Addressing the treatment gap for perinatal depression

Perinatal mental health has been a particular interest for me and my research journey into this field began during my Master’s degree. Following a natural trajectory, I began my current (PhD) research in perinatal depression when this opportunity was presented in the PRIME South Africa project, particularly as one of the focal areas of interest in PRIME was to develop mental health programmes to reduce the mental health treatment gap in maternal mental health care, and my principal role as the PRIME project coordinator for South Africa provided a unique opportunity to engage with and understand the health context before commencing my study.

Perinatal primary health care in South Africa has focussed strongly on maternal and child morbidity and mortality, and perinatal mental health in this context has been mostly ignored. Perinatal depression is associated with many health and social burdens including negative child outcomes such as stunting, poor cognition and socio-emotional development, and adverse mental health outcomes for mothers, yet despite high prevalence rates perinatal depression has historically been neglected in public health care in South Africa. A situational analysis of maternal mental health services in the PRIME South Africa site i.e. Dr Kenneth Kaunda District (DKKD) in the North West Province, revealed an absence of routine and/or dedicated perinatal mental health services at primary health care level. Despite the National Mental Health Policy Framework and Strategic Plan 2013–2020  having mooted plans to address perinatal mental health at primary health care level there has been little progress towards including mental health in the maternal and child health platform and/or Basic Antenatal Care (BANC) package that is used in routine perinatal care.

What is this study about?

There were three objectives in terms of this PhD study:

• Initially we conducted a qualitative investigation of mental health care needs and pathways to care for perinatal women with depression in DKKD, with service users who screened positive for perinatal depression and with primary care service providers who acknowledged the huge gap in services for perinatal depression. Based on this, recommendations were provided for task-shared interventions for perinatal depression and this information guided the intervention.
• We co-developed a task-shared, collaborative care plan for perinatal depression with district health stakeholders. Professional nurses were trained to identify and refer women with mild to moderate depression attending antenatal and postnatal services, for psychoeducation on depression and for counselling to an existing counselling service provided by a trained facility-based lay counsellor. Women with moderate to severe depression were referred to both the counsellor and the clinic doctor and/or a mental health specialist and referred for suicide risk if required. The counselling intervention was an existing facility-based task shared psychosocial intervention developed and used for chronic care patients with depression in the PRIME-South Africa cohort study and PRIME randomized controlled trial.
• Using mixed methods we evaluated the feasibility and acceptability of extending this existing facility-based task shared psychosocial intervention for chronic care patients with depression to perinatal patients with depression, and the potential of this intervention to reduce depressive symptoms and improve functionality in women with perinatal depression who were referred for counselling /other treatment per the collaborative care model. We used a pre/post quasi-experimental design with a baseline interview after screening & confirmation of depression, and a 4-month follow-up; and qualitative evaluation with a subset of participants who received varying dosages of the counselling, and service providers who participated in the collaborative care model for perinatal depression.

What did we find?

Depression scores on the Patient Health Questionnaire-9  (PHQ-9) indicated a clinically significantly decrease   in the treatment vs control group and similarly stigma scores on the Internalized Stigma of Mental Illness Scale  decreased in the treatment vs control group. Although the intervention group did show a clinically and statistically significant reduction of more than five points in PHQ9 scores, the small sample limits us in terms of meaningful statistical inferences. Qualitative results indicate that screening and referral to lay counsellors was acceptable by nurses and patients, the treatment was acceptable to service users, and that while most nurses were comfortable referring to the behaviour change counsellor some nurses were reluctant to refer to doctors/specialists citing delays due to waiting lists for mental health specialist consultations.

Recommendations

This study suggests that a task-shared collaborative care approach leveraging existing primary health care resources is feasible  and acceptable to treat perinatal depression and is more likely to be scaled up as it supports the use of existing clinic resources;  but the model requires further research in terms of appropriate content, training, supervision and support. Future studies should focus on evaluating such a collaborative care model to detect and manage perinatal depression integrated into the BANC guideline, but for mental health care to be integrated into routine perinatal health care there needs to be policy level engagement and a concerted effort from diverse stakeholders to promote perinatal mental health. This requires strengthening the health system with appropriate training and support for the relevant health worker cadres including doctors, nurses, mental health specialists, lay counsellors, mentor mothers and community health workers, strengthened referral pathways, perinatal mental health indicators and reporting targets for perinatal depression. It is no small task, and while advocacy from funding bodies, researchers and NGOs has pushed perinatal depression onto a more visible platform there needs to be willingness from perinatal and mental health stakeholders to promote and support investment in perinatal mental health.