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What is the effectiveness and costs effectiveness of training health visitors to identify and deliver psychologically informed interventions for postnatal depression?
4084 women from participating general practices who were 36 weeks’ pregnant, had a live baby and remained on the health visitor's caseload for at least 4 months postna-tally. Exclusions: age <18 years; mental health issues (such as schizophrenia or bipolar disorder); moving away or temporary resident.
101 general practices in 29 Primary Care Trusts in the Trent Regional Health Authority, UK; randomisation February and March 2003.
Specific health visitor training in postnatal depression or health visitor usual care. Health visitors in the training group were trained in assessing women and in providing psychological sessions. Heath visitors were also randomised to train to deliver either a cognitive behavioural approach (CBA) or a person centred approach (PCA) to women at risk of depression; health visitors could offer a general practitioner appointment (GP) for selective serotonin reuptake inhibitor treatment if indicated and if this was the woman's preference.
Proportion of women at risk of postnatal depression (Edinburgh Postnatal Depression Scale (EPDS) score >12).
72% of women at 6 months and 56% at 18 months.
Cluster randomised controlled trial (GP practices the unit of randomisation).
18 months (primary outcome assessed at 6 months).
Overall, health visitor training reduced the proportion of women at risk of postnatal depression (EPDS score >12) at 6 months (11.7% with training vs 16.4% with usual care; p=0.003). At 6 weeks, 17.3% of participants (595 women) were at risk of postnatal depression. Six month assessments were available for 70.3% of these at risk women. When looking at these at risk women alone, health visitor training reduced the proportion who were still at risk after 6 months compared with usual care (33.9% with training vs 45.6% with usual care; OR 0.62, 95% CI 0.40 to 0.97; p=0.036). This effect remained for 1 year. Within the training group, there was no significant difference in the proportion of women remaining at risk between the different types of psychological approaches (32.9% with CBA vs 35.1% with PCA; p=0.74). Economic analyses found that the training was highly likely to be cost effective compared with the control.
Health visitor training reduced the proportion of women at risk of depression at 6 months after birth; confidence intervals were wide, which suggests that the intervention effect may be small.
Postnatal depression affects in excess of 1 in 10 women who have given birth to a live, healthy baby. In combination with socioeconomic risk factors it can have an adverse impact on caregiving that in turn is associated with developmental delay in the exposed infant.1 Infant exposure to maternal depression also appears to confer a significantly elevated risk of mental health problems in later childhood. Given the potentially major public health implications of these findings, the emphasis placed by NICE on the need for better identification, diagnosis and treatment of depression in both the antenatal and postnatal periods appears well justified.2
Publication of the results of the PoNDER Trial is therefore extremely timely, particularly as the role of the health visitor is under renewed scrutiny in the context of a wider political debate about how best to provide support to vulnerable families. A recent review published by the Department of Health3 has recommended that health visitors should be focused on early intervention, prevention and health promotion but furthermore that their primary role should either be to lead and deliverthe Child Health Promotion Programme using a family focused public health approach or alternatively to deliver intensive programmes to the most vulnerable children and families.
The results of the PoNDER Trial lend strong support to the latter direct role for health visitors in relation to postnatal depression. Taken together with the results of other studies, they suggest that there could be significant and trans-generational public health benefit in health visitors delivering psychologically informed treatments to the more socially disadvantaged mothers with postnatal depression, whether these treatments are based on a cognitive behavioural approach or a person centred approach.
Sources of funding The UK Health Technology Assessment (HTA) programme.
Competing interests None
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