Severe Postnatal Depression Doubles Child Behavioral Problems

Batya Swift Yasgur, MA, LSW

February 05, 2018

Children born to mothers with postnatal depression (PND) that is severe and persistent have twice the risk for behavioral disturbances compared to their counterparts whose mothers are not depressed.

A large UK study of children of mothers with severe and persistent PND showed that offspring were at substantially increased risk for behavioral problems at age 3.5 years, as well as increased risk of having lower grades in mathematics at age 16 years, compared with mothers whose depression was not severe or persistent. The prevalence of depression was also higher among these offspring at age 18 years compared with mothers whose depression was not severe or persistent.

Moreover, many women with severe, persistent PND showed symptoms up to 11 years after childbirth.

"When depression persists beyond the first 6 months after birth, and especially when the symptoms are severe, the risk for negative effects in the short and long term, both for women and for their children, is raised," lead author Elena Netsi, DPhil, a postdoctoral fellow in the Department of Psychiatry at the University of Oxford, United Kingdom, told Medscape Medical News.

"Screening both early and late in the postnatal year will help identify families where the depression is both persistent and severe and who should be prioritized for treatment, which is important, as good evidence-based treatments are available for depression."

The study was published online January 31 in JAMA Psychiatry.


Chronicity and severity of maternal depression are two key factors in determining child outcome in the context of maternal depression, the authors note. However, they add, data specifically for PND are limited.

Research into PND that is both persistent and severe has been limited by small sample sizes and short-term follow-up periods and by the fact that a limited range of outcomes were studied.

"While episodes of depression are understandably distressing to the mother, we wanted to understand the potential effects on children's development at different levels of severity and persistence, which allowed us to identify a group which needs to be prioritized for treatment," she reported.

To investigate the question, the researchers drew on participants in the Avon Longitudinal Study of Parents and Children (ALSPAC), a population-based study that enrolled pregnant women in a defined area in England. The expected date of delivery for the particiapants was between April 1, 1991, and December 31, 1992.

"We specifically wanted to use the ALSPAC cohort, as it is a unique resource with multiple follow-ups, which allowed us to investigate potential effects, both in the short and long term, investigating a range out outcomes for children," Dr Netsi explained.

The researchers analyzed data on maternal depression during the postnatal year and at six additional time points until 11 years after childbirth (n = 9848 and n = 6182 mothers, respectively; mean age at delivery, 28.5 [SD, 4.7] years).

They also analyzed data on child behavioral problems at age 3.5 years, mathematics grades at age 16 years, and depression at age 18 years (n = 8419, n = 5198, and n = 3613 children, respectively).

Of the total number of offspring in the sample, 4227 (51%) were male, and 4060 (49%) were female.

Severity of maternal depression was measured using the self-rated Edinburgh Postnatal Depression Score (EPDS). For the study, a score of less than 13 points on the EPDS indicated no depression; a score of 13 to 14 points indicated moderate depression; 15 to 16 points, marked depression; and 17 points or more, severe depression.

"Persistence" in postnatal depression was defined as an individual's scoring higher than the EPDS threshold at both the 2- and 8-month postnatal assessments.

The researchers examined the association of PND with outcomes in seven groups: those with no depression (reference group); those with moderate but not persistent depression; those with marked but not persistent depression; those with severe but not persistent depression; those with moderate and persistent depression; those with marked and persistent depression; and those with severe and persistent depression.

The Rutter Total Problems Scale was used to measure child behavioral problems at age 3.5 years.

Grades achieved in mathematics were extracted from records of the GCSE (external public examinations taken by 16-year-olds at the end of high school in the United Kingdom).

The Clinical Interview Schedule–Revised was used to assess depression in offspring.

Treat Depression

The mean EPDS score for women with persistent, severe PND remained high, with little improvement, up to 11 years after childbirth (16.29 [SD, 4.98] points at 21 months and 14.49 [SD, 6.13] points at 11 years).

For the sample as a whole, after the postnatal year, there was little change in the mean EPDS scores over time, although mean EPDS scores rose by 0.004 points (95% confidence interval, -0.02 to 0.03) at each repeated assessment.

The researches applied a linear growth model to depression scores during the postnatal year and found that, compared with the reference group, the other groups had consistently higher EPDS scores up to 11 years after childbirth. The scores progressed in a stepwise function.

Across the six time points at which depression was assessed after the postnatal year, the researchers found "relative stability" — ie, mean depression scores were higher for women whose PND persisted from 2 to 8 months after childbirth.

For women with nonpersistent PND (depression present only at 2 months after childbirth), regardless of its severity, the risk for child behavioral disturbance at 3.5 years of age was still somewhat elevated.

The odds ratio (OR) for child behavioral disturbance for the maternal groups with nonpersistent moderate, marked, or severe PND were 2.22 (range, 1.74 - 2.83), 1.91 (range, 1.36 - 2.68), and 2.39 (range, 1.78 - 3.22), respectively.

Nonpersistent moderate or marked PND was not associated with lower mathematical grades at age 16 years or with offspring depression at age 18 years.

However, compared with the reference group, offspring of women with both persistent and severe depression were at the highest risk for all three adverse child outcomes: behavioral problems (OR, 4.84 [range, 2.94 - 7.98]); lower mathematical grades (OR, 2.65 [range, 1.26 - 5.57]); and higher depression rate (OR, 7.44; [range, 2.89 - 19.11]).

Given these findings, clinicians should consider evidence-based treatments, including cognitive-behavioral therapy (CBT) and behavioral activation, in mothers with PND, Dr Netsi advised.

She added that antidepressants might be another option. However, a "collaborative, individual risk-benefit analysis needs to be made when considering antidepressant medication during pregnancy or breastfeeding because antidepressants pass through the placenta and can be expressed in breast milk," she said.

"Clear Findings"

Commenting on the study for Medscape Medical News, Myrna Weissman, PhD, professor of epidemiology in psychiatry, Columbia University Mailman School of Public Health, New York City, who was not involved with the study, said that it "fills in a gap," because the length of time the children were followed and the "huge sample size" are important study strengths.

The clinical findings are "clear" and have important implications, said Dr Weissman, who is the author of an accompanying editorial.

These findings suggest that continued screening of pregnant and postpartum women should be conducted for at least a year, she said. She noted that "screening should not be difficult and could be part of well-baby visits or routine Ob/Gyn visits."

If a woman is depressed, "she should be offered treatment, preferably with psychotherapy as the first alternative if she is pregnant and probably if she is nursing."

Dr Netsi noted that her team recently conducted a trial of the use of CBT, with a focus on behavioral activation, for women with persistent PND.

"We report high remission rates, with over 80% of women no longer meeting criteria for depression at the end of therapy — a finding maintained 1 year after the end of therapy, when children were 2 years of age."

The UK Medical Research Council, the Wellcome Trust, and the University of Bristol provide core support for the Avon Longitudinal Study of Parents and Children (ALSPAC). The study was supported by the Wellcome Trust and by the National Institute for Health Research Biomedical Research Center at the University Hospitals Bristol National Health Service Foundation Trust, the University of Bristol, and the NIHR Oxford Health Biomedical Research Centre. Dr Netsi is supported by a postdoctoral fellowship from the Economic and Social Research Council Global Challenges Research Fund. The other authors have disclosed no relevant financial relationships. In the past 3 years, Dr Weissman has received funding from the National Institute of Mental Health, the National Alliance for Research on Schizophrenia and Depression, the Sackler Foundation, and the Templeton Foundation, as well as royalties from the Oxford University Press, Perseus Press, the American Psychiatric Association Press, and the MultiHealth Systems outside the submitted work. She is one of the developers of Interpersonal Psychotherapy.

JAMA Psychiatry. Published online January 31, 2018. Abstract, Editorial


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