Comment

No health without perinatal mental health

Pregnancy and the arrival of a new baby signal a time
of unparalleled change and hope for the future. For
many women, however, it is a challenging time; for a
minority of mothers this period can be overshadowed
by mental illness, aggravated by widespread stigma.1
There is no time in the lifespan that the statement
“there is no health without mental health”2 rings truer
than in the perinatal period. The perinatal mental
health Series in The Lancet reviews the epidemiology
and treatment of perinatal mental disorders and their
effect on mother and child.3–5 The Series reviews a wide
spectrum of disorders that can occur in pregnancy and
post partum, from common mental disorders, such
as depression and anxiety, to mania and psychosis in
early post partum.
The focus of research and policy has, until recently,
largely centred on postnatal depression. There is
evidence for effective interventions for postnatal
depression, and that in low-income and middle-
income countries (LMICs) trained non-specialist health
workers can provide these.3 However, for more severe
perinatal mental disorders, and for disorders other than
postnatal depression, there is a more limited evidence
base. The recognition and treatment of perinatal
mental illness is important not least because suicide
is a major cause of maternal deaths in high-income
countries.6 Perinatal mental illness might also account
for a substantial proportion of maternal deaths in low-
income countries if suicide were properly classified
and reported.7 The Series emphasises the need for
individualised risk-benefit analyses when considering
psychotropic medication in the perinatal period
to balance risks of untreated illness for the mother
and fetus or child with possible adverse effects of
medication.
Treating the mother’s disorder alone, however,
is not always sufficient to mitigate the impact on
the child. The final Series paper5 focuses on possible
effects of perinatal mental illness on the fetus and
child. There is evidence that perinatal depression raises
the risks for children even into late adolescence in
terms of increased rates of depression.8 Of particular
concern is the extent to which outcomes for children
that these risks are therefore increased for many See Series pages 1775, 1789,
and 1800
children living in LMICs.5 Perinatal depression in LMICs
is also associated with poorer infant growth and even
stunting.5 Furthermore, comorbidity is more common
in LMICs, which makes the consequences of perinatal
mental illness potentially even more serious. For
example, 90% of the total number of pregnant women
with HIV worldwide live in sub-Saharan Africa.9 Being
diagnosed with HIV during pregnancy, which is when
many African women learn of their diagnosis, increases
the risk of depression. It is a cause for concern that
women who are depressed are less likely to adhere to
antiretroviral therapy, which is critical for the mother’s
survival and to prevent transmission of HIV to the child.
The need to take account of the mother’s mental health
is compelling.
The Series emphasises that adverse effects of
perinatal disorders on children are not inevitable.
Whether and to what extent children are affected
depends on a range of mediating and moderating
factors. The most important remediable factors
include quality of parenting, social support, and the
length and severity of the parental disorder. Therefore,
effective identification and (where necessary)
early intervention to treat the parent and enhance
parenting skills are critical.5
Kelvin Murray

are moderated by persistent maternal disorder and

socioeconomic disadvantage. The Series highlights

www.thelancet.com Vol 384 November 15, 2014 1723

 Comment
Paternal mental illness in the perinatal period has
been researched less than maternal illness. However,
there is emerging evidence that depression in fathers
is more common than previously thought and is
also associated with negative effects on children.5
Furthermore, social support, particularly that of the
partner, is critical for the mother and the family.5
Partner violence is, therefore, increasingly recognised as
an important risk factor for perinatal mental disorders
across the diagnostic spectrum.10
A recent report11 revealed the economic costs of
perinatal mental disorders to society and public
services in the UK: long-term costs are estimated
to exceed £8 billion for each annual cohort, and
there is a lack of services in many places to deal with
perinatal mental health. Urgent action for perinatal
mental health is required from governments,
professional bodies, and organisations. The updated
National Institute for Health and Care Excellence
(NICE) guidance on antenatal and postnatal mental
health currently being developed will provide
recommendations on interventions that can be
delivered in high-income countries.12 In LMICs,
where disorders are often more prevalent, the costs
of perinatal mental disorders might be greater
particularly because of the impact of loss of earnings
on the family and children’s health and nutrition.
We know that there is an economic benefit of early
intervention for young children in adversity;13,14
interventions for perinatal mental disorders could
improve maternal and child physical and mental
health and, therefore, should be a critical part of any
new Sustainable Development Goals.15
Louise M Howard, Peter Piot, *Alan Stein
Health Service and Population Research Department, Institute of
Psychiatry, Psychology, and Neuroscience, King’s College
London, London, UK (LMH); Office of Director, London School of
Hygiene & Tropical Medicine, London, UK (PP); Section of Child
and Adolescent Psychiatry, Department of Psychiatry, University
of Oxford, Oxford OX3 7JX, UK (AS); and MRC/Wits Rural Public
Health and Health Transitions Research Unit (Agincourt), School
of Public Health, University of the Witwatersrand, Johannesburg,
South Africa (AS)
alan.stein@psych.ox.ac.uk
1724
LMH is Chair of the National Institute for Health and Care Excellence update
guideline on antenatal and postnatal mental health, and Chief Investigator of a
National Institute of Health Research (NIHR) programme grant for applied
research on the effectiveness of perinatal mental health services
(RP-RPDG-1108–10012); LMH also receives funding from an NIHR Research
Professorship on maternal mental health (NIHR-RP-R3–12–011), and has
received a grant from Tommy’s baby charity, with the support of a corporate
social responsibility grant from Johnson and Johnson, on antipsychotics in
pregnancy. AS has received a number of grants in relation to parental perinatal
health and child development including from the Wellcome Trust, Medical
Research Council UK, Barclay Foundation, Grand Challenges (Canada), and the
Department for Education UK. PP declares no competing interests.
1 Farrelly S, Clement S, Gabbidon J, et al. Anticipated and experienced
discrimination amongst people with schizophrenia, bipolar disorder and
major depressive disorder: a cross sectional study. BMC Psychiatry 2014;
14: 157.
2 Prince M, Patel V, Saxena S, et al. No health without mental health.
Lancet 2007; 370: 859–77.
3 Howard LM, Molyneaux E, Dennis C-L, Rochat T, Stein A, Milgrom J.
Non-psychotic mental disorders in the perinatal period. Lancet 2014;
384: 1775–88.
4 Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, affective
psychosis, and schizophrenia in pregnancy and the post-partum period.
Lancet 2014; 384: 1789–99.
5 Stein A, Pearson RM, Goodman SH. Effects of perinatal mental disorders on
the fetus and child. Lancet 2014; 384: 1800–19.
6 Cantwell R, Clutton-Brock T, Cooper G, et al. Saving mothers’ lives:
reviewing maternal deaths to make motherhood safer: 2006–2008. The
Eighth Report of the Confidential Enquiries into Maternal Deaths in the
United Kingdom. BJOG 2011; 118 (suppl 1): 1–203.
7 Fuhr DC, Calvert C, Ronsmans C, et al. Contribution of suicide and injuries
to pregnancy-related mortality in low-income and middle-income
countries: a systematic review and meta-analysis. Lancet Psychiatry
2014; 1: 213–25.
8 Pearson RM, Evans J, Kounali D, et al. Maternal depression during
pregnancy and the postnatal period: risks and possible mechanisms for
offspring depression at age 18 years. JAMA Psychiatry 2013; 70: 1312–19.
9 UNAIDS. Regional fact sheet 2012 sub-Saharan Africa, 2012. Geneva: Joint
United Nations Programme on HIV/AIDS, 2012.
10 Howard LM, Oram S, Galley H, Trevillion K, Feder G. Domestic violence and
perinatal mental disorders: a systematic review and meta-analysis.
PLoS Med 2013; 10: e1001452.
11 Bauer A, Parsonage M, Knapp M, Iemmi V, Adelaja B. The costs of perinatal
mental health problems. London: London School of Economics and
Political Science, 2014. http://www.centreformentalhealth.org.uk/pdfs/
Costs_of_perinatal_mh.pdf (accessed Nov 6, 2014).
12 National Institute for Health and Care Excellence. Antenatal and postnatal
mental health (update). 2014. https://www.nice.org.uk/guidance/
indevelopment/gid-cgwave0598 (accessed Nov 6, 2014).
13 Carneiro P, Heckman J. Human capital policy NBER working paper no 9495.
Cambridge, MA: National Bureau of Economic Research, 2003. http://
www.nber.org/papers/w9495 (accessed Nov 6, 2014).
14 WHO, Calouste Gulbenkian Foundation. Social determinants of mental
health. Geneva: World Health Organization, 2014.
15 Thornicroft G, Patel V. Including mental health among the new sustainable
development goals. BMJ 2014; 349: g5189.
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