Group treatment for depression in mothers of young children compared to standard individual therapy

Holistic community-based group parenting programs for mothers with maternal mental health issues help address a growing public health need for a diversity of vulnerable mothers, children and families: Findings from an action research study

Background

Maternal mental illness is a major growing global concern which can affect parenting with serious negative implications for offspring. Group-based parenting programs for mothers which both enhance the parent-child relationship and address mental health symptoms in a supportive social setting may optimise better outcomes for mothers and children. The Acorn program in South Australia draws on attachment theory to integrate dance play, reflective diary keeping and therapeutic letters in a holistic program for a diversity of vulnerable mothers and children aged 1-36 months. The program seeks to nurture and enhance parental wellbeing and the quality of the parent-child relationship for mothers experiencing identified mental health illnesses that impinge upon their parenting. This study presents the evaluation of the program and its effectiveness.

Methods

Action research approach for continuous monitoring and program improvement engaging Acorn program staff in evaluation data collection and interpretation of pre and post self-completion measures and standardized observations. Additional data was collected through a telephone interview of attending mothers 6-8 months after program completion to address sustainable impacts on parenting and wellbeing.

Results

The program engaged 353 diverse vulnerable mothers with their children. Many had profound overlapping mental health issues including borderline personality disorder (BPD) and depression. The quality of the parent-child interaction, parental confidence, competence and enjoyment were enhanced; mothers' wellbeing, ability to cope and lasting social supports were augmented. This occurred for a number of "most vulnerable" subgroups including single mothers, mothers with BPD, mothers from non-English speaking households and those with lower levels of education or household income. Mothers reported sustained improvements in their wellbeing, parenting, social and family lives, and feeling closer to their child as a result of participating in the program.

Conclusions

Given the high prevalence of maternal mental health issues and substantial potential negative consequences for mothers and offspring, the Acorn parenting program offers an effective means of addressing this pressing public health issue potentially helping large numbers of vulnerable mothers and their children. This has additional gravitas in the shadow of COVID-19 due to expanded numbers of those experiencing greater parental stress, isolation and mental illness.

Parent-infant psychotherapy for improving parental and infant mental health

BACKGROUND

Parent-infant psychotherapy (PIP) is a dyadic intervention that works with parent and infant together, with the aim of improving the parent-infant relationship and promoting infant attachment and optimal infant development. PIP aims to achieve this by targeting the mother's view of her infant, which may be affected by her own experiences, and linking them to her current relationship to her child, in order to improve the parent-infant relationship directly.

OBJECTIVES

1. To assess the effectiveness of PIP in improving parental and infant mental health and the parent-infant relationship.2. To identify the programme components that appear to be associated with more effective outcomes and factors that modify intervention effectiveness (e.g. programme duration, programme focus).

SEARCH METHODS

We searched the following electronic databases on 13 January 2014: Cochrane Central Register of Controlled Trials (CENTRAL, 2014, Issue 1), Ovid MEDLINE, EMBASE, CINAHL, PsycINFO, BIOSIS Citation Index, Science Citation Index, ERIC, and Sociological Abstracts. We also searched the metaRegister of Controlled Trials, checked reference lists, and contacted study authors and other experts.

SELECTION CRITERIA

Two review authors assessed study eligibility independently. We included randomised controlled trials (RCT) and quasi-randomised controlled trials (quasi-RCT) that compared a PIP programme directed at parents with infants aged 24 months or less at study entry, with a control condition (i.e. waiting-list, no treatment or treatment-as-usual), and used at least one standardised measure of parental or infant functioning. We also included studies that only used a second treatment group.

DATA COLLECTION AND ANALYSIS

We adhered to the standard methodological procedures of The Cochrane Collaboration. We standardised the treatment effect for each outcome in each study by dividing the mean difference (MD) in post-intervention scores between the intervention and control groups by the pooled standard deviation. We presented standardised mean differences (SMDs) and 95% confidence intervals (CI) for continuous data, and risk ratios (RR) for dichotomous data. We undertook meta-analysis using a random-effects model.

MAIN RESULTS

We included eight studies comprising 846 randomised participants, of which four studies involved comparisons of PIP with control groups only. Four studies involved comparisons with another treatment group (i.e. another PIP, video-interaction guidance, psychoeducation, counselling or cognitive behavioural therapy (CBT)), two of these studies included a control group in addition to an alternative treatment group. Samples included women with postpartum depression, anxious or insecure attachment, maltreated, and prison populations. We assessed potential bias (random sequence generation, allocation concealment, incomplete outcome data, selective reporting, blinding of participants and personnel, blinding of outcome assessment, and other bias). Four studies were at low risk of bias in four or more domains. Four studies were at high risk of bias for allocation concealment, and no study blinded participants or personnel to the intervention. Five studies did not provide adequate information for assessment of risk of bias in at least one domain (rated as unclear).Six studies contributed data to the PIP versus control comparisons producing 19 meta-analyses of outcomes measured at post-intervention or follow-up, or both, for the primary outcomes of parental depression (both dichotomous and continuous data); measures of parent-child interaction (i.e. maternal sensitivity, child involvement and parent engagement; infant attachment category (secure, avoidant, disorganised, resistant); attachment change (insecure to secure, stable secure, secure to insecure, stable insecure); infant behaviour and secondary outcomes (e.g. infant cognitive development). The results favoured neither PIP nor control for incidence of parental depression (RR 0.74, 95% CI 0.52 to 1.04, 3 studies, 278 participants, low quality evidence) or parent-reported levels of depression (SMD -0.22, 95% CI -0.46 to 0.02, 4 studies, 356 participants, low quality evidence). There were improvements favouring PIP in the proportion of infants securely attached at post-intervention (RR 8.93, 95% CI 1.25 to 63.70, 2 studies, 168 participants, very low quality evidence); a reduction in the number of infants with an avoidant attachment style at post-intervention (RR 0.48, 95% CI 0.24 to 0.95, 2 studies, 168 participants, low quality evidence); fewer infants with disorganised attachment at post-intervention (RR 0.32, 95% CI 0.17 to 0.58, 2 studies, 168 participants, low quality evidence); and an increase in the proportion of infants moving from insecure to secure attachment at post-intervention (RR 11.45, 95% CI 3.11 to 42.08, 2 studies, 168 participants, low quality evidence). There were no differences between PIP and control in any of the meta-analyses for the remaining primary outcomes (i.e. adverse effects), or secondary outcomes.Four studies contributed data at post-intervention or follow-up to the PIP versus alternative treatment analyses producing 15 meta-analyses measuring parent mental health (depression); parent-infant interaction (maternal sensitivity); infant attachment category (secure, avoidant, resistant, disorganised) and attachment change (insecure to secure, stable secure, secure to insecure, stable insecure); infant behaviour and infant cognitive development. None of the remaining meta-analyses of PIP versus alternative treatment for primary outcomes (i.e. adverse effects), or secondary outcomes showed differences in outcome or any adverse changes.We used the Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE) approach to rate the overall quality of the evidence. For all comparisons, we rated the evidence as low or very low quality for parental depression and secure or disorganised infant attachment. Where we downgraded the evidence, it was because there was risk of bias in the study design or execution of the trial. The included studies also involved relatively few participants and wide CI values (imprecision), and, in some cases, we detected clinical and statistical heterogeneity (inconsistency). Lower quality evidence resulted in lower confidence in the estimate of effect for those outcomes.

AUTHORS' CONCLUSIONS

Although the findings of the current review suggest that PIP is a promising model in terms of improving infant attachment security in high-risk families, there were no significant differences compared with no treatment or treatment-as-usual for other parent-based or relationship-based outcomes, and no evidence that PIP is more effective than other methods of working with parents and infants. Further rigorous research is needed to establish the impact of PIP on potentially important mediating factors such as parental mental health, reflective functioning, and parent-infant interaction.

Mental health services for parents affected by mental illness

PURPOSE OF REVIEW

Despite an increasing awareness of support needs of families affected by parental mental illness, there is a lack of adequate mental healthcare provision for parents. As contemporary mental health services are both user-focused and evidence based, the present review focuses on knowledge regarding the subjective perspective on parenting issues among affected parents and the evidence base for parenting programs.

RECENT FINDINGS

There has been a shift in the research focus from adverse effects of parental mental illness on children toward inclusion and the subjective perspective in affected mothers and, more recently, fathers with mental health problems. Parents report on role conflicts, parenting difficulties, and stigma. Despite a broad spectrum of parental needs, many parents are reluctant to use services. There is an increasing evidence base for intervention programs.

SUMMARY

Adequate care for parents affected by mental illness requires sensitivity for parents' subjective perspective, interagency collaboration, standard intake practice, high level of professional knowledge and skills, provision of family-friendly environments, evidence-based parenting programs comprising both individual and group approaches and peer support. There is a lack of research on other parenting needs such as desire for children, coping with custody loss, and childlessness related to mental illness.