CAPPD. Community-based Approaches to Perinatal and Postpartum Depression

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CAPPD Community-based Approaches to Perinatal and Postpartum Depression Community support for perinatal and postpartum depressive episodes

1 CAPPD Community-based Approaches to Perinatal and Postpartum Depression Community support for perinatal and postpartum depressive episodes and outcomes in Kenya: effect of community mobilization and Community Health Workers on awareness, identification and psychosocial support.

Background: Perinatal and Postpartum Depression in Low Income Countries 2 Despite their increased diagnosis worldwide, these disorders receive inadequate global attention.

2 Background: Perinatal and Postpartum Depression in Low Income Countries 2 Despite their increased diagnosis worldwide, these disorders receive inadequate global attention. Currently, common mental health disorders (mood disorders, schizophrenia and specific anxiety disorders) represent 7% of the global burden of disease for women of all ages, with mood disorders, such as depression, being the biggest contributor (WHO 2008a). Common mental health disorders are therefore the third leading global burden of disease for women of reproductive age (Mayosi 2009) and are predicted to rise to the second and, subsequently the first leading global burden of disease for women in 2020 and 2030, respectively (Mayosi 2009; WHO 2001; WHO 2008b. Despite their increased diagnosis worldwide, these disorders receive inadequate global attention. Of these mental disorders, perinatal and postpartum depression, collectively called maternal depression, are estimated to range in prevalence from 10-41%, in lowand middle-income countries (LMICs) (WHO 2008a). This represents a rate three times higher than that of developed countries (WHO 2008a). Though perinatal depression is most prevalent in low-and middle-income countries, these contexts allocate the lowest percentages of their health budget to mental health, if any. For example, Kenya spends less than 1% of its total health budget on mental health services (Saxena 2007). Services that are available typically exclude the most vulnerable of populations and are heavily institutionalized, which often create barriers to access and utilization (WHO 2008a). As well as a lack of prioritization, lowincome countries (LICs) face a Human Resources for Health (HRH) crisis that is particularly evident when examining the availability of mental health services. LICs on average have 0.05 psychiatrists and 0.16 psychiatric nurses per100,000 people, in comparison to average rates 200 times greater in high-income countries (Saxena 2007). Interventions at the community level and task-shifting 1 are commonly accepted and proposed methods to assist in mitigating the effects of the HRH crisis, especially in LICs and rural areas, with growing support for extending these strategies to mental health services (WHO, 2008).

Community Based Strategies Recognising the lack of available resources for mental health services in LICs, community interventions utilising nonspecialists have shown success in reducing the impact

3 Community Based Strategies Recognising the lack of available resources for mental health services in LICs, community interventions utilising nonspecialists have shown success in reducing the impact of mental health disorders. For postpartum depression, several studies have shown that psychosocial support interventions delivered by specifically trained lay workers are effective in reducing depression prevalence (Rahman et al. 2008; Cooper et al. 2009). However, both of these studies used intensive training and supervision by highly qualified mental health professionals to support their lay health workers. Health Impacts Maternal depression should be a priority for primary health care as it impacts the health of the mother as well as the development and health of her children. Though most mental health research occurs in HICs, the emotional needs of mothers and children and the impact on a child s psychological health as a consequence of a mother s depression is well documented (Weinberg and Tronick 1998; Rutter and Quinton 1984; Anderson and Hammen 1993). Moreover, evidence links perinatal depression to early childhood underweight and stunting (Surkan 2011), reduced breastfeeding, increased episodes of diarrhoea, lower compliance with immunization schedules (WHO 2008a), and an increased risk of having a preterm or low-birth weight baby (Grote et al. 2010). Children of socioeconomically vulnerable women with perinatal depression have been found to have an even higher prevalence of negative health outcomes compared to the less vulnerable within countries, indicating an even more pertinent need to target these individuals (Grote et al. 2010). 3

4 Rationale As previously stated, perinatal depression rates in LICs are extremely high (10-41%), yet countries lack both prioritization and resources for mental health services, especially for vulnerable populations. As well as impacting the health and well-being of mothers, perinatal depression has negative health impacts for children that can be severe and debilitating. Studies suggest, however, that with early identification, treatment and prevention techniques, several of these, including undernutrition, can be significantly reduced (Surkan 2011). Recognising a lack of mental health commitment, specifically in LICs, priorities for global mental health research have identified focusing on community actions and the delivery of cost-effective interventions that can be administered by Community Health Workers (Tomlinson 2009; Lancet Global Mental Health Group 2007). Though currently there is limited evidence on maternal depression interventions delivered at the community level, evidence suggests that these services can be delivered effectively through task-sharing and community based programmes. Lay health workers have been shown to positively contribute to the detection, diagnosis and treatment of severe mental health disorders, including perinatal depression, in LICs (Kakuma 2011); however, the training and supervision required for such activities is often intense and frequent, which can cause difficulty for sustainability and scaling-up such initiatives. The proposed intervention study will develop community networks in addition to providing specific training in mental health for a selection of pre-existing CHWs. These community networks will also increase awareness and have the potential to de-stigmatise perinatal depression as well as increase the likelihood that symptomatic women will receive appropriate treatment at early onset. An additional reason for increasing community awareness and participation in maternal depression activities is that social support has been shown to provide a protective function against postpartum depression (Cutrona and Troutman 1986). 4

5 Proposed Research Phase I An exploratory study investigating the current conceptualization of depression in this context. This includes an in-depth ethnographic study to better understand local beliefs about depression, how it manifests itself, why it occurs, cultural taboos, and how people believe it should be treated. This first phase will provide an important springboard for the design of the intervention phase. Phase II An intervention study potentially utilising community health workers and community networks to first increase the timely identification of perinatal and postnatal depression in a vulnerable population in Kenya. Second, will be to develop an appropriate strategy to mitigate against the harmful effects of perinatal and postnatal depression through increased knowledge and practice of peer-to-peer counselling and improved community social support structures. Developing these networks and having the community as the driving force for the identification and support for affected women, with CHWs providing a more supportive role, there is greater ownership within the community and the likelihood of sustaining services can be greatly increased. If this intervention is proven effective, it can have implications not only for perinatal and postnatal depression in LICs, but may also be used to model interventions for other mental disorders across different settings, particularly those that face the highest burden of mental illness yet have the least amount of dedicated resources to provide treatment and support for individuals. 5

6 Aim References To decrease the burden of perinatal depression and assist in rehabilitation for those affected as to ultimately improve health outcomes for women and children through community participation and mobilization. - Anderson, C.A. & Hammen, C.L. Psychosocial outcomes of children of unipolar depressed, bipolar, medically ill and normal women: A longitudinal study. Journal of Consulting and Clinical Psychology, 61, pp Cooper, P.J., Tomlinson, M., Swartz, L., Landman, M., Molteno, C., Stein, A., McPherson, K., Murray, L Improving quality of mother-infant Objectives relationships and infant attachment in socioeconomically deprived community in South Africa: randomised controlled trial. British Medical Journal, 338 (b974) Intervention - Cutrona, C. E., & Troutman, B.R Social Support, Infant Temperament, and Parenting Self-Efficacy: A Meditational Model of Postpartum Depression. Child Development, 57 (6), pp Lancet Establish Global community Mental Health networks Group. to raise awareness Scale up services of perinatal for mental and disorders: postpartum a call depression for action. The and Lancet, assist in 307, identifying pp and providing - Grote, psychosocial N.K., Bridge, support J.A., for Gavin, at-risk A.R., and/or Meville, diagnosed J.L., Iyengar, women S. & Katon, W.J A Meta-analysis of Depression During Pregnancy and the Risk of Preterm Birth, Low Birth Weight, and Intrauterine Growth Restriction. Archives of General Psychiatry, 67 (10), pp Provide specific training for Community Health Workers to manage community mental health education and provide increased - Kakuma, R., Minas, H., van Ginneken, N., Dal Poz, M.R., Desiraju, K., Morris, J.E., Saxena, S. & Scheffler, R Human resources for mental health psychosocial care: current support situation for women and strategies with perinatal for action. and The postpartum Lancet, 378, depression pp Mayosi B.M., Fisher, A.J., Lalloo, U.G., Sitas, F., Tollman, S.M. Et al The burden of non-communicable diseases in South Africa. The Lancet, Research 374, pp Rahman, A., Malik, A., Sikander, S., Roberts, C. & Creed, F Cognitive behaviour therapy-based intervention by community health 1. workers Contribute for mothers to limited with depression epidemiological and their infants knowledge in rural of Pakistan: perinatal a cluster and postpartum randomized controlled depression trial. in sub-saharan The Lancet, 372(9642), Africa pp Rutter, M. & Quinton, D Parental psychiatric disorder: Effects on children. Psychological Medicine, 14, pp Investigate the feasibility and potential of using community networks and Community Health Workers to target perinatal - Surkan, P.J., Kennedy, C.E., Hurley, K.M., & Black, M.M Maternal depression and early childhood growth in developing countries: systematic depression review and meta-analysis. Bulletin of the World Health Organization, 287, pp Saxena, Provide S., evidence Thornicroft, on G., the Knapp, effectiveness M. & Whiteford, of community H interventions Resources for for mental perinatal health: and scarcity, postpartum inequity, depression and inefficiency. on both The maternal Lancet, 370, pp. and child health Suspendisse - Tomlinson, elementum M., Rudan, rhoncus I., Saxena, velit. S., Swartz, L., Tsai, A.C. & Patel, V Setting priorities for global mental health research. Bulletin of the Nulla World turpis Health metus, Organization, faucibus nec, 87, pp Research Methodology - Weinberg, dignissim M.K. at, cursus & Tronick, in, tortor. E.D The impact of maternal psychiatric illness on infant development. Journal of Clinical Psychiatry, 59 (2), pp This - intervention WHO The study World is a Health cross-sectional Report study Mental in Health: an area New of Understanding, Eastern Kenya New that Hope. currently Geneva. has World Vision Kenya Maternal and - Child WHO Health 2008a. Maternal programmes. mental Both health qualitative and child health and and quantitative development research in low and methods middle will income be utilized countries: including: report of the meeting held in Geneva, Switzerland, 30 January - 1 February Geneva - WHO Ethnographic 2008b. The investigation global burden of to disease understand 2004 update. existing Department constructs of Health of depression Statistics and and Information. how it Geneva. is manifested WHO Press. and understood - WHO Task shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines. Geneva. in this context. - Baseline survey of prevalence and knowledge, attitudes and practices for perinatal depression - Ongoing monitoring through Community Participatory Research - Mid-term evaluation - Final Evaluation

7 For more information: Centre for Global Health, Trinity College Dublin 7-9 Leinster Street, Dublin 2

TTC Evidence Brief: Evidence for Maternal Mental Health within World Vision Core Health Model Timed and Targeted Counselling (ttc)

TTC Evidence Brief: Evidence for Maternal Mental Health within World Vision Core Health Model Timed and Targeted Counselling (ttc) Introduction Megan McGrath, World Vision Australia Polly Walker, World