreatment of post-partum depression I: impact on maternalmood. Br J Psychiatry 2003;182:412–419.

4. Murray L, Cooper PJ, Wilson A, Romaniuk H. Controlledtrial of the short- and long-term effect of psychologicaltreatment of post-partum depression II: impact on themother-child relationship and child outcome. Br J Psy-chiatry 2003;182:420–427.

5. Patel V, Rahman A, Jacob KS, Hughes M. Effect ofmaternal health on infant growth in low income countries:new evidence from South Asia. BMJ 2004;328:820–823.

6. Cox JL, Holden JM, Sagovsky R. Detection of postnataldepression. Br J Psychiatry 1987;150:782–786.

7. Carter AS, Garrity-Roukas FE, Chazan-Cohen R, Little C,Broggs-Gowan M. Maternal depression and co-morbidity:predicting early parenting, attachment security and toddlersocial-emotional problems and competencies. J Am AcadChild Adolesc Psych 2003;40:18–26.

8. Oates M. Perinatal psychiatric disorders: a leading cause ofmaternal morbidity and mortality. Br J Psychiat 2003;67:219–229.

9. Glover V, O’Connor TG. Effects of antenatal stress andanxiety: implications for development and psychiatry. Br JPsychiatry 2002;180:389–391.

10. O’Connor TG, Heron J, Golding J, Beveridge M, Glover V.Maternal antenatal anxiety and children’s behavioural/emotional problems at 4 years: report from the ALSPAC.Br J Psychiatry 2002;180:502–508.

11. Lovejoy MC, Graczyk PA, O’Hare E, Neuman G. Maternaldepression and parenting behaviour: a meta-analytic re-view. Clin Psychol Rev 2000;20:561–592.

12. Austin M-P, Lumley J. Antenatal screening for women atrisk of postnatal depression. Acta Psychiatr Scand 2002;106:1–8.

13. Dennis C-L, Janssen PA, Singer J. Identifying women at-risk for postpartum depression in the immediate postpar-tum period. Acta Psychiatr Scand, 2004;110:338–346.

14. Austin M-P. Targeted group antenatal prevention of post-natal depression: a review. Acta Psychiatr Scand 2003;107:10–17.

15. Milgrom J, Negri L, McNeil M, Martin PR. A randomisedcontrolled trial of psychological interventions for postnataldepression. Br J Clin Psychol 2004, in press.

16. Austin M-P, Mitchell P. The use of psychotropic medica-tions in pregnant women. Med J Aust 1998;169:428–431.

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