The world's first ever analysis of data from a full scale clinical trial in adults shows that training Health Visitors to assess and psychologically support mothers after childbirth can prevent the development of depression over the following year.
But the substantial reduction in the number of NHS health visitors was identified by researchers as a key issue for the health and well-being of mums.
The prevention study was led at the University of Leicester by Professor Terry Brugha with researchers from the universities of Nottingham and Sheffield. It is being published in the Cambridge University Press journal Psychological Medicine.
While small scale studies have been carried out into the prevention of depression among adults, this peer refereed scientific report is the first sufficiently large scale randomised trial to clearly show a statistically significant reduction in future cases of depression in women living in the community who were not depressed when they joined the study.
Lead author Professor Brugha, of the University of Leicester Clinical Division of Psychiatry, Department of Health Sciences, said: "Up until now, it was thought that depression could only be treated when it is picked up by a GP or Health Visitor. But this study shows that women are less likely to become depressed in the year after child birth if they are attended by an NHS Health Visitor who has undergone additional training in specific mental health assessment and in psychological approaches based on either cognitive behavioural or listening techniques.
"Women receiving usual care were significantly more likely to develop depression six months after childbirth.
"However, when the research team set out to repeat and develop further this research they were unable to make sufficient progress because in most parts of England there has been a substantial reduction in the number of health visitors funded by the NHS. Mothers were fortunate if they receive just one home visit from a Health Visitor. Health Visitors were unable to take time off to undergo the extra training in assessment of depression and psychologically support approaches. Therefore the research team at the University of Leicester are now considering undertaking further research on prevention of postnatal depression in other parts of the world."
Other key findings were:
- Intervention women, who had a Health Visitor with additional mental health training, were 30% less likely to have developed depression six months after child birth compared to control women receiving usual care.
- The results suggest that these improvements continued throughout the eighteen month follow-up. Even women who had few or no complaints of depression at six weeks following child birth appeared to benefit later if their Health Visitor had additional training.
- If the Health Visitor with additional training discussed the results of depression screening with the mother at six weeks it appears there was even more benefit and less risk of developing later depression.
- There was evidence that the training programme was also cost effective even when the cost of extra training was taken into account. Health visitors with the new training were found to spend less general time with mothers but more time with those who needed emotional support.
- In discussing the findings the investigators considered that the quality of the ongoing relationship between the Health Visitor and mother, which can continue until the child starts to attend school, may have provided the mother with a reliable confidant she knew she could turn to later if necessary. It may also have helped to know that she would not have to discuss emotional concerns with a different person such as her doctor or a psychologist and that access to help would be easy and non stigmatizing.
- The investigators were successful in obtaining further funding to undertake similar research in Leicestershire and Northamptonshire but were unable to do so because of the critical reduction in the number of Health Visitor Staff available. Health Visitors told them that they wanted to receive such training and to support such research but they were struggling to provide a minimum of one home visit for each new childbirth.
Depression is thought to affect about one in ten women following child birth, depending on the definition and method used to assess depression. The consequences for the child and family are even more profound and concerning than when depression affects adults at other times.
The World Health Organisation has predicted that depression will be a leading cause of disability due to ill health by the year 2020. Although depression can be treated effectively with medication and psychological approaches there is no evidence that rates of depression have fallen since these treatments became available. It is also often the case that once treatment is stopped the condition can relapse.
The prevention study involved analysing data already collected as part of the PoNDER clinical trial originally designed to test the effectiveness of health visitors identifying and managing postnatal depression following child birth. Dr Jane Morrell, now at the University of Nottingham, was Principal Investigator for the PoNDER trial with a team of researchers at the Universities of Sheffield (Jane Morrell, Pauline Slade, Stephen Walters), Leicester and Leeds, with funding from the NIHR Health Technology Assessment programme , London.
While the PoNDER treatment trial was published in the BMJ in 2009, the research into prevention of depression required additional collaborative analysis by the authors of this new scientific paper which is now published separately in the Cambridge University Press journal Psychological Medicine.
"Universal prevention of depression in women postnatally: cluster randomized trial evidence in primary care", appears in the journal Psychological Medicine (2010) Vol 40. Cambridge University Press, doi:10.1017/S0033291710001467 at (http://dx.doi.org/10.1017/S0033291710001467)
NOTES TO EDITORS:
For interviews contact Professor Terry Brugha, University of Leicester, on tel 0116 258 4395 or email firstname.lastname@example.org
For interviews with Health Visitors contact Jimmy Endicott, of NHS Leicester City, on tel 0116 295 8319 or email Jimmy.email@example.com
For any further interview enquires, contact Ather Mirza at the University of Leicester Press Office, 0116 252 3335, firstname.lastname@example.org
Peer referees who advised the scientific journals asked to consider publishing these findings offered the following comments:
"I think this is an excellent piece of work. It contains secondary data from a well-designed randomized controlled trial, which has sufficient statistical power to show that universal prevention is effective for preventing postpartum depression. This is the first trial that has had sufficient power to find this... my compliments for an excellent piece of work."
"Overall, this is a novel study that extends published reports of the parent study findings (Morrell et al., 2009a; Morrell et al., 2009b) to a subgroup of women with subthreshold postnatal depressive symptoms. The research topic is important, timely, and appropriate for scientific publication. Additional strengths of the study include a large sample (that was calculated to account for both individual and cluster-level effects), the use of well-validated measures, and longitudinal data".
"There are significant strengths to this paper. First of all, it addresses an important problem, that of depressive symptomatology and post natal depression. Secondly, it uses an approach which relies not on physicians or other highly trained personnel but rather on a standard public health intervention group, i.e., home visitors. Thus, dissemination of the program is likely to be quite possible".
The study was a prospective cluster trial, randomized by GP practice, with follow-up for 18 months in 101 primary care teams in the Trent area of England. The participants were women scoring as not depressed on the Edinburgh Postnatal Depression Scale (EPDS) at 6 weeks after child birth (1474 intervention women and 767 control women).
Additional analyses from this trial showed the probability that the intervention is cost-effective at various 'threshold values' of a quality-adjusted life year (QALY). In the range of QALY values between £20 000 and £30 000, the probability of the intervention being cost-effective was over 99%.
The National Institute for Clinical Excellent (NICE) has developed guidance on the identification and treatment of depression during pregnancy and following childbirth.