Psychologist
Jeannette Milgrom discusses mental health issues that can arise in
women during pregnancy, and their effect on the developing fetus.
Despite considerable research and media attention on postnatal
depression (PND), we learn that the antenatal period, too, has its
associated risks, and that treatment and intervention programs can have a
positive impact over the entire perinatal period. Presented by Dr Andi
Horvath. - See more at:
http://upclose.unimelb.edu.au/episode/337-fetal-impact-managing-depression-during-pregnancy-and-beyond#transcription
ANDI
HORVATH
I'm Dr Andi Horvath. Thanks for joining us. We know from decades of researching infant development that the early parent-infant relationship provides a critical foundation for the child's future learning abilities and self-management of emotions. Our guest on Up Close today is psychologist, Jeanette Milgrom. She started her early research on mother and infant interactions and explored what situations put infants at higher risk of behavioural, emotional and cognitive problems. She also highlighted the importance of treating both mothers and infants linking the effect of postnatal depression or PND on infant development. Her later applied research at the Parent Infant Research Institute led to setting up effective treatment programs for PND which have been adopted around the world. Her recent published work shows that treatment of depression and anxiety during pregnancy, the ante-natal period, produces better early infant outcomes. So treating antenatal depression will be as critical as treating postnatal depression, especially as antenatal depression can also be an indicator of postnatal depression. It appears treating depression and mental wellbeing for society starts in the womb and treating maternal depression and anxiety across the entire perinatal period is the key. Professor Jeanette Milgrom is founder and executive director of the internationally recognised Parent Infant Research Institute (PIRI) which is part of Austin Life Sciences based at Austin Health and affiliated with the University of Melbourne. Welcome to Up Close, Jeanette.
JEANETTE MILGROM
Thank you.
ANDI HORVATH
Pregnancy is stressful on its own but what are the trouble signs in antenatal and postnatal maternal mental health?
JEANETTE MILGROM
Yes, it's a big area because it's so common, mental health difficulties, in both pregnancy and in the first year postpartum. We know that severity of anxiety and depression, which are the most common problems, varies - so it varies right from mild mood symptoms to rather severe disorders that we call clinical depression. If a woman has a clinical depression then she will have a number of symptoms which might include not only depressed mood but loss of interest, there might be some mood and weight changes, inability to concentrate, feelings of worthlessness and quite worryingly, a number of women do have fleeting thoughts of suicide which we need to pay attention to. Taken together these symptoms constitute a clinical depression. The less severe forms are more or less, less of those symptoms and less severe and less of the time. We know that depression is something that affects one in 10 women but that also anxiety usually appears or coexists with postnatal depression and antenatal depression. We know that antenatal depression is a very powerful predictor of postnatal depression so whilst there's been a lot of emphasis on postnatal depression we're coming to recognise also that you need to be very watchful about a woman's mental health at this time where women expect it to be a terribly joyous time, not a time society generally expects women to be feeling so black and so low and it's devastating for women and their partners.
ANDI HORVATH
You mentioned that one in 10 women suffer PND so what actually is the incidence in maternal depression? I mean this sounds like it's actually a public health priority that's quite prevalent.
JEANETTE MILGROM
Absolutely. There's many figures that are around depending on how you measure depression but if we stick to measuring a depression that has a clinical diagnosis then it's about 12.9 per cent is the best estimate at let's say three months postpartum and it varies across the first year but it ends up being about one in seven, one in 10 women. If you start adding how many women have depression in the entire first year it gets closer to 19 per cent so we're really talking about a lot of women. Similarly for anxiety, for example a generalised anxiety disorder, about eight per cent of women postnatally may suffer from anxiety of a general sort. It is something that we no longer think of as something only a few women have it because even more will just have low days or find it hard to cope.
ANDI HORVATH
Does pregnancy bring on a whole new set of stressors that means we actually see more antenatal and postnatal depression?
JEANETTE MILGROM
More than in the past or just more than at other times of life?
ANDI HORVATH
More than at other times of life.
JEANETTE MILGROM
That's a really interesting question I think and it's actually still being debated a little. There is some evidence that the incidence of depression just across the lifespan is also pretty high so one in five people might experience depression. How much more is debatable and there's two ways I can answer that really. One is that it's probably a little higher but the symptoms of depression take on a very particular significance when you have a baby. When you're feeling so low that all you want to do is curl up in bed, you can't really talk, everything looks black and you have a baby crying who needs you all the time then the symptoms become even worse because you are having to meet a demand that is on you 24 hours a day. Secondly, for what we call the psychotic disorders which are the more rarer forms of mental health disorders like bipolar disorders and so on, then we do see definitely an increased incidence in the postpartum particularly of postpartum psychosis. So yes there probably is an increased risk associated with the perinatal period but it's also a terrible time to be depressed.
ANDI HORVATH
Jeanette, what's the definition of perinatal?
JEANETTE MILGROM
Yes, the common definition is from conception to two years of age. Infant - there's some definitions that take on infant up to one year of age because the word infant comes from the Latin, infants meaning speechless but generally what is meant by that perinatal period is definitely conception to one year and we extend that to two years where often infancy is part of that.
ANDI HORVATH
Talking about this perinatal period, is it universal across countries? Do we see it in all cultures?
JEANETTE MILGROM
The short answer is yes. I think that there are some reports of variations in how symptomatology might be expressed in different cultures but there's a lot of interest now in cross-cultural research of perinatal depression. Low income countries however do have a higher incidence of postnatal depression according to what we know, quite alarmingly high whilst they're grappling with a whole lot of other social problems. However, there's culturally appropriate ways of disclosing your depression. Some cultures may somatise or show bodily symptoms more than talk about their worries and anxieties so we also need to be aware that diagnosing or identifying depression in other cultures may require a different approach.
ANDI HORVATH
Right so there's obviously stigma still in many cultures and pockets of the community, our own communities even where depression is sort of not expressed and as you said, expressed through the body instead so these are signs that we need to look out for?
JEANETTE MILGROM
Yes, as you say, in our culture stigma still seems alive and well not only from other people but women themselves who really feel that they should be coping, feel shame, may feel that somebody might take their baby away if they're found to be depressed and what's fascinating is that even once identified as depressed very few women seek help. And that is probably one of our biggest problems, this reluctance to seek help, this need to help women come to recognise that this is something that's quite common.
ANDI HORVATH
So what happens if maternal depression and anxiety is not picked up? If it's not picked up antenatally or even postnatally how does it affect infant learning and emotional mental development? How did we come to know this link?
JEANETTE MILGROM
Well this is what's worrisome. There are some quite significant impacts on the mother herself as well as the infant. Antenatally for example we find that there's probably biological mechanisms that affect the developing foetus of depression and anxiety. Whilst we don't fully understand those mechanisms there is some longer term evidence of really quite substantial impact on infant development. Cognitive, behavioural, attention deficit disorder for example have been identified in repeated studies following severe stress, depression and anxiety. Postnatally there may be a number of mechanisms by which postnatal depression affects the infant for example. We now know how important a responsive contingent relationship between a mother and baby is and we find that women who are depressed not surprisingly find it very difficult to engage in the sort of interaction that is optimum for child development. This can be an escalating spiral of ongoing difficulties. If you can imagine a mother who is depressed and not very emotionally available and her infant learns to look away and feels that no one's there. Then the infant's looking away, the mother feels rejected, she has such low self-esteem anyway that it's a very difficult time for both. We find again that postnatal depression possibly mediated by that early relationship has effects on the child's behavioural and cognitive development later on and some of our own research has done that too. Recently we were co-authors in a Lancet series in late 2014 really talking about what do we know about what happens and the long term consequences are there.
ANDI HORVATH
I'm Andi Horvath and our guest today on Up Close is clinical psychologist, researcher and infant mental health specialist Jeanette Milgrom. We're talking about the importance of maternal support in the perinatal period. The first step to treating antenatal depression and anxiety in the perinatal period is identification of risk factors and diagnosis. Jeanette, what led you to investigate antenatal depression?
JEANETTE MILGROM
As a researcher we look at the research literature and the alarming thing is for well over a decade we have known about the detrimental impact of antenatal depression on the developing foetus and yet there have been very little attempts to remedy that. We've just had a paper accepted in the Archives of Women's Mental Health 2015 which is really the first to look at well if there's this terrible impact of depression on the infant, if you treat it does it make a difference? Our preliminary findings are very exciting but that is the sort of reason we got into the area; that we have known about it for a long time. We've also known about the risk factors. Depression in pregnancy is one of the most powerful predictors of postnatal depression. Everything points to well let's start as early as we can. We need to focus both on antenatal depression and new episodes of postnatal depression and also because the longer a woman is depressed, chronicity, the worse the outcome for herself and her baby and also the partner relationship. There is a high incidence of distress amongst couples if one partner is depressed.
ANDI HORVATH
Tell me more about the risk factors and signatures for perinatal depression. For instance, are there predispositions and what if there isn't partner support or these situations which can occur?
JEANETTE MILGROM
Yes so of course there's been endless studies trying to understand what causes postnatal depression. We tend to employ what we call a biopsychosocial model because there are biological influences where, you're right, genetics and a family history of depression all predict later depression. There are also social influences but probably the largest number of factors are what we call psychosocial. I've already mentioned antenatal depression but I want to highlight anxiety as well, antenatal anxiety. Lack of support not just from the partner but practical, financial, people type support is also another risk factor, also life stressors and adverse life events that take a toll. I like to talk about when we treat mothers a stress and coping model that the more stressors you have, we all have resources but the balance gets tipped for any of us. Concurrent stressors could include things even like social isolation. That can be a real stressor for a young mother with an infant. The sleep deprivation, the lack of support is really a big one. Domestic violence is also emerging as a big one, child past abuse. Then some of the general factors that predispose any individual to depression such as low self-esteem and negative thinking style. There are a lot but those are some of the big ones that could tip the balance.
ANDI HORVATH
Jeanette, pace us through your research methodology because we're keen to understand how you collect data about parent-infant relationships.
JEANETTE MILGROM
Yes, well I go back to my PhD there. I started with looking at mother-infant relationships and it is a very difficult thing to measure and very time consuming. There's really two ways of measuring the mother-infant relationship. One is through asking the mother questions about her relationship but probably the more powerful one is through direct observation. We actually video mothers and babies doing a number of tasks such as playing as they normally do, doing structured tasks together and then there's a huge number of rating scales. When I started we were rating second by second eye gaze and vocalisation. I'm glad to say that that's not the current trend. The current trend, more global types of attributes such as how responsive the mother is to her infant's cues, how appropriate, how timely, that's one major factor and you can rate that in an interaction, how engaged, how synchronous is the interaction because interactions involve an interdependent complex series of behaviours. It's those things that lay the foundation to learning interpersonal communication, the baby getting a sense of that they are a person or that what they do creates a response in the world. They're the sorts of things that are well done through actual observation of mothers and babies but it's still very time consuming.
ANDI HORVATH
Do you ever have any situations where the mother is not able to look after the child for a number of reasons but you have the partner who becomes the primary carer?
JEANETTE MILGROM
Well absolutely. This is one of the difficulties when you're trying to help families where one person - where the mother might be seriously depressed. How much do you bring in other people to help support the baby without further making the mother feel a total failure? Dancing through that fine line where you do try to involve the mother and what Australia really can boast with some of the very serious cases of depression is that we have a lot of what we call mother-baby units in hospitals so if a mother actually needs an admission we admit her with her baby. Having said that, having the partner or flying in relatives or mother-in-law or mother can be part of what can help that baby continue to receive that sort of important dyadic interplay that is needed and develop a good attachment, which is the other thing that we find a good mother-infant relationship does or a good enough attachment we talk about - that's very important, good enough - to develop secure attachment and later interpersonal relationships.
ANDI HORVATH
There really is wisdom in the phrase it takes a village to raise a child?
JEANETTE MILGROM
Absolutely. Absolutely like social support, partner support, family support, community awareness and acceptance is terribly important and we really need to be all working together to pull in.
ANDI HORVATH
I'm Andi Horvath and our guest today on Up Close is clinical psychologist, researcher and infant mental health specialist Jeanette Milgrom. We're talking about the importance of maternal support in the perinatal period. Intervention and treatments for maternal depression and anxiety in the perinatal period provide better outcomes for both the infant and the mother. Some of Jeanette's online interactive initiatives are now used around the globe. Jeanette, tell us about the development of these online interactive interventions for antenatal depression.
JEANETTE MILGROM
Well I'll start perhaps at the beginning of when we first started our signature intervention so to speak because we've now developed a suite of interventions for assisting mothers and babies and fathers, which was depression treatment, a face-to face-treatment in the traditional style. It's one of the first that was developed specifically for postnatal depression. If you're going to help women manage their anxiety let's say and they have a baby you're not going to have them lying down three times a day doing relaxation and we coined [it] ‘relaxation on the run’. We spent a lot of time thinking about how do you adapt psychological treatment for women with postnatal depression.
Then the next stage of development, more recently in the last five years, was we know the incredible prevalence of ante and postnatal depression. We now have in Australia a national perinatal depression initiative and we contributed to the research that led to that initiative, which has a government recommendation and some support to identify every pregnant and postnatal woman. Whilst we're going to use local primary care services and in Australia we're lucky we have Medicare, we also need to improve access for remote and isolated women and also those who can't even make it out of the house being depressed and with a baby. So we teamed up with a group in the US at Oregon Research Institute, Dr Brian Danaher and Dr John Seeley who were behavioural change experts online. With National Institutes of Health (NIH) funding we spent three years developing a MumMoodBooster program. It's called MomMoodBooster in the US so it has two versions. And we spent a long time making it very interactive so that it isn't just information about depression. We involve a telephone coach and women are able to create their own workbook to see how they're going, to see how their mood is tracking over time and to really be able to engage in a very live way with an online sort of video host that takes them through it.
We've had fantastic response to it and we've now published two papers on this. We've had lots of interest. We're about to publish the first randomised control trial and we're now going on to even more different types of evaluations. We're now adapting the postnatal version for antenatal use.
ANDI HORVATH
Tell me about your PRIMER program. This program's actually directed towards healthcare professionals.
JEANETTE MILGROM
Well that's right. I was mentioning before how many women do not seek help so we need to understand why that is. One of the reasons we come to understand is that women feel stigmatised but another reason is that they haven't yet come to the point of feeling that they want to admit to the problem and that they can seek help. So motivational interviewing is a technique that's been used rather successfully in other areas of health and we decided to adapt it for the perinatal period. In Australia women are fortunate that they usually have a series of encounters with maternal and child health nurses after the birth of their baby so we trained nurses and we've just finalised a large cluster randomised trial. We taught nurses to do motivational interviewing to help women move towards being ready to say I have a problem and I'm going to seek help. The program's been very well received by women and nurses. That is just one step in helping the engagement process.
ANDI HORVATH
Whilst your programs are very maternal orientated is there a chance for these programs to actually involve the broader family, partners, fathers, carers?
JEANETTE MILGROM
Absolutely. Our programs involve fathers and increasingly the more we research the role of fathers the more relevant it is. Right from the beginning our treating postnatal depression programs, we'd always have some couples sessions. We really need to recognise that partners might have their own mental health issues or might need help and understand what on earth is happening to their partner. If you imagine a typical family situation where the father might be the sole breadwinner for the first time, he's feeling very burdened, very tired because he gets woken up by the baby, he goes to work, he has all these financial problems but also he comes home and his wife's not coping, he gets handed the baby the minute he walks in the door. It's really very stressful. Communication between couples is imperative so we also developed a program called "Towards Parenthood" which is now being used in the UK in a big trial which is for mothers and fathers to understand postnatal depression, to improve their communication skills. It's like a self-help workbook that they work through together, not just talk how are we going to get through the birth and breathe better but how are we going to manage with what is going to be a big lifestyle change for us as a couple with a baby. We need to start antenatally as well as then support couples postnatally. On our online treatment we're now looking to try and hopefully seek funding to expand the father's website for that too.
If I can add, the other critical member of the family is the infant. Because we now know that unfortunately treating postnatal depression is not sufficient to necessarily reverse what's happened to the mother and the baby we've now developed programs and continue to evaluate them as we speak, of how we can, in a manageable way because we live in a world where cost effectiveness is important, how we can try to improve the mother-infant interaction. The good news is that even with very brief interventions we are able to start achieving some very significant changes.
ANDI HORVATH
These interventions and treatments are essentially talk therapies. Is there often pharmaceuticals involved as well?
JEANETTE MILGROM
Absolutely. Depression in general is often treated with antidepressants in the general community. Having said that, the perinatal period is a time that women are often very reluctant to have antidepressants because the evidence about the impact on the developing foetus and postnatally when you're breastfeeding still has some concerns. Generally what we advise women is that they have to with their health professional discuss the risks and benefits. For some women at the more severe end a combination therapy may be helpful. We just finished a trial which again has been published just last year, comparing depression treatment and psychological treatment. The good news is that, for moderately severe depression, talk therapies did better.
ANDI HORVATH
Jeanette, talk us through the professional screening that Australia has set up for perinatal depression and also does it happen in other countries?
JEANETTE MILGROM
The answer is there's a huge variation and I might take one step back about why should we screen and why should we identify women. Apart from the tremendous emotional cost and consequences on the infant a recent economic analysis by the London School of Economics (LSE) just late last year talked about the huge economic impact equivalent to about $20,000 per birth of perinatal depression. So there's an economic and a social emotional reason to identify all women and we know women will not necessarily seek help on their own. Screening usually refers to the health profession who regularly sees women antenatally or postnatally including in their medical assessment a question about mental health. There's been some very simple tools developed to do this. Now there is some controversy about it because there still is some lack of large scale studies that have shown where the screening actually does result in what you hope it will. Nevertheless, having just finished a book to be released in 2015 on screening by Wiley, which brought together international experts from a lot of countries around the world to talk about well what are the controversies and what do we need to do to make it happen and make it better? More research is needed but we know enough that not doing anything is not the answer, that we need to use what we know to improve identification at this stage.
ANDI HORVATH
Perinatal mental health is critical not just to an infant's welfare but to entire communities everywhere as mental wellbeing allows us to thrive collectively. Professor Jeanette Milgrom from the Parent Infant Research Institute (PIRI) which is part of Austin Life Sciences based at Austin Health and affiliated with the University of Melbourne, thank you so much for being our guest here on Up Close today.
JEANETTE MILGROM
Thank you very much. It's been a pleasure.
ANDI HORVATH
You'll find details of Jeanette's publications and some of the programs that Jeanette has mentioned in this episode of Up Close on our Up Close website, together with a full transcript of this and all our other programs. Up Close is a production of the University of Melbourne, Australia. This episode was recorded on 3 March 2015. Producer was Eric van Bemmel, audio engineering by Gavin Nebauer. Up Close was created by Eric van Bemmel and Kelvin Param. I'm Dr Andi. Cheers.
- See more at: http://upclose.unimelb.edu.au/episode/337-fetal-impact-managing-depression-during-pregnancy-and-beyond#transcription
I'm Dr Andi Horvath. Thanks for joining us. We know from decades of researching infant development that the early parent-infant relationship provides a critical foundation for the child's future learning abilities and self-management of emotions. Our guest on Up Close today is psychologist, Jeanette Milgrom. She started her early research on mother and infant interactions and explored what situations put infants at higher risk of behavioural, emotional and cognitive problems. She also highlighted the importance of treating both mothers and infants linking the effect of postnatal depression or PND on infant development. Her later applied research at the Parent Infant Research Institute led to setting up effective treatment programs for PND which have been adopted around the world. Her recent published work shows that treatment of depression and anxiety during pregnancy, the ante-natal period, produces better early infant outcomes. So treating antenatal depression will be as critical as treating postnatal depression, especially as antenatal depression can also be an indicator of postnatal depression. It appears treating depression and mental wellbeing for society starts in the womb and treating maternal depression and anxiety across the entire perinatal period is the key. Professor Jeanette Milgrom is founder and executive director of the internationally recognised Parent Infant Research Institute (PIRI) which is part of Austin Life Sciences based at Austin Health and affiliated with the University of Melbourne. Welcome to Up Close, Jeanette.
JEANETTE MILGROM
Thank you.
ANDI HORVATH
Pregnancy is stressful on its own but what are the trouble signs in antenatal and postnatal maternal mental health?
JEANETTE MILGROM
Yes, it's a big area because it's so common, mental health difficulties, in both pregnancy and in the first year postpartum. We know that severity of anxiety and depression, which are the most common problems, varies - so it varies right from mild mood symptoms to rather severe disorders that we call clinical depression. If a woman has a clinical depression then she will have a number of symptoms which might include not only depressed mood but loss of interest, there might be some mood and weight changes, inability to concentrate, feelings of worthlessness and quite worryingly, a number of women do have fleeting thoughts of suicide which we need to pay attention to. Taken together these symptoms constitute a clinical depression. The less severe forms are more or less, less of those symptoms and less severe and less of the time. We know that depression is something that affects one in 10 women but that also anxiety usually appears or coexists with postnatal depression and antenatal depression. We know that antenatal depression is a very powerful predictor of postnatal depression so whilst there's been a lot of emphasis on postnatal depression we're coming to recognise also that you need to be very watchful about a woman's mental health at this time where women expect it to be a terribly joyous time, not a time society generally expects women to be feeling so black and so low and it's devastating for women and their partners.
ANDI HORVATH
You mentioned that one in 10 women suffer PND so what actually is the incidence in maternal depression? I mean this sounds like it's actually a public health priority that's quite prevalent.
JEANETTE MILGROM
Absolutely. There's many figures that are around depending on how you measure depression but if we stick to measuring a depression that has a clinical diagnosis then it's about 12.9 per cent is the best estimate at let's say three months postpartum and it varies across the first year but it ends up being about one in seven, one in 10 women. If you start adding how many women have depression in the entire first year it gets closer to 19 per cent so we're really talking about a lot of women. Similarly for anxiety, for example a generalised anxiety disorder, about eight per cent of women postnatally may suffer from anxiety of a general sort. It is something that we no longer think of as something only a few women have it because even more will just have low days or find it hard to cope.
ANDI HORVATH
Does pregnancy bring on a whole new set of stressors that means we actually see more antenatal and postnatal depression?
JEANETTE MILGROM
More than in the past or just more than at other times of life?
ANDI HORVATH
More than at other times of life.
JEANETTE MILGROM
That's a really interesting question I think and it's actually still being debated a little. There is some evidence that the incidence of depression just across the lifespan is also pretty high so one in five people might experience depression. How much more is debatable and there's two ways I can answer that really. One is that it's probably a little higher but the symptoms of depression take on a very particular significance when you have a baby. When you're feeling so low that all you want to do is curl up in bed, you can't really talk, everything looks black and you have a baby crying who needs you all the time then the symptoms become even worse because you are having to meet a demand that is on you 24 hours a day. Secondly, for what we call the psychotic disorders which are the more rarer forms of mental health disorders like bipolar disorders and so on, then we do see definitely an increased incidence in the postpartum particularly of postpartum psychosis. So yes there probably is an increased risk associated with the perinatal period but it's also a terrible time to be depressed.
ANDI HORVATH
Jeanette, what's the definition of perinatal?
JEANETTE MILGROM
Yes, the common definition is from conception to two years of age. Infant - there's some definitions that take on infant up to one year of age because the word infant comes from the Latin, infants meaning speechless but generally what is meant by that perinatal period is definitely conception to one year and we extend that to two years where often infancy is part of that.
ANDI HORVATH
Talking about this perinatal period, is it universal across countries? Do we see it in all cultures?
JEANETTE MILGROM
The short answer is yes. I think that there are some reports of variations in how symptomatology might be expressed in different cultures but there's a lot of interest now in cross-cultural research of perinatal depression. Low income countries however do have a higher incidence of postnatal depression according to what we know, quite alarmingly high whilst they're grappling with a whole lot of other social problems. However, there's culturally appropriate ways of disclosing your depression. Some cultures may somatise or show bodily symptoms more than talk about their worries and anxieties so we also need to be aware that diagnosing or identifying depression in other cultures may require a different approach.
ANDI HORVATH
Right so there's obviously stigma still in many cultures and pockets of the community, our own communities even where depression is sort of not expressed and as you said, expressed through the body instead so these are signs that we need to look out for?
JEANETTE MILGROM
Yes, as you say, in our culture stigma still seems alive and well not only from other people but women themselves who really feel that they should be coping, feel shame, may feel that somebody might take their baby away if they're found to be depressed and what's fascinating is that even once identified as depressed very few women seek help. And that is probably one of our biggest problems, this reluctance to seek help, this need to help women come to recognise that this is something that's quite common.
ANDI HORVATH
So what happens if maternal depression and anxiety is not picked up? If it's not picked up antenatally or even postnatally how does it affect infant learning and emotional mental development? How did we come to know this link?
JEANETTE MILGROM
Well this is what's worrisome. There are some quite significant impacts on the mother herself as well as the infant. Antenatally for example we find that there's probably biological mechanisms that affect the developing foetus of depression and anxiety. Whilst we don't fully understand those mechanisms there is some longer term evidence of really quite substantial impact on infant development. Cognitive, behavioural, attention deficit disorder for example have been identified in repeated studies following severe stress, depression and anxiety. Postnatally there may be a number of mechanisms by which postnatal depression affects the infant for example. We now know how important a responsive contingent relationship between a mother and baby is and we find that women who are depressed not surprisingly find it very difficult to engage in the sort of interaction that is optimum for child development. This can be an escalating spiral of ongoing difficulties. If you can imagine a mother who is depressed and not very emotionally available and her infant learns to look away and feels that no one's there. Then the infant's looking away, the mother feels rejected, she has such low self-esteem anyway that it's a very difficult time for both. We find again that postnatal depression possibly mediated by that early relationship has effects on the child's behavioural and cognitive development later on and some of our own research has done that too. Recently we were co-authors in a Lancet series in late 2014 really talking about what do we know about what happens and the long term consequences are there.
ANDI HORVATH
I'm Andi Horvath and our guest today on Up Close is clinical psychologist, researcher and infant mental health specialist Jeanette Milgrom. We're talking about the importance of maternal support in the perinatal period. The first step to treating antenatal depression and anxiety in the perinatal period is identification of risk factors and diagnosis. Jeanette, what led you to investigate antenatal depression?
JEANETTE MILGROM
As a researcher we look at the research literature and the alarming thing is for well over a decade we have known about the detrimental impact of antenatal depression on the developing foetus and yet there have been very little attempts to remedy that. We've just had a paper accepted in the Archives of Women's Mental Health 2015 which is really the first to look at well if there's this terrible impact of depression on the infant, if you treat it does it make a difference? Our preliminary findings are very exciting but that is the sort of reason we got into the area; that we have known about it for a long time. We've also known about the risk factors. Depression in pregnancy is one of the most powerful predictors of postnatal depression. Everything points to well let's start as early as we can. We need to focus both on antenatal depression and new episodes of postnatal depression and also because the longer a woman is depressed, chronicity, the worse the outcome for herself and her baby and also the partner relationship. There is a high incidence of distress amongst couples if one partner is depressed.
ANDI HORVATH
Tell me more about the risk factors and signatures for perinatal depression. For instance, are there predispositions and what if there isn't partner support or these situations which can occur?
JEANETTE MILGROM
Yes so of course there's been endless studies trying to understand what causes postnatal depression. We tend to employ what we call a biopsychosocial model because there are biological influences where, you're right, genetics and a family history of depression all predict later depression. There are also social influences but probably the largest number of factors are what we call psychosocial. I've already mentioned antenatal depression but I want to highlight anxiety as well, antenatal anxiety. Lack of support not just from the partner but practical, financial, people type support is also another risk factor, also life stressors and adverse life events that take a toll. I like to talk about when we treat mothers a stress and coping model that the more stressors you have, we all have resources but the balance gets tipped for any of us. Concurrent stressors could include things even like social isolation. That can be a real stressor for a young mother with an infant. The sleep deprivation, the lack of support is really a big one. Domestic violence is also emerging as a big one, child past abuse. Then some of the general factors that predispose any individual to depression such as low self-esteem and negative thinking style. There are a lot but those are some of the big ones that could tip the balance.
ANDI HORVATH
Jeanette, pace us through your research methodology because we're keen to understand how you collect data about parent-infant relationships.
JEANETTE MILGROM
Yes, well I go back to my PhD there. I started with looking at mother-infant relationships and it is a very difficult thing to measure and very time consuming. There's really two ways of measuring the mother-infant relationship. One is through asking the mother questions about her relationship but probably the more powerful one is through direct observation. We actually video mothers and babies doing a number of tasks such as playing as they normally do, doing structured tasks together and then there's a huge number of rating scales. When I started we were rating second by second eye gaze and vocalisation. I'm glad to say that that's not the current trend. The current trend, more global types of attributes such as how responsive the mother is to her infant's cues, how appropriate, how timely, that's one major factor and you can rate that in an interaction, how engaged, how synchronous is the interaction because interactions involve an interdependent complex series of behaviours. It's those things that lay the foundation to learning interpersonal communication, the baby getting a sense of that they are a person or that what they do creates a response in the world. They're the sorts of things that are well done through actual observation of mothers and babies but it's still very time consuming.
ANDI HORVATH
Do you ever have any situations where the mother is not able to look after the child for a number of reasons but you have the partner who becomes the primary carer?
JEANETTE MILGROM
Well absolutely. This is one of the difficulties when you're trying to help families where one person - where the mother might be seriously depressed. How much do you bring in other people to help support the baby without further making the mother feel a total failure? Dancing through that fine line where you do try to involve the mother and what Australia really can boast with some of the very serious cases of depression is that we have a lot of what we call mother-baby units in hospitals so if a mother actually needs an admission we admit her with her baby. Having said that, having the partner or flying in relatives or mother-in-law or mother can be part of what can help that baby continue to receive that sort of important dyadic interplay that is needed and develop a good attachment, which is the other thing that we find a good mother-infant relationship does or a good enough attachment we talk about - that's very important, good enough - to develop secure attachment and later interpersonal relationships.
ANDI HORVATH
There really is wisdom in the phrase it takes a village to raise a child?
JEANETTE MILGROM
Absolutely. Absolutely like social support, partner support, family support, community awareness and acceptance is terribly important and we really need to be all working together to pull in.
ANDI HORVATH
I'm Andi Horvath and our guest today on Up Close is clinical psychologist, researcher and infant mental health specialist Jeanette Milgrom. We're talking about the importance of maternal support in the perinatal period. Intervention and treatments for maternal depression and anxiety in the perinatal period provide better outcomes for both the infant and the mother. Some of Jeanette's online interactive initiatives are now used around the globe. Jeanette, tell us about the development of these online interactive interventions for antenatal depression.
JEANETTE MILGROM
Well I'll start perhaps at the beginning of when we first started our signature intervention so to speak because we've now developed a suite of interventions for assisting mothers and babies and fathers, which was depression treatment, a face-to face-treatment in the traditional style. It's one of the first that was developed specifically for postnatal depression. If you're going to help women manage their anxiety let's say and they have a baby you're not going to have them lying down three times a day doing relaxation and we coined [it] ‘relaxation on the run’. We spent a lot of time thinking about how do you adapt psychological treatment for women with postnatal depression.
Then the next stage of development, more recently in the last five years, was we know the incredible prevalence of ante and postnatal depression. We now have in Australia a national perinatal depression initiative and we contributed to the research that led to that initiative, which has a government recommendation and some support to identify every pregnant and postnatal woman. Whilst we're going to use local primary care services and in Australia we're lucky we have Medicare, we also need to improve access for remote and isolated women and also those who can't even make it out of the house being depressed and with a baby. So we teamed up with a group in the US at Oregon Research Institute, Dr Brian Danaher and Dr John Seeley who were behavioural change experts online. With National Institutes of Health (NIH) funding we spent three years developing a MumMoodBooster program. It's called MomMoodBooster in the US so it has two versions. And we spent a long time making it very interactive so that it isn't just information about depression. We involve a telephone coach and women are able to create their own workbook to see how they're going, to see how their mood is tracking over time and to really be able to engage in a very live way with an online sort of video host that takes them through it.
We've had fantastic response to it and we've now published two papers on this. We've had lots of interest. We're about to publish the first randomised control trial and we're now going on to even more different types of evaluations. We're now adapting the postnatal version for antenatal use.
ANDI HORVATH
Tell me about your PRIMER program. This program's actually directed towards healthcare professionals.
JEANETTE MILGROM
Well that's right. I was mentioning before how many women do not seek help so we need to understand why that is. One of the reasons we come to understand is that women feel stigmatised but another reason is that they haven't yet come to the point of feeling that they want to admit to the problem and that they can seek help. So motivational interviewing is a technique that's been used rather successfully in other areas of health and we decided to adapt it for the perinatal period. In Australia women are fortunate that they usually have a series of encounters with maternal and child health nurses after the birth of their baby so we trained nurses and we've just finalised a large cluster randomised trial. We taught nurses to do motivational interviewing to help women move towards being ready to say I have a problem and I'm going to seek help. The program's been very well received by women and nurses. That is just one step in helping the engagement process.
ANDI HORVATH
Whilst your programs are very maternal orientated is there a chance for these programs to actually involve the broader family, partners, fathers, carers?
JEANETTE MILGROM
Absolutely. Our programs involve fathers and increasingly the more we research the role of fathers the more relevant it is. Right from the beginning our treating postnatal depression programs, we'd always have some couples sessions. We really need to recognise that partners might have their own mental health issues or might need help and understand what on earth is happening to their partner. If you imagine a typical family situation where the father might be the sole breadwinner for the first time, he's feeling very burdened, very tired because he gets woken up by the baby, he goes to work, he has all these financial problems but also he comes home and his wife's not coping, he gets handed the baby the minute he walks in the door. It's really very stressful. Communication between couples is imperative so we also developed a program called "Towards Parenthood" which is now being used in the UK in a big trial which is for mothers and fathers to understand postnatal depression, to improve their communication skills. It's like a self-help workbook that they work through together, not just talk how are we going to get through the birth and breathe better but how are we going to manage with what is going to be a big lifestyle change for us as a couple with a baby. We need to start antenatally as well as then support couples postnatally. On our online treatment we're now looking to try and hopefully seek funding to expand the father's website for that too.
If I can add, the other critical member of the family is the infant. Because we now know that unfortunately treating postnatal depression is not sufficient to necessarily reverse what's happened to the mother and the baby we've now developed programs and continue to evaluate them as we speak, of how we can, in a manageable way because we live in a world where cost effectiveness is important, how we can try to improve the mother-infant interaction. The good news is that even with very brief interventions we are able to start achieving some very significant changes.
ANDI HORVATH
These interventions and treatments are essentially talk therapies. Is there often pharmaceuticals involved as well?
JEANETTE MILGROM
Absolutely. Depression in general is often treated with antidepressants in the general community. Having said that, the perinatal period is a time that women are often very reluctant to have antidepressants because the evidence about the impact on the developing foetus and postnatally when you're breastfeeding still has some concerns. Generally what we advise women is that they have to with their health professional discuss the risks and benefits. For some women at the more severe end a combination therapy may be helpful. We just finished a trial which again has been published just last year, comparing depression treatment and psychological treatment. The good news is that, for moderately severe depression, talk therapies did better.
ANDI HORVATH
Jeanette, talk us through the professional screening that Australia has set up for perinatal depression and also does it happen in other countries?
JEANETTE MILGROM
The answer is there's a huge variation and I might take one step back about why should we screen and why should we identify women. Apart from the tremendous emotional cost and consequences on the infant a recent economic analysis by the London School of Economics (LSE) just late last year talked about the huge economic impact equivalent to about $20,000 per birth of perinatal depression. So there's an economic and a social emotional reason to identify all women and we know women will not necessarily seek help on their own. Screening usually refers to the health profession who regularly sees women antenatally or postnatally including in their medical assessment a question about mental health. There's been some very simple tools developed to do this. Now there is some controversy about it because there still is some lack of large scale studies that have shown where the screening actually does result in what you hope it will. Nevertheless, having just finished a book to be released in 2015 on screening by Wiley, which brought together international experts from a lot of countries around the world to talk about well what are the controversies and what do we need to do to make it happen and make it better? More research is needed but we know enough that not doing anything is not the answer, that we need to use what we know to improve identification at this stage.
ANDI HORVATH
Perinatal mental health is critical not just to an infant's welfare but to entire communities everywhere as mental wellbeing allows us to thrive collectively. Professor Jeanette Milgrom from the Parent Infant Research Institute (PIRI) which is part of Austin Life Sciences based at Austin Health and affiliated with the University of Melbourne, thank you so much for being our guest here on Up Close today.
JEANETTE MILGROM
Thank you very much. It's been a pleasure.
ANDI HORVATH
You'll find details of Jeanette's publications and some of the programs that Jeanette has mentioned in this episode of Up Close on our Up Close website, together with a full transcript of this and all our other programs. Up Close is a production of the University of Melbourne, Australia. This episode was recorded on 3 March 2015. Producer was Eric van Bemmel, audio engineering by Gavin Nebauer. Up Close was created by Eric van Bemmel and Kelvin Param. I'm Dr Andi. Cheers.
- See more at: http://upclose.unimelb.edu.au/episode/337-fetal-impact-managing-depression-during-pregnancy-and-beyond#transcription