Effects of Perinatal Mental Disorders on the Fetus and Child

Series Perinatal mental health 3 Eff ects of perinatal mental disorders on the fetus and child Alan Stein*, Rebecca M Pearson*, Sherryl H Goodman, Elizabeth Rapa, Atif Rahman, Meaghan McCallum, Louise M Howard, Carmine M Pariante Lancet 2014; 384: 1800–19 Perinatal mental disorders are associated with increased risk of psychological and developmental disturbances in This is the third in the Series of children. However, these disturbances are not inevitable. In this Series paper, we summarise evidence for three papers about perinatal associations between parental disorders and off spring outcomes from fetal development to adolescence in mental health high-income, middle-income, and low-income countries. We assess evidence for mechanisms underlying *Joint fi rst authorship transmission of disturbance, the role of mediating variables (underlying links between parent psychopathology and Section of Child and Adolescent off spring outcomes) and possible moderators (which change the strength of any association), and focus on factors Psychiatry, Department of Psychiatry, University of that are potentially modifi able, including parenting quality, social (including partner) and material support, and Oxford, Oxford, UK duration of the parental disorder. We review research of interventions, which are mostly about maternal depression, (Prof A Stein FRCPsych, and emphasise the need to both treat the parent’s disorder and help with associated caregiving diffi culties. We R M Pearson PhD, E Rapa DPhil); conclude with policy implications and underline the need for early identifi cation of those parents at high risk and MRC/Wits Rural Public Health and Health Transitions for more early interventions and prevention research, especially in socioeconomically disadvantaged populations Research Unit (Agincourt), and low-income countries. School of Public Health, University of the Introduction risk is accentuated or ameliorated, is important to Witwatersrand, Johannesburg, South Africa (Prof A Stein); A substantial body of evidence now exists that shows understand. Most investigators have tried to answer Elizabeth Blackwell Institute perinatal mental disorders are associated with an this question with attempts to elucidate possible for Health Research, School of increase in a range of psychological and developmental mechanisms of transmission, that is, the role of Social and Community disturbances in children. However, disturbances are mediating variables underlying associations between Medicine, University of Bristol, Bristol, UK (R M Pearson); not inevitable and eff ect sizes for these associations parent psychopathology and outcomes in their Department of Psychology, are mostly moderate or small. Therefore, why an children, and possible moderators that change the Emory University, Atlanta, USA association exists between a particular parental strength of any association. (S H GoodmanPhD, disorder and child outcome, and in what situations the In this Series paper, we summarise the evidence M McCallum MA); Institute of Psychology, Health and about the diff erent domains of development that are Society, University of aff ected by perinatal mental disorders, and describe Liverpool, Liverpool, UK Key messages mediating and moderating variables, interventions, and (A RahmanPhD); Health Service implications of policies. and Population Research • Substantial global evidence exists that perinatal disorders Department, Institute of are associated with risks for a broad range of negative We mainly focus on depression and anxiety disorders Psychiatry, King’s College child outcomes, which can persist into late adolescence during the perinatal period, but also assess the evidence London, UK • However, risks are not inevitable and in the absence of for bipolar disorder, other psychoses, personality (Prof L M Howard MRCPsych); disorders, and eating disorders, although little research and Department of severe or chronic maternal disorder or other adversities, Psychological Medicine, the eff ect sizes are generally small or moderate has been done about these disorders in relation to child Institute of Psychiatry, King’s • Most research has focused on mothers, but growing outcomes. We prioritise fi ndings from longitudinal College London, London, UK studies (especially meta-analyses of such studies) for (C M Pariante FRCPsych) evidence suggests that the fathers’ mental health is also associated with child developmental disturbances which, by contrast with cross-sectional designs, the Correspondence to: temporal sequence of exposure and outcome is known. Prof Alan Stein, Section of Child • Mechanisms underlying associations are complex and and Adolescent Psychiatry, include a range of genetic, other biological, and This knowledge helps to increase the potential for causal Department of Psychiatry, environmental pathways inference, although still not as clearly as experimental University of Oxford, Oxford • Research should prioritise investigating the eff ectiveness designs. We report evidence from studies that use reliable OX3 7JX, UK and valid measures of mental disorders of either [email protected] of interventions in reducing risk to the child and reducing symptoms in the aff ected parent interviews (providing categorical clinical diagnoses) or • Parenting is a key modifi able pathway to explain some of self-report symptom questionnaires. Questionnaires are the risks of perinatal disorders to the child and should be feasible in large population-level studies, often have well specifi cally targeted in interventions established thresholds to suggest clinically signifi cant • Interventions could be most important in the context of levels of symptoms, and can be used as continuous scales. additional adversities, such as in socioeconomically We take a developmental perspective, report associations disadvantaged populations, where risks to the child seem between perinatal disorders and off spring outcomes, highest; where several risks are present and resources are beginning with fetal and proceeding through to adolescent scarce, especially in areas in low-income and middle-income outcomes. Although the focus of this Series is maternal countries, innovative strategies are needed disorders, when deeming the eff ect on the child, paternal disorders also need to be taken into account. 1800 www.thelancet.com Vol 384 November 15, 2014 Series Fetal and neonatal outcomes Two meta-analyses1,2 have assessed the association Search strategy and selection criteria between antenatal depression and fetal and neonatal We searched in PubMed, Embase, PsycINFO, and the Cochrane Library without language outcomes. Both reports showed that symptoms of restrictions using the search terms: “mothers” (exploded MeSH term), “fathers” (exploded antenatal depression are associated with an increased MeSH term), “parents” (exploded MeSH term), “Mum”, “Mom”, and “Dad” in combination risk for premature delivery (<37 weeks’ gestation). with “pregnancy”, “prenatal”, “antenatal”, “postnatal”, “postpartum”, “perinatal”, One reported that studies controlling for women taking “puerperal”, “breastfeeding”, “birth”, “weaning”, “childbirth”, “trimester”, “peripartum”, antidepressant drugs or smoking generated small (and “lactation”, “antenatal”, “postnatal”, “postpartum” and “mood disorder” (exploded MeSH non-signifi cant) odds ratios,1 whereas the second2 term), “anxiety disorder” (exploded MeSH term), “eating disorder” (exploded MeSH concluded that “the summary relative risk was term), “psychotic disorders” (exploded MeSH term), “depression”, “anxiety”, “eating comparable for depressed women treated and not disorder”, “psychotic disorders”, “psychoses”, “mania”, “Schizophrenia”, and “fetus”, treated with antidepressants”.2 Antidepressants or “in-utero”, “child” (exploded MeSH term), “toddler”, “infant”, “adolescent” (exploded smoking can be markers for more severe depression3 MeSH term), “off spring”, “boy”, or “girl”. We searched for systematic reviews (between and the eff ects of antenatal depression on prematurity 1984–2014) and epidemiological or experimental studies (between 2009 and 2014 for (and low birthweight) were strong in studies where studies of depression; between 1984 and 2014 for studies of other disorders, and from depression was defi ned by a disorder,2 suggesting that low-income and middle-income countries) using the aforementioned search terms. severity of disorder is important. Search terms (all Mesh terms were included where available for child development terms) A discrepancy was noted between the fi ndings relating were combined for sections about obstetric complications, prematurity or sudden infant to depression and low birthweight; one meta-analysis2 death syndrome, stillbirth, childhood maltreatment, maternal care, or epigenetics with reported a modest association whereas the other “cognition”, “cognitive”, “IQ”, “attention”, “memory”, “language” “ability”, “development” reported a non-signifi cant association.1 However, in the “learning”; or “emotion*, “aff ective”, “emotion-regulation”, “crying”, “internalizing”, meta-analysis reporting no association,1 studies from “depression” “anxiety”, “mood” “temperament” “sad” “fearful” “mental health” low-income and middle-income countries (LMICs) were “psychopathology”; or “attachment”, “secure”, “insecure”, “avoidant”, “anxious”, excluded from analyses. In geographically diverse studies “resistant”, “bonding”, “relationships”, “strange situation”; or “behaviour”, “externalising”, incorporated within the second meta-analysis,2 moderator “aggressive”,

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