Journal of Affective Disorders 109 (2008) 189–192www.elsevier.com/locate/jad

Brief report

Postnatal depression and mother and infant outcomes afterinfant massage

M. O′Higgins a, I. St. James Roberts b, V. Glover a,⁎

a Imperial College Faculty of Medicine, 4th Floor, IRDB, Hammersmith Campus, Du Cane Road, London W12 0NN, United Kingdomb Thomas Coram Research Unit Institute of Education, University of London, 27/28 Woburn Square, London WC1H 0AA, United Kingdom

Received 6 March 2007; received in revised form 30 October 2007; accepted 31 October 2007Available online 20 December 2007

Abstract

Background: Postnatal depression can be a long lasting condition which affects both the mother and her baby. A pilot studyindicated that attending baby massage improved maternal depression and mother–infant interactions. The current study furtherinvestigates any benefits of baby massage for mothers with postnatal depression and their infants.Methods: Mothers scoring ³13 on the Edinburgh Postnatal Depression Scale (EPDS) at 4 weeks postpartum were randomlyassigned to attend baby massage classes (n=31) or a support group (n=31). They completed depression, anxiety and InfantCharacteristics Questionnaires and were filmed interacting with their infants before and after 6 intervention sessions, and at oneyear. Thirty four non-depressed mothers also completed the study.Results: More of the massage than support group mothers showed a clinical reduction in EPDS scores between four weeks andoutcome ( pb0.05). At one year, massage-group mothers had non-depressed levels of sensitivity of interaction with their babies,whereas the support group did not. There were no other differences in either mother or child between the two intervention groups.Depressed mothers did not achieve control depression or anxiety scores at one year.Limitations: For ethical reasons, the study did not include a control group of depressed mothers who did not receive an intervention.Conclusions: Both intervention groups showed reductions in depression scores across the study period, but the massage group didbetter on some indices. They also had somewhat better interactions with their infants at one year, but these effects were limited.© 2007 Elsevier B.V. All rights reserved.

Keywords: Postnatal depression; Infant massage

1. Introduction

Depression is a disorder for which very many in thegeneral population seek alternative, rather than conven-tional, treatments (Kessler et al., 2001). Evaluating al-ternative treatments for depression in the postnatal period

⁎ Corresponding author. Tel.: +44 0207 594 2136; fax: +44 0207 5942138.

E-mail address: v.glover@imperial.ac.uk (V. Glover).

0165-0327/$ - see front matter © 2007 Elsevier B.V. All rights reserved.doi:10.1016/j.jad.2007.10.027

is particularly important as mothers are reluctant to takeanti-depressants at this time. A pilot study found thatattending infant massage classes reduced maternaldepression and improved mother–infant interactions towithin the normal range (Onozawa et al., 2001) and arecent study re-emphasised the need to treat more than justthe mother's depression in cases of postnatal depression(Forman et al., 2007). We here present results from alarger andmore controlled study of the effects of attendinginfant massage classes for mothers with postnatal

190 M. O′Higgins et al. / Journal of Affective Disorders 109 (2008) 189–192

depression. The aim was to investigate whether maternalmood, mother–infant interaction and infant characteris-tics improved after these sessions, with a follow-up atinfant age one year.

2. Materials and methods

The study used a prospective block-controlled rando-mised design. Mothers who consented postnatallyreceived the Edinburgh Postnatal Depression Scale(EPDS) and the Spielberger State Anxiety Inventory(SSAI) by post when their infants were 4 weeks old.Mothers scoring above 12 (n=285) on the EPDS wereinvited to participate and those that agreed were assignedto one of two interventions – infant massage classes(n=31) or support group sessions (n=31) – according to

Table 1Means, SD and statistical information for comparisons of massage group, supfor each measure

Massagemean (SD)

Supportmean (SD)

Non-depressedmean (SD)

F (

BaselineEPDS 13.19 (3.84) 13.81 (4.98) 3.24 (2.19) 80.1SSAI 44.7 (11.25) 45.49 (12.84) 24.69 (5.74) 12.0ICQ — fussy/difficultscale

34.4 (6.24) 31.69 (7.36) 25.79 (7.19) 12

Maternal sensitivityin interaction

4.13 (.52) 4.0 (.88) 4.24 (.53)

Infant performancein interaction

2.59 (1.0) 2.57 (1.08) 2.67 (1.0)

Overall interaction 2.95 (.95) 2.96 (.91) 3.07 (.93) .1

OutcomeEPDS 9.29 (3.47) 11 (6.43) 3.82 (2.66) 23.4SSAI 37.6 (11.15) 37.97 (14.25) 24.61 (4.21) 15.5ICQ — fussy/difficultscale

27.83 (6.48) 26.46 (8.54) 25.68 (8)

Maternal sensitivityin interaction

4 (.57) 4.05 (.88) 4.28 (.44) 2

Infant performancein interaction

2.63 (.93) 2.65 (1.08) 2.51 (.93)

Overall interaction 3.27 (.7) 3.26 (.91) 3.28 (.92) .0

One yearEPDS 9.15 (5.43) 9.82 (6.25) 3.39 (3.22) 1SSAI 36.08 (14.06) 39.58 (16.76) 25.54 (6.96) 7.5ICQ — fussy/difficultscale

27.57 (6.36) 26.52 (6.17) 24.56 (6.01) 1.6

Maternal sensitivityin interaction

4.07 (.47) 3.86 (.28) 4.23 (.27) 4.9

Infant performancein interaction

3.15 (.65) 3.33 (.5) 2.93 (.46) 2.6

Overall interaction 3.79 (.56) 3.65 (.4) 3.73 (.5) .3

which was running at the time. Ninety mothers whosescore was below 9 on the four week EPDSwere contactedto take part in the non-depressed control group and 34took part.

The baseline appointment took place when the infantswere 9–12 weeks old (median, 10) before the first sessionof the intervention. Mothers completed the EPDS, SSAIand the Infant Characteristics Questionnaire (ICQ). Theywere filmed interacting with their infants for 5 min in astandardised protocol. The interactions were rated usingthe Global Ratings for Mother–Infant Interactions (seeMurray et al., 1996) by a blinded, trained rater.

Mothers were asked to attend six sessions of theirassigned intervention after which they completed ques-tionnaires and were filmed interacting with their infantagain at infant age 19 weeks (median 19). Any mother

port group and non-depressed group at baseline, outcome and one year

df) p p (massage andsupport groups)

p (massage andnon-depressed)

p (support groupand non-depressed)

4 (2) b .01 .53 b .01 b .011 (2) b .01 .77 b .01 b .01.01(2) b .01 .15 b .01 b .01

.98(2) .38 .47 .53 .17

.1(2) .4 .43 .18 .58

7 (2) .85 .96 .61 .64

5 (2) b .01 .13 b .01 b .015 (2) b .01 .9 b .01 b .01.68(2) .53 .5 .26 .69

.2 (2) .12 .77 .06 .1

.2 (2) .82 .93 .63 .56

1 (2) .99 .98 .93 .91

3 (2) b .01 .65 b .01 b .013 (2) b .01 .39 b .05 b .015 (2) .2 .55 .08 .27

5 (2) b .05 .08 .13 b .01

2 (2) .08 .3 .18 b .05

5 (2) .71 .41 .67 .66

Fig. 1. Median EPDS scores at each timepoint for each study group(median scores illustrated due to non-normal distribution of scores atone year).

191M. O′Higgins et al. / Journal of Affective Disorders 109 (2008) 189–192

who completed four sessions or more as well as theoutcome measures was included in the analyses.

Mothers were followed up at one year when theycompleted the questionnaires again and were filmedinteracting with their baby. Mothers and babies sat onthe floor and were free to move about. They were filmedby a concealed camera as they played with two toyspresented one at a time for 4 min each. The same ratingscale was used as previously, adapted for the infant′sdevelopment.

Mothers in the non-depressed group attended ap-pointments at the same timepoints but did not attend anyinterventions.

2.1. Interventions

The 1 h infant massage classes were run by trainedmembers of the International Association of InfantMassage (http://www.iaim.org.uk/). Each class beganwith a group discussion and then focussed on differentmassage strokes demonstrated by the instructors ondolls. The emphasis was on paying attention to infantcues and responding appropriately so different massagestrokes and amounts of massage would happen for eachmother–infant pair and in each class.

The support group was set up specifically for theresearch project and was run by an experienced researchteam member. The 1 h groups were open-ended with nodefined start or end session. Numbers attending rangedfrom 2 to 6 per week as not all mothers on the registerwere able to attend each week. Practical help withtelephone helpline numbers and information on benefitentitlements was given.

2.2. Analysis

To compare scores between groups, ANOVAs withpost hoc Bonferroni tests were run. To evaluate theEPDS scores in the context of clinical improvement,the proportion of mothers in the two depressed groupswho showed a clinical reduction of four points or morebetween timepoints was compared (see Matthey, 2004).In addition, mean (or median, as appropriate) scoreswere examined to assess whether scores were in thedepressed or non-depressed range for each group at eachtimepoint.

3. Results

All subjects were well educated, with 88% of thedepressed group having been educated until at least18 years, predominantly white (70%) and married or

living with their partner (87%). At baseline, the twodepressed groups were similar to each other on allquestionnaire measures but differed significantly fromthe non-depressed group (see results in Table 1). On thevideo-taped observed interaction, there were no sig-nificant differences between the three groups.

At outcome, anxiety and depression scores (SSAIand EPDS) for both depressed groups remained higherthan those in the non-depressed group. The massage-group EPDS scores were non-significantly lower thanthe support group. However significantly more of themassage group had achieved a clinically significantreduction in EPDS score (87%) than the support group(63%) over the study period (pb0.05). The infant ICQratings had normalised to those for the non-depressedmothers. The mother–infant interactions for all groupsremained similar.

At one year the depressed groups were still scoringsignificantly higher than the non-depressed on the de-pression and anxiety scales. The change in scores on theEPDS over the course of the study is illustrated in Fig. 1.The median score for the massage group was below thecut-off for possible depression at one year, whereas thatfor the support group was not. However, there was nosignificant difference between the scores of the massageand support groups at this point.

A notable difference between the groups in theirmother–infant interactions at one year was that themassage group and non-depressed group were equivalentin their scores on the scale looking at maternal sensitivity

Role of funding sourceFunding of this study was provided by the Foundation for Inte-

grated Health. The FIH had no further role in the study design, thecollection, analysis and interpretation of data or in the writing of thereport and decision to submit the paper for publication.

Conflict of interestNo conflict declared.

192 M. O′Higgins et al. / Journal of Affective Disorders 109 (2008) 189–192

while the support group was performing significantly lesswell than the non-depressed group.

4. Discussion

Mothers with postnatal depression who attendedinfant massage classes or support group sessions bothshowed a marked improvement in depression scores, butboth groups still scored significantly above the non-depressed controls at one year. Since a no-treatmentdepressed group was not included for ethical reasons, itis not possible to be sure that any reduction in de-pression was due to intervention rather than spontaneousrecovery, although an early study found no improve-ment in women with postnatal depression withoutintervention (Holden, Sagovsky, & Cox, 1989). Onsome indices the massage group did do better than thesupport group, particularly those who showed aclinically meaningful reduction in EPDS score (at least4 points) from recruitment to outcome. Some of this fallwas between recruitment and baseline. This phenom-enon has been described previously and suggests thatanticipated as well as actual support can be beneficial(Appleby, Warner, Whitton, & Faragher, 1997). On theInfant Characteristics Questionnaire, both depressedgroups showed an improvement in scores and wereequivalent to the non-depressed group at outcome andremained so at one year.

One aim of the study was to investigate possibleimprovements in mother–infant interaction. This wasconfounded by the fact that this group of depressedmothers did not show impaired interaction at baseline.This may be because they were generally a well edu-cated group without the extra stresses of poverty. How-ever it is of some interest that those in the support groupdid show impaired sensitivity at one year, whereas themassage group did not. It may be that continued de-pression did have an impact over the course of a year,and this was helped by the understanding of infant cuesand behaviour learned in the massage classes. Howeverone must be cautious in this interpretation, and note thatother aspects of interaction were similar in all threegroups.

In conclusion, the mothers attending both types ofgroup improved substantially, but not into the controlrange. Some of the results favour the infant massageclasses but these are not very marked. There is no

evidence to suggest that infant massage classes are inany way harmful and as an intervention that is non-pharmacological and includes the baby, they are apractical option for mothers, which they often enjoy.

Acknowledgements

We would like to thank Diana Adams for all her helpon the project and also all the mothers and babies whotook part as well as Cherry Bond and her team who ranthe infant massage classes.

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