This presentation looks at what maternal depression is and why we should treat it. Prevention of intergenerational impact is important here. Integrating treatment into health systems is discussed.

1. Maternal Mental Health: Overview of
the HEART Reading Pack
Prof Crick Lund
Department of Psychiatry and Mental Health
University of Cape Town
Email: crick.lund@uct.ac.za

2. 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/suicide
Note:
• 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

3. 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

4. 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

5. Why should we treat maternal depression?
Prevention: intergenerational impact
Antenatal distress Postnatal distress
• Chronic mental illness
• Drugs / alcohol
• Suicide/Infanticide
Child
Infancy
• 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

6. Risk Factors

7. 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)

8. 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.

10. 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

11. 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