Psychological Therapy for Postnatal Depression in UK Primary Care Mental Health Services: A Qualitative Investigation Using Framework Analysis
Postnatal depression (PND) can have negative consequences for mother and infant. Current psychological therapies are effective in treating depression but improvements in mother-infant outcomes have not yet been established. We aimed to capture mothers’ experiences of therapy for PND with a focus on parenting-related outcomes. We also sought their views on including parenting support within interventions.
Fourteen mothers who received psychological therapy in the United Kingdom’s National Health Service (NHS) participated in semi-structured interviews. Data were audio-recorded, transcribed, coded and analysed using Framework Analysis.
Three main themes were identified: ‘The experience of therapy’, ‘Therapy outcomes’ and ‘Views about parenting interventions for postnatal depression’. The main themes were underpinned by other themes. Overall the findings revealed that mothers perceived therapy as helpful in improving mood, confidence as a parent and relationship with their infant. Mothers valued the process of normalising their experiences within group therapy and by their therapists because it reduced any shame and stigma associated with PND. Mothers thought parenting support within therapy would be acceptable if delivered collaboratively.
Primary care-based psychological therapy for PND was perceived as helpful and acceptable. It clearly met some of the mothers’ goals, especially if their beliefs about being a ‘bad mother’ was challenged and modified. Barriers to engagement, such as childcare issues and therapist’s knowledge about perinatal mental health, would also need to be overcome. Finally, mother-infant interventions should be further explored as an adjunct treatment option.
KeywordsParenting Mother-infant outcomes Primary care mental health Group therapy Perinatal mental health, Service user experience
Postnatal depression (PND), a serious health concern for both mother and infant, is defined as an episode of depression that occurs in the first year after the birth of a child (O’Hara and McCabe, 2013). In PND the impact of depression is complicated by additional caring responsibilities, disturbances in the mother-infant-relationship and adverse outcomes for the infant’s cognitive and emotional development (Junge et al. 2017; O’Hara and McCabe 2013). PND can have a detrimental impact on maternal parenting behaviour (Letourneau et al. 2012; O’Hara and McCabe 2013); for example, it has been observed to negatively affect maternal sensitivity and responses towards the infant (Hipwell et al. 2000), and has been associated with increased hostility (Cornish et al. 2008). Perinatal depression on the whole is estimated to cost the United Kingdom (UK) £22,360 per mother and £51,462 per child (Bauer et al. 2015). The Department of Health (DH) has published their Five Year Forward View for Mental Health in 2016 with plans to increase funding for perinatal mental health services by £365 million over five years, supporting an additional 30,000 women. These plans present an ideal opportunity to develop new or refine existing psychological therapies which effectively address PND, both in terms of symptom reduction and improved parent-child outcomes (Dennis 2017; Dennis and Hodnett 2007; O’Hara and McCabe 2013).
In the UK, guidelines from the National Institute of Health and Care Excellence (NICE) suggest treating mild PND with guided self-help and moderate to severe PND with a high intensity intervention including Cognitive-Behavioural Therapy (CBT; NICE, 2014). In primary care services in England, mild to moderate depression is typically treated in Improving Access to Psychological Therapy (IAPT) services following referral from a General Practitioner (GP) or via self-referral (Radhakrishnan et al.2013). Based on the NICE guidelines (2014), this typically involves 6–12 sessions of CBT, which focuses on behavioural activation and cognitive restructuring (Beck et al. 1979; Bower and Gilbody 2005).
Both individual and group-based psychological interventions have been shown to be effective in reducing symptoms of depression (Cuijpers et al. 2008; Dennis and Hodnett 2007; Scope et al. 2013). Historically, psychological therapies for PND have focused on depression symptoms and less on mother-infant outcomes, including the mother-infant-relationship or the infant’s development (e.g., see Tsivos et al. 2015). Evaluations of parent-child outcomes indicate that traditional psychosocial and psychological therapies for PND do not lead to significant improvements in these areas, even when symptoms of PND have improved (Cooper et al. 2003; Cooper et al. 2010; Tsivos et al. 2015).
Conversely, although interventions that specifically target the mother-infant-relationship, such as mother-infant-psychotherapy, have demonstrated effectiveness in improving maternal parenting behaviour and child developmental outcomes (Nylen et al. 2006), their impact on the mothers’ symptoms of depression was less clear. There has been a lack of research into the effects of psychological therapy for PND on both maternal mood and mother-infant outcomes. Given that many of the sequelae of PND relate to parent-child outcomes as well as maternal wellbeing, it is important that research and interventions explore all of these aspects (Cooper et al. 2010).
Consequently, researchers in the field of maternal mental health have proposed that new approaches to treating PND are necessary to meet the needs of mothers with this complex mental health problem (Dennis 2017; O’Hara and McCabe 2013). A programme combining brief CBT skills with parenting skills training (Baby ‘Triple P’; Sanders 2012) was found to lead to non-significant improvements in maternal mood as well as subjective bonding in a pilot study, and the intervention was rated as highly acceptable to mothers (Tsivos et al. 2014). An intervention like Baby Triple P was also viewed as acceptable by mothers with severe mental health difficulties admitted to an inpatient Mother and Baby Unit (Butler et al. 2014). Thus, therapies for PND which also address the mother-infant-relationship are a promising area of research.
In-depth understandings of service users’ experiences are an important component of mental health research and intervention development (Levitt et al. 2006). Qualitative research into the experience of PND highlights themes of unmet maternal expectations, isolation, vulnerability, loss of identity and views of the self as a ‘bad’ parent (Beck 2002; Mollard 2014). Metasyntheses of qualitative research report that psychological and psychosocial interventions for postnatal mental health difficulties can be difficult for mothers to access due to barriers including stigma, poor healthcare experiences and childcare issues (Hadfield and Wittkowski 2017; Megnin-Viggars et al. 2015). However, these interventions were generally found to be acceptable and beneficial, with particular value placed on the relationship with the therapist, feeling listened to without judgement, and receiving information on PND and parenting (Hadfield and Wittkowski 2017). Studies of mothers’ treatment preferences have highlighted the importance of focusing on maternal cognitions and improving social support (O’Mahen et al. 2012) as well as providing the opportunity to have experiences validated (Dennis and Chung-Lee 2006). However, fewer studies have explored in depth the experience of specific psychological intervention techniques for PND, such as those used in CBT; the ‘active ingredients’ of therapy are less well understood (Hadfield and Wittkowski 2017; O’Hara and McCabe 2013). Furthermore, Hadfield and Wittkowski (2017) identified that hardly any qualitative studies had explored mothers’ views on the inclusion of parenting-related aspects to the therapy they received for PND.
Therefore, the aim of this study was to explore mothers’ experiences of psychological interventions for PND in UK NHS primary care mental health settings. A particular focus was on the perceived impact of current psychological therapies on parenting-related outcomes such as the mother-baby-relationship and parenting confidence. We also aimed to elicit mothers’ views on including parenting support in a therapeutic intervention for PND. Our research questions were: (1) How did mothers experience primary care mental health interventions for PND? (2) Did mothers believe that these interventions adequately met their mental health needs as parents of young infants? (3) What were mothers’ views on including parenting-based approach in their treatment for PND?
Participants were included if they were mothers of a healthy infant under two years old and had received psychological therapy for PND (as the main focus) within primary care mental health/psychology services in the NHS in the last two years. IAPT services were the main target setting because they predominantly provide NICE recommended CBT for depression, including PND (NICE 2014). All consenting participants provided basic demographic information and were asked questions using a semi-structured interview schedule, developed in conjunction with a researcher experienced in qualitative methodologies and in consultation with the University’s Community Liaison Group to ensure acceptable questions were asked.
Demographic details of participants
Type of therapy received for PND
Previous therapy received
Number of children
Counselling and CBT
Counselling and CBT
Counselling x 2
Word of mouth
Individual CBT (did not complete) and counselling
Group and individual CBT
Psychotherapy (as part of own psychotherapy training)
Individual CBT (home visits)
CAMHS input, hypnotherapy
Word of mouth
Counselling and CBT
Support group, interpersonal psychotherapy
Ethical approval was sought to recruit participants through NHS services and through charities and social media. Local collaborators (e.g. clinical psychologists and cognitive behaviour therapists) were identified to facilitate recruitment using convenience sampling and to approach potential participants, who gave their consent to be contacted by the main researcher (HH).
The study was also advertised on social media platforms (Facebook, Instagram and Twitter) using a poster, inviting interested participants to contact the researcher directly. The study was also advertised by charities the PANDAS Foundation and MIND via their own communications, and interested participants contacted the researcher via email. Interviews were conducted at the participant’s home address or over the telephone, and information sheets and consent forms were posted ahead of the interview.
Confidentiality and the process of audio-recording were explained to participants, and written informed consent was obtained before proceeding. Interviews followed a topic interview guide and lasted between 30 and 75 min. Interviews were audio-recorded and later transcribed, removing all identifying information.
Data were analysed using framework analysis (Ritchie and Spencer 1994), a realist method of qualitative analysis within the family of thematic analysis (Gale et al. 2013; Ritchie and Spencer 1994). A major advantage of framework analysis over other qualitative methodologies is its ability to answer specific research questions, particularly relevant in applied research to inform policies and clinical practice (Ward et al. 2013). Five stages of analysis take data from line-by-line codes to a working framework which encapsulates themes, including defining concepts, finding associations and developing explanations (Ritchie and Spencer 1994). A key component of framework analysis also includes looking for negative cases (Furber 2010; Ward et al. 2013). Throughout the analysis, the reflexive position of both researchers was considered, including the impact of their life experiences and professional orientations on the interpretations of the data (Berger 2015). A reflection diary was used by the main researcher (HH) to promote reflexivity.
Superordinate themes, themes and subthemes developed in the framework analysis
1. Experience of therapy for postnatal depression
1.1 Hopes for therapy
1.2 Overall impressions of therapy
1.3 Important aspects of therapy
1.4 Ending therapy
1.3.2 Therapeutic techniques
1.3.3 Supportive relationships
1.3.4 Acceptance of my experience
2. Therapy outcomes
2.1 Intrapersonal changes
2.1.1 Changes to mood
2.1.2 Changes to cognition
2.2 Interpersonal changes
2.2.1 Changes to the mother-infant relationship
2.2.2 Changes to the infant
3. Views about parenting in therapy
3.1 Advantages to including parenting in therapy
3.2 Disadvantages to including parenting in therapy
Experience of Therapy for PND: Hopes for Therapy
I just hoped, even at that point, I was a great believer in talking therapies because I’d had talking therapies before and other types of therapy, so I sort of knew it was roughly about, it would look at how I was. (Participant 3, individual CBT, 2nd time mother).
I was just looking for ways to manage it really you know instead of digging myself into a hole with it I was looking for ways I could manage it myself […] like different techniques I could pick up. (Participant 13, group CBT, 2nd time mother).
Experience of Therapy for PND: Overall Impressions of Therapy
I was a bit intimidated – intimidated’s [sic] the wrong word I was a bit hesitant at first because I thought oh my God I’ve gotta sit in front of a bunch of other people and talk about the problems I was having, you know what are they gonna think of me, but it actually ended up being better for me being in a group (Participant 5, group CBT, 1st time mother).
The finding that the group format for CBT was acceptable in the current study suggests that the advantages and disadvantages of attending a group, as well as previous clients’ experiences, should be discussed with potential attendees. Little research has directly compared the effectiveness or acceptability of group CBT to individual CBT for PND, or indeed depression in general, although it has been reported to be more effective than treatment as usual (Scope et al. 2013).
Experience of Therapy for PND: Important Aspects of Therapy
It was useful to get the break away from [X] my little boy as well, so for him to be in the crèche, that was quite a big thing for me to do because I’d never really given him to anybody. So to hand him over was quite a big thing, and I think it probably helped prepare me for when he went to nursery actually so I think that was really useful (Participant 1, group CBT, 1st time mother).
Cause it’s like some days, obviously when I’d be having a bad day, and I’d be thinking oh I don’t wanna go out I’ve gotta get them ready, I’ve gotta get them in the car, and I’ve gotta get the pram together to get there and I just didn’t want to. ‘Cause I thought being so far away it was too much time and effort to get there (Participant 5, group CBT, 1st time mother).
Whilst impaired motivation and practical considerations, such as time commitments, have been documented as barriers to attending therapy for depression more generally (Mohr et al. 2010), higher levels of guilt in leaving the infant to attend therapy appear to be a barrier specific to PND. Furthermore, although guilt at leaving an infant is considered to be a normal process in the adjustment to motherhood, intense guilt is recognised as a key factor in PND (Liss et al. 2013).
I found it [thought challenging] very easy and I kind of thought it gave me a good explanation for why I was feeling that way, and it kind of put it into more of a, not a scientific context but it took it, it took the onus away from me - it didn’t feel like it was my fault then, this was something that happened to lots of people and there are reasons for it, it depersonalised it in a way (Participant 12, group CBT, 1st time mother).
Findings regarding the value of specific therapeutic techniques for various mental health difficulties have been mixed (Ahn and Wampold 2001). However, a common theme in the literature, echoed in the current findings, is the importance of increasing understanding of thoughts, feelings and behaviour as mechanisms of change (Levitt et al. 2006). Slade et al. (2010) also reported that mothers found identifying thought patterns helpful in CBT for PND. The current findings suggest that cognitive techniques had particular value for cognitions relating to being a mother in the context of PND, corroborating the notion that this is a key aspect of the PND experience. CBT techniques were found useful if they were delivered or presented in an open, collaborative manner.
Yeah we did that you know that worrying thing, it was homework that you were supposed to try it out and you had to come back with like a goal that we were gonna achieve by the next week and then we had to come back and report back on how that went (Participant 2, group CBT, 2nd time mother).
I think the, ‘cos you feel like every things so tiring as it is with depression, doing board work and lots of home work when you got home just felt like something added to that stress that you didn’t need (Participant 7, individual CBT and counselling, 1st time mother).
So at the time [CBT] was extremely helpful because I was lacking support and needed to feel like I was being looked after, so I think it did help me and it was very important but I don’t think, I think now I can say it hasn’t been the thing that has really helped me […] It’s more like thinking positively isn’t it it’s almost like you’re, you’re sort of trying to teach yourself to be more positive to see it in a different way, but I don’t think it touches on really deep seated emotional problems that people might have that causes depression (Participant 14, individual CBT, 2nd time mother).
I: How important do you think the therapeutic relationship is in a therapy for postnatal depression? P: well really important because if you go to a session and you feel like you don’t get on with that person, or they’re judging you or you just don’t have a rapport with them, then you’re not gonna bother are you (Participant 4, group CBT, 2nd time mother).
Overall, the therapeutic relationship was thought to have a substantial impact on the perceived success and outcomes of the mothers’ intervention (Lambert and Barley 2001). This seemed particularly pertinent for mothers receiving individual interventions. These mothers reported feeling cared for by their therapist, an experience also reported by Myors et al. (2014), and described by mothers in therapy for PND in one study as “mothering the mother” (Bilzsta et al. 2010, p. 50). This experience was not evident in the narratives of mothers in group therapy. Whilst the therapeutic relationship appears crucial in therapy in general, the building of a supportive therapeutic relationship appeared particularly vital to participants due to the nature of PND and the isolation the mothers experienced after having a child (Beck 2002).
I ended up making a really good friend out of the group, erm, so to me I did find that the group helped but then meeting [friend] was really really good […]. We speak to each other nearly every day, and if we’re struggling then we talk to each other about it, so it, having that support there of someone who kind understands what you’re talking about (Participant 1, group CBT, 1st time mother).
Acceptance of my experience
A prominent theme across the participants’ narratives was the value of having their experiences listened to, validated and understood without judgement. This is a common finding in the experience of psychological therapy in general (Levitt et al. 2006) and was also reported by a qualitative systematic review of 40 studies of treatment preferences for PND (Dennis and Chung-Lee 2006). Whilst acceptance appeared to be integral to the formation of a good therapeutic relationship, it also had additional separate benefits. For mothers in this study, acceptance (including from other mothers in group therapy) helped to normalise their experiences and appeared to reduce some of the shame and stigma surrounding PND (McLoughlin 2013). Furthermore, having their experiences normalised and accepted challenged participants’ beliefs about being a bad mother (Beck 2002). Davies and Jasper (2004) also reported that social comparison appeared to be a key factor in the experience of group CBT for PND. Mothers with PND often report comparing their experiences against ‘idealised’ others and ‘perfect’ mothers (Bilzsta et al. 2010; Henderson et al. 2016). While mothers valued validation from a professional with relevant expertise, experiential understanding of the problem from other mothers in the group interventions meant that their feedback and support was often ascribed more value.
Experience of Therapy for PND: Ending Therapy
They signposted us back to [service] you know if you need further help, you can contact them, but had I not met these group of ladies I would have felt on my own (Participant 13, group CBT, 2nd time mother).
Therapy Outcomes: Intrapersonal Changes
Changes to mood
All mothers in the study reported positive changes to their mood and quality of life following therapy.
So I definitely feel more happy and more positive, and I’m doing a lot more things for myself and I feel like our family and home life is a lot happier than it was before I did group (Participant 4, group CBT).
It’s really funny, it’s probably not gonna go away, so I feel the tools she’s given me are really gonna help if I, you know, have moments in my life where that, I feel that way again, I can, I can go back to it really (Participant 10, individual CBT).
Changes to Cognition
I feel like a much more capable mum now, even though what I do is no different to what I was doing back then (Participant 1, group CBT).
Not dwelling on all the negatives that I might feel, and she really made me see the little things that actually were big things that I’d done in life, so, yeah, I think it made me a very different, you know, person (Participant 7, individual CBT and counselling).
While reduction of self-critical beliefs and more balanced thinking is common following CBT for depression (Farabaugh et al. 2015), it is important to note that in PND, mothers typically must continue engaging in caring for their infant which may trigger their self-critical beliefs. Mothers must also manage the societal pressures of meeting idealised standards of motherhood (Henderson et al. 2016). Although CBT has been reported to be effective in reducing mood related symptoms of PND in several trials (Stephens et al. 2016), the evidence of the impact of CBT on maternal confidence and cognitions has been equivocal (O’Hara and McCabe 2013). However, this study is one of the first to explore in depth the perceptions of specific therapeutic techniques, such as thought challenging, and their impact on beliefs related to parenting confidence and identity as a mother and, as such, generated novel findings.
Therapy Outcomes: Interpersonal Changes
Changes to the mother-infant-relationship
Yeah, yeah, erm, our relationship’s so much different now, I mean I did, I loved her from the day she was born, but I think I had a lot of resentment […] whereas now, I love, I love just you know, cuddling up to her and just you know making sure she’s ok now, it’s completely different (Participant 7, individual CBT and counselling).
I don’t think I had a bad relationship with him anyway… I don’t think the depression was anything to do with him as such (Participant 1, group CBT).
The extent to which CBT and other psychotherapies address parent-child aspects of PND has been questioned (O’Hara and McCabe 2013). In a systematic review of 19 studies, psychological therapies were not found to have a significant impact on mother-infant-relationships despite improvements in PND (Tsivos et al. 2015). Mothers in the current study perceived some impact on confidence as a parent as with as relationships with their infants even if this was indirectly via improvements in mood. This observation may highlight the benefits of using qualitative methods to assess how therapy functions (Levitt et al. 2006). Mothers in this study appeared to differentiate between PND in which the mother-infant relationship was affected and PND in which the relationship was not affected. This finding is also novel and may offer insight into the equivocal findings reported in the literature, but further research using longitudinal designs is warranted to explore this concept more thoroughly.
Changes to the infant
Yeah I think yeah, obviously it’s hard cause with a baby they’re changing all the time anyway so it could be, cause yeah he’s a lot happier but that could just be because he’s learning to smile more and things like that… but it could just be that he’s noticing me smile more so it’s that copying that he’s noticing (Participant 4, group CBT).
Views about parenting in therapy
Participants were asked about including parent-related topics in therapy for PND, such as their identity as a mother and interactions with their infant. Most mothers reflected that their therapy had focused on mood rather than parenting, although they might have challenged thoughts about being a ‘bad mother’ in relation to mood. However, a small number of mothers also discussed parenting issues within therapy, such as ideas about interacting with and soothing their baby. Mothers’ views on whether parenting-related issues belonged in therapy for PND were mixed, identifying both advantages and disadvantages to including them.
Views about parenting in therapy: advantages to including parenting in therapy
Yeah it’s very important ‘cause postnatal depression is basically around the fact that you’ve had a baby. Otherwise it would just be depression, wouldn’t it, so yeah it’s very important to speak about the whole bond with a child cause if you have that… people probably don’t admit to not having a bond, because they feel it’s not, it’s a bad thing to do to say well oh I’ve not been bonding with my baby. So to obviously speak about that and let them know that it is a normal thing (Participant 4, group CBT).
Because it’s massive and it’s not just that your personal life is so encompassing, but parenting is just, it just takes over your life it’s just so overwhelming especially in the newborn stage everything is about that so of course your mental health and any issues you have with it become about parenting and what it’s like to live it day by day (Participant 9, individual EMDR).
Views About Parenting in Therapy: Disadvantages to Including Parenting in Therapy
Somebody [with] postnatal depression could think oh no, they could easily think I’m not doing enough, I’m not good enough (Participant 3, individual CBT).
Sensitivity to criticism and self-criticism are well established to be important factors in depression more generally (Dinger et al. 2015). Many of the barriers women face in accessing therapy for PND in particular are related to stigma and worries about parental performance being scrutinised (Edwards and Timmons 2005).
I don’t know if that’s a universal feeling but I know for me that [focusing on parenting] would have been really terrible because one of the things that bothered me was how much I disappeared once I had [son] (Participant 9, individual EMDR).
It didn’t really apply to me, because my anxieties were from having a baby but they weren’t really connected, they weren’t about my relationship with my child (Participant 13, group CBT).
I think if you kind of interspersed it with different things kind of like with this is what you could potentially do to make yourself feel better or challenge some of your behaviours yeah that could work, but a standalone parenting thing I would have probably took quite badly (Participant 1, group CBT).
This study is one of the first to qualitatively explore mothers’ views about the potential inclusion of parenting-related support within an intervention for postnatal depression. Tsivos et al. (2014) reported that their pilot parenting intervention was rated as highly acceptable by mothers, which suggests that mothers did not feel criticised or neglected in the intervention. Nevertheless, it may be important that future therapies for PND which do include parenting elements are designed to minimise the risks of increasing perceived criticism or neglect the mothers’ wellbeing.
This study is one of the first to explore mothers’ experiences of therapy offered within UK primary care mental health services for PND in depth with a specific focus on parenting-related outcomes and support. Overall, mothers described the therapy they received to be helpful and effective in treating their PND. Some of the experiences reported in the current study are comparable to the experiences of psychological therapy for depression more generally. However, certain aspects of the participants’ experiences were clearly specific to the experience of PND: the therapeutic relationship was viewed as particularly important in light of the numerous relational challenges inherent in becoming a mother, such as increased isolation (Beck 2002; Mollard 2014). Acceptance of and normalising the mothers’ experiences from both group members and therapists helped reduce the shame and stigma associated with PND (Edwards and Timmons 2005) and challenge societal pressures relating to the concept of the ideal mother (Henderson et al. 2016). Furthermore, childcare was a particular aspect of therapy which could either facilitate or hinder engagement in therapy. Mothers found the cognitive-behavioural approach helpful in addressing symptoms of PND and reported that their confidence as parents increased and they no longer believed they were a ‘bad mother’. Parenting support was viewed as potentially useful in improving knowledge and confidence, provided it was collaborative and their own needs were central to therapy. There were, however, some potential disadvantages, in particular mothers feeling criticised. The findings will be pertinent for the further development of perinatal mental health services, especially within the UK (NICE 2014; NHS England 2018).
Qualitative methods as used in the present study provide appropriate means to develop understandings of key processes within psychological therapy (Levitt et al. 2006) and offer opportunities for service users’ perspectives to be an integral part of clinical decision making processes (Hodgetts and Wright 2007). However, one potential limitation of this study is that there was variability in the therapy offered across different mental health services, including both individual and group-based interventions. This may mean that experiences inherent to each format were not explored sufficiently, or that intrinsically different experiences were combined. However, this approach reflected the real make-up of UK mental health service provision related to PND in primary care. Additionally, it allowed for similarities and differences between group and individual formats to be identified; for example, both groups of participants valued thought challenging and experienced the ending of therapy as significant.
Furthermore, depression scores (and therefore indicators of PND severity) were not obtained. However, having been accepted into primary care mental health services, it was concluded that the participants would have undergone a thorough psychological assessment by a qualified mental health professional. In addition to this, qualitative approaches prioritise the views of the participants rather than quantitative ratings or scores (Levitt et al. 2006).
Finally, all the participants were of White British ethnicity. Concepts relevant to mothers from different cultural backgrounds were perhaps not represented in the analysis. For example, immigrant mothers and mothers of Black and Minority Ethnic (BAME) background often experience further challenges in accessing mental health services for postnatal depression (National Institute for Mental Health in England 2003; Wittkowski et al. 2017). Although the current study was open to mothers of all ethnicities, recruitment strategies could have been tailored more effectively to facilitate BAME mothers’ participation.
The findings of the current study have important implications for future research into psychological interventions offered to women with PND. The results suggested that there were certain aspects of psychological therapy for PND that were particularly pertinent for the engagement of mothers with a new infant. Research into future interventions for PND should take into consideration the impact of minimising barriers, such as childcare and PND-related stigma. The findings in our study relating to the changes reported in maternal cognitions warrant further exploration, and future research would benefit from investigating the impact of therapy on maternal guilt and shame more thoroughly. It would also be important to take into account the societal pressures and ideals around being the ‘perfect mother’ in this regard.
Additionally, the current study adds to the growing literature around parenting interventions as part of treatment of PND, and we suggest that the addition of tailored parenting support as well as or alongside a psychological therapy should be explored in future research. Interventions exist that combine psychological therapeutic principles with parenting support, such as Baby Triple P (Sanders 2012). This approach has been reported to be acceptable to mothers with PND (Tsivos et al. 2014), but its evidence base is still developing (e.g., see Wittkowski et al. 2018; Henderson et al. 2019). Given the limitations of this study, we also suggest that further research explores the specific experiences of particular therapeutic interventions, such as CBT, for PND. Finally, although group and individual therapy have been found to have similar cost effectiveness (Radhakrishnan et al. 2013), the current results identified that the group format conferred additional benefits in terms of providing additional social support and normalising from other mothers. It would be important to assess the effectiveness for group therapy for PND against the current evidence base for individual therapy for PND.
The authors gratefully acknowledge the involvement of the service users and mothers who dedicated their time and shared their experiences for this study. The authors also acknowledge the support from mental health clinicians in various NHS trusts, in particular the invaluable support from Joanne Gisbourne and Dr Catherine Houseman.
H.H.: designed and executed the study, completed analyses of data, and wrote the paper. P.B.: assisted with data analysis and collaborated in editing the manuscript. S.G.: collaborated with the design of the study and assisted in recruitment of participants. A.W.: developed the original idea for this study and oversaw all aspects of it, including finalising all drafts of this paper.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
This study obtained all relevant NHS and University of Manchester ethical, HRA and R&I approvals (NHS REC ID: 194202; UREC ID: 2016-0256-119).
In accordance with research ethics principles, all participants gave full informed consent to participate in the research. The consent form used in the study was approved by all relevant ethical bodies.
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