Antenatal depression can affect child development
A prospective cohort study has found that the children of mothers with persistent antenatal depression are more likely to have developmental delay at 18 months.
The Avon Longitudinal Study of Parents and Children recruited 14,000 women during pregnancy in 1991-2 and has been following them up ever since. Persistent antenatal depression was defined as an EPDS score above the standard 12/13 cut-off at both 18 and 32 weeks' gestation. When the results were adjusted to allow for continuing postnatal depression, children of mothers with persistent antenatal depression were 34% more likely to have developmental delay.1
Although the study controlled for many potential confounding variables, some caution is necessary. Depressed mothers may not recognise their child's abilities; there may be residual confounders, for example mother-child interaction; and the study did not show a linear relationship between EPDS scores and risk of developmental delay.
Previous results from the study have shown that mothers have higher EPDS scores during pregnancy than postnatally,2 and a meta-analysis estimated the point prevalence of major depression at the end of the second trimester to be 4.9%,3 compared with 2.5% in women in the general population.
There are a number of ways in which maternal depression in pregnancy may affect the child. These include poor maternal health behaviours, increased uterine artery resistance,4 effects on the developing fetal HPA axis1 and an increased risk of postnatal depression. Postnatal depression is thought to affect child development as a result of impaired communication between the mother and infant.5
Screening for postnatal depression is well established, although as yet we have no evidence that treatment can improve long-term outcomes for the child.6 If depression is both more common and more likely to harm the child in the antenatal period, then a strong case can be made for antenatal screening. However, although the reported sensitivity for the EPDS in pregnancy is 100%, the specificity is only 87%; given a point prevalence of 4.9% at the end of the second trimester,3 this gives a positive predictive value of only 0.28. False positives may cause maternal anxiety and there is little evidence on the efficacy of treatments for depression in pregnancy.7
We need to reintegrate antenatal, postnatal and child healthcare. This will facilitate both the identification of women at risk of postnatal depression and children at risk of developmental delay. It is unclear, however, who should be responsible for the management of perinatal depression. Health visitors have the lead role in the Child Health Promotion Programme,8 and counselling by health visitors has traditionally been promoted as the treatment of choice for postnatal depression.5 However, their numbers have dwindled, resources are targeted at high-risk families and postnatal depression is no longer regarded as a priority.9
NICE proposes the establishment of perinatal mental health networks managed by a coordinating centre10 but this will increase, rather than reduce, fragmentation of care.
I would advocate a central role for GPs: we see mothers and their children on a regular basis and often have an unrivalled knowledge and understanding of the family context.
While care remains fragmented, there is a case for recording relevant risk factors for developmental delay in the child's notes and personal child health record. The study identified three other risk factors in addition to maternal depression: young maternal age, smoking and adverse life events.1
All healthcare professionals involved in perinatal care need to be aware of the risk posed to the child by ante- and postnatal depression. The challenge is to provide effective treatment and developmental surveillance without exacerbating the mother's feelings of guilt.Author
Dr Phillip Bland
BA BM BCh MRCGP DRCOG
Children of mothers with persistent antenatal depression were 34% more likely to have developmental delay