Maternal depression and child behavioural outcomes

Depression is a leading cause of disability worldwide,1Murray CJ Lopez AD Measuring the global burden of disease.N Engl J Med. 2013; 369: 448-457Crossref PubMed Scopus (1197) Google Scholar with higher prevalence in women than in men. The postpartum period might confer additional risk to women; rates of major depressive disorder are raised slightly in the postnatal period relative to women who are not pregnant.2Vesga-Lopez O Blanco C Keyes K Olfson M Grant BF Hasin DS Psychiatric disorders in pregnant and postpartum women in the United States.Arch Gen Psychiatry. 2008; 65: 805-815Crossref PubMed Scopus (676) Google Scholar Postpartum depression affects about 15% of women.3Marcus SM Depression during pregnancy: rates, risks and consequences—Motherisk Update 2008.Can J Clin Pharmacol. 2009; 16: e15-e22PubMed Google Scholar Little is known about maternal depression in countries of low and middle income, although in a review of 47 studies spanning pregnancy and the postnatal period, common maternal mental health disorders (including depression) were noted in 19·8% of women.4Fisher J Cabral de Mello M Patel V et al.Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review.Bull World Health Organ. 2012; 90: 139G-149GCrossref PubMed Scopus (907) Google Scholar These findings are worrying because, globally, many children will be exposed to maternal depression, and maternal depression is generally regarded as a robust risk factor with wide-reaching effects on children's emotional, behavioural, cognitive, physical, and neural development.5Weissman MM Wickramaratne P Nomura Y Warner V Pilowsky D Verdeli H Offspring of depressed parents: 20 years later.Am J Psychiatry. 2006; 163: 1001-1008Crossref PubMed Scopus (461) Google Scholar, 6Lupien SJ Parent S Evans AC et al.Larger amygdala but no change in hippocampal volume in 10-year-old children exposed to maternal depressive symptomatology since birth.Proc Natl Acad Sci USA. 2011; 108: 14324-14329Crossref PubMed Scopus (252) Google Scholar Empirical information on the long-term association between maternal depression and child outcome in countries of low and middle income is scarce.7Rahman A Surkan PJ Cayetano CE Rwagatare P Dickson KE Grand challenges: integrating maternal mental health into maternal and child health programmes.PLoS Med. 2013; 10: e1001442Crossref PubMed Scopus (150) Google Scholar Children in these settings are potentially at even greater risk from the negative effects of maternal depression, beginning very early in life. Strong associations exist between maternal depression and infant undernutrition, low birthweight, and psychosocial risk, possibly compounded by in-utero adversity because of famine or natural disasters.7Rahman A Surkan PJ Cayetano CE Rwagatare P Dickson KE Grand challenges: integrating maternal mental health into maternal and child health programmes.PLoS Med. 2013; 10: e1001442Crossref PubMed Scopus (150) Google Scholar, 8Monk C Spicer J Champagne FA Linking prenatal maternal adversity to developmental outcomes in infants: the role of epigenetic pathways.Dev Psychopathol. 2012; 24: 1361-1376Crossref PubMed Scopus (271) Google Scholar In The Lancet Psychiatry, Nienke Verkuijl and colleagues report a longitudinal study in South Africa to investigate the association between symptoms of postnatal maternal depression and children's psychological development at age 10 years.9Verkuijl NE Richter L Norris SA Stein A Avan B Ramchandani PG Postnatal depressive symptoms and child psychological development at 10 years: a prospective study of longitudinal data from the South African Birth to Twenty cohort.Lancet Psychiatry. 2014; (published online Oct 10.)http://dx.doi.org/S2215-0366(14)70361-XGoogle Scholar Children whose mothers had symptoms of depression at 6 months postpartum were more than twice as likely as children whose mothers did not have postnatal depression to have psychological problems at age 10 years, controlling for socioeconomic status and current maternal depression (adjusted odds ratio 2·26, 95% CI 1·23–4·16). These longitudinal associations pertained most specifically to children scoring in the upper 10th percentile for externalising problems at age 10 years (1·71, 0·95–3·10). Longitudinal links between postnatal depression and children's internalising difficulties disappeared once current maternal depression was taken into account (1·38, 0·77–2·48). To my knowledge, this study is one of only a few done in countries of low and middle income to include a long-term behavioural follow-up of children whose mothers have elevated depressive symptoms. However, the study by Verkuijl and colleagues is not without its limitations. At the best of times, retaining participants in a longitudinal study for more than a decade, particularly vulnerable individuals, is a challenge. Attrition is possibly more pronounced in countries of low and middle income than in high-income settings because the research infrastructure might be less developed; moreover, sociocultural factors could affect attrition—eg, no permanent home. Attrition was one of the main limitations of the study by Verkuijl and colleagues.9Verkuijl NE Richter L Norris SA Stein A Avan B Ramchandani PG Postnatal depressive symptoms and child psychological development at 10 years: a prospective study of longitudinal data from the South African Birth to Twenty cohort.Lancet Psychiatry. 2014; (published online Oct 10.)http://dx.doi.org/S2215-0366(14)70361-XGoogle Scholar 3273 women were enrolled when mother-child dyads were recruited, yet 10-year follow-up data were available for only 644 dyads, translating to a retention rate of about 20% of the original sample. The authors acknowledged this limitation and noted that it could be attributable partly to patterns of circular urban-rural temporary migration. Furthermore, different measures were used to assess maternal depression, with the Pitt depression inventory administered in the early postnatal period (6 months after birth) and the Center for Epidemiologic Studies depression scale (CES-D) used at 10-year follow-up. Correlations between these two timepoints were low, although about 20% of women scored above the cutoff at both 6 months and 10 years. No measures of maternal depression or children's psychological difficulties were recorded between these two timepoints, which is unfortunate in view of the links between postnatal depression and child psychological outcome. We are left with a snapshot of maternal depression 6 months after birth and at 10-year follow-up, but without information throughout the child's life, which could help us to better understand the underlying mechanisms in the intergenerational transfer of risk. Therefore, drawing a conclusion about whether the postpartum period confers a specific risk for child psychological functioning is difficult, without understanding more about the chronicity and severity of depression over time, factors that have been shown to affect child outcome in studies set in high-income countries.10Brennan PA Hammen C Andersen MJ Bor W Najman JM Williams GM Chronicity, severity, and timing of maternal depressive symptoms: relationships with child outcomes at age 5.Dev Psychol. 2000; 36: 759-766Crossref PubMed Scopus (373) Google Scholar Despite these methodological shortcomings, findings of studies in countries of low and middle income must reach the public and receive the attention they deserve. Since we know that maternal depression is a robust risk factor for poor child outcome, and that associations can be striking in low-income and middle-income settings because of biological (eg, the effects of undernutrition) and psychosocial stressors, Verkuijl and colleagues' findings could represent a conservative estimate of the problem. Research studies on maternal mental health in countries of low and middle income will raise awareness of issues faced by women and the negative effects for the child; furthermore, they could indicate to whom and how best to target interventions in an attempt to reduce the intergenerational transfer of risk. I declare no competing interests. Postnatal depressive symptoms and child psychological development at 10 years: a prospective study of longitudinal data from the South African Birth to Twenty cohortMaternal postnatal depression is associated with adverse psychological outcomes in children up to 10 years later in countries of low and middle income. In view of the increased prevalence of postnatal depression in these settings, this finding has important implications for policy and interventions for children and their mothers. Full-Text PDF Open Access

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