Maternal Mental Health: Overview of the HEART Reading Pack

Prof Crick LundDepartment of Psychiatry and Mental Health

University of Cape TownEmail: crick.lund@uct.ac.za

What is depression?1

Core requirements:• Depressed mood (feels sad, empty or hopeless)• Loss of interest and enjoyment/pleasure• Reduced energy leading to increased fatigue and diminished activity. Plus 3 or more of the following: significant weight gain/loss; insomnia/hypersomnia; psychomotor agitation/retardation; feeling excessively worthless/guilty; diminished ability to think/concentrate; recurrent thoughts of death/suicideNote: • Symptoms must cause clinically significant distress or impairment in

social, occupational or other important areas of functioning• Symptoms must persist for at least a 2 week period (major depressive

episode)

1. DSM-5, American Psychiatric Association, 2013; ICD-10, WHO, 2010

What is maternal depression?

• Depression experienced by a mother during pregnancy or the postnatal period (first 12 months of her baby’s life)

• The experience of maternal depression may vary substantially across cultures, and is expressed in various idioms of distress, e.g.:– kufungisisa “thinking too much” in Zimbabwe– ukudakumba “being sad or unhappy” and ucingakakhulu

“thinking too much” in South Africa– yandimukuba “being struck by pressure” in Uganda

Why should we treat maternal depression?

The burden of Common perinatal mental disorders (depression and anxiety) is high:

– High income countries: 13% (antenatal); 10% (postnatal)

– Low and middle-income countries: 16% (antenatal) ; 20% (postnatal)

Fisher et al 2012

Photo: Alexia Beckerling

Why should we treat maternal depression?Prevention: intergenerational impact

Antenatal distress Postnatal distress• Chronic mental illness• Drugs / alcohol• Suicide/Infanticide

ChildInfancy• Emotional

problems• Cognitive

problems• Poor growth• Diarrhoeal

disease• Malnutrition

Childhood / Adolescence• Mental health problems• Impaired mother-child

relationships

Mother

Poor bonding

Dysfunction may influence

the next generation

Trans-placental

Risk Factors

Why should we integrate?The good news

• Unique opportunities for health system contact with mothers– Antenatal Care– Postnatal Care

• Evidence for effective treatment– Low resource settings (India, Pakistan, Chile) –

WHO Thinking Healthy Manual– The Perinatal Mental Health Project model

(South Africa) • Efficient investment for child outcomes

(Heckman’s model)

Investment hypothesis

Investing in Early Human Development: Timing and Economic Efficiency Orla Doyle, Colm P. Harmon, James J. Heckman,and Richard E. Tremblay Econ Hum Biol. 2009 March; 7(1): 1–6.

Steps to integrating mental health care into routine maternal health care • Select a suitable locally relevant screening or

detection tool. • Adapt and translate the screening tool if

necessary.• Conduct a needs assessment.• Based on the identified need, design a

stepped care approach, appropriate to local setting:– Step 1: Routine or selected antenatal and

postnatal screening– Step 2: Screen positives referred for evidence-

based counseling– Step 3: Referral of mothers who are not

responsive to counseling for assessment by medical doctor for potential anti-depressant medication.

Photo: PMHP

Cautionary notes

• Consider options for screening tools carefully.

• 5-day training using the WHO Thinking Healthy manual

• Ongoing supervision of counselors is essential!

• Select counselors carefully based on:– Personal capacity for empathy– Motivation– Skills