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Policy Forum Grand Challenges: Integrating Maternal Mental Health into Maternal and Child Health Programmes Atif Rahman1*, Pamela J. Surkan2, Claudina E. Cayetano3, Patrick Rwagatare4, Kim E. Dickson5 1University of Liverpool, Institute of Psychology, Health & Society, Child Mental Health Unit, Alder Hey Children’s NHS Foundation Trust, Mulberry House, Eaton Road, Liverpool, United Kingdom, 2Social and Behavioral Interventions Programme, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America, 3Mental Health Programme, Ministry of Health, Belmopan, Belize, 4Department of Mental Health, University Teaching Hospital of Kigali, Nyarugenge District, Rwanda, 5Health Section, UNICEF, United Nations Plaza, New York, United States of America This is one article in a five-part series providing a global perspective on integrating mental health. Introduction Over the last decade, a number of influential organisations have called for the integration of mental, neurological and substance use (MNS) disorders into large scale public health programmes . Al- though progress at the implementation level has been slow, the development of a number of evidence-based, potentially scalable interventions in the MNS field  provides new impetus to develop strategies for integration with broader programmes. The World Health Organization defines maternal mental health as ‘‘a state of well- being in which a mother realizes her own abilities, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to her community’’ . Globally, in women of child-bearing age, depression accounts for the largest proportion of the burden associated with mental or neurological disorders [4,5] (Box 1). In addition to the economic and human costs of maternal depression, children of depressed mothers are at risk for health, developmental, and behavioral problems , thereby contrib- uting to inter-generational disadvantage that accumulates throughout the life span. Addressing mental health concerns such as maternal depression could play an impor- tant role in achieving the Millennium Development Goals set by the United Nations (three out of the eight goals refer specifically to women and children) . However, mental health care remains conspicuous by its absence in large scale global maternal and child health (MCH) programmes. Critical obstacles include a number of misconceptions, or myths, about maternal depression. These myths have important consequences, depriving many mothers of their basic right to health and well-being, and preventing their children from reaching their full developmental potential. In this paper, one in a five-part series, we examine the state of the field of maternal mental health and consider the challenges as well as the opportunities for integration into MCH programmes. Misconceptions about Maternal Mental Health Myth 1: Maternal Depression is Rare A common perception is that depression is a construct of affluent Western societies that is infrequent or non-existent in traditional communities. Perinatal depres- sion (during pregnancy and in the year after birth) has been reported in all cultures. Rates vary considerably, but the average in high-income countries about 10% to 15% . A recent meta-analysis shows that the rates in low- and middle- income countries (LMICs) are even high- er, ranging from 18% to 25% . Contributing factors related to depression in women include poverty and persistent poor health; a poor relationship with a partner (including intimate partner vio- lence); insufficient practical or emotional support from the family; few confiding relationships and lack of assistance in crises; social adversity; limited control or participation in financial decisions or reproductive health, including crowded living conditions and lack of employment; and coincidental adverse life events, such as financial difficulties, unwanted preg- nancy, or illness in the child [6,9]. Myth 2: Maternal Depression is Not Relevant to MCH Programmes Depression is the leading contributor to the global burden of disease (more years of life lived with disability, reduced produc- tivity including unemployment, increased physical illness, increased health expendi- ture, impact on families and caregivers, and premature mortality) . Strong evidence shows that maternal depression, especially amongst those experiencing social disadvantage, is linked to poor outcomes in infants. Although some stud- ies have not found associations or only found them in subgroups [10–13], others show strong and independent associations with pre-term birth , low birthweight  and undernutrition in the first year of life , higher rates of diarrheal diseases, and early cessation of breastfeeding . The Policy Forum allows health policy makers around the world to discuss challenges and opportunities for improving health care in their societies. Citation: Rahman A, Surkan PJ, Cayetano CE, Rwagatare P, Dickson KE (2013) Grand Challenges: Integrating Maternal Mental Health into Maternal and Child Health Programmes. PLoS Med 10(5): e1001442. doi:10.1371/ journal.pmed.1001442 Published May 7, 2013 Copyright: 2013 Rahman et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: No direct funding was received for this study. The authors were personally salaried by their institutions during the period of writing (though no specific salary was set aside or given for the writing of this paper). Competing Interests: The authors have declared that no competing interests exist. Abbreviations: LMICs, low- and middle-income countries; MCH, maternal and child health.. * E-mail: Atif.Rahman@liverpool.ac.uk Provenance: Not commissioned; externally peer reviewed. PLOS Medicine | www.plosmedicine.org 1 May 2013 | Volume 10 | Issue 5 | e1001442 Depressive symptoms in low-income preg- nant women and mothers have been associated with use of tobacco, alcohol, and illicit drugs ; adverse birth out- comes ; chronic health problems ; low maternal self-esteem [18,19]; and parenting difficulties . The strength of associations vary across studies, howev- er, which could be attributable to social and cultural differences between popula- tions as well as differences and quality of the study designs. Notably, one review indicated that children of depressed moth- ers have significantly poorer long-term cognitive development; have higher rates of antisocial behaviour, hyperactivity and attention difficulties; and more frequently experience emotional problems . None- theless, despite this adversity, many chil- dren remain physically healthy and devel- op normally, demonstrating resilience of maternal care and child development. Suicide, strongly associated with depres- sion, is a leading contributor to maternal mortality globally. Maternal depression and suicide are strongly associated with gender-based violence; i.e., more than one fifth of women who have experienced violence attempt suicide . Suicidality – thoughts of suicide or actual self-harm – occurs in up to 20% of mothers in LMICs and from 5% to 14%in high-income countries , and rates are even higher in displaced populations . It is com- mon in young women and associated with abuse and stress that might be caused by such events as unwanted pregnancy. Myth 3: Only Specialists Can Treat Maternal Depression ‘‘Talking’’ or psychological therapies typically are a front-line treatment for depression. Only a minority of individuals with depression will require anti-depres- sant medication. Psychological therapies include cognitive behavioral therapy, in- terpersonal therapy, supportive therapy, and group therapy. Systematic reviews from high-income countries provide evi- dence of the effectiveness of both psycho- logical therapies and pharmacotherapy in the treatment of perinatal depression . Over the last decade, the evidence for the effectiveness of non-mental health specialist-led interventions (e.g., involving nurses, health visitors, and midwives) in high-income countries has been building [25–30]. Efforts to improve maternal mental health through such interventions in developing countries are promising. Several successful randomized controlled trials have been delivered by lay health workers, a critical resource in settings in which formally trained health profession- als are often scarce. Studies where mater- nal mental health was delivered effectively by non-specialists are summarized in Table 1 [31–33]. Myth 4: It is Not Possible to Integrate Mental Health Care into MCH Programmes Policy makers fear that mental health interventions will divert the energies of health care staff and dilute the impact of other ‘‘priority’’ interventions. This view fails to take into account the holistic nature of health and erroneously propagates the defunct theory of ‘‘mind-body’’ dualism. Most current evidence demonstrates the inter-connectedness of physical and men- tal health and suggests that integrated interventions can achieve synergistic re- sults . Examples of community-based trials with a maternal mental health component integrated into a MCH programme [31– 33] (Table 1) and a case study demon- strating that the screening and manage- ment of maternal mental disorders can be integrated successfully into an existing health system at a facility level  (Box 2) build a strong case for integration of mental health care into MCH pro- grammes. The studies in Table 1, all examples of community-based interven- tions, have common elements that make them more amenable to integration. Some of these elements are described in the formative research to develop the Think- ing Healthy Programme in Pakistan : (a) The intervention has a child-focus, thus ensuring buy-in from the families, and avoiding stigmatization; (b) It is woven into the routine work of the community health worker so it is not seen as an extra burden but, being delivered alongside normal duties, is seen to support his or her routine work; and (c) The intervention itself is simple and culturally appropriate and employs robust and supportive train- ing and supervision processes. The Think- ing Healthy Programme has been further adapted so that it can be used universally for all women rather than only depressed women. The challenges to integrating maternal mental health interventions at scale re- main substantial. In LMICs, the main barriers include resource allocation, lack of human resource, and weak health systems [36,37]. Globally, a major barrier remains the social exclusion and negative attitudes attached to mental illnesses – a problem as much of the public health Summary Points N Integrating maternal mental health care will help advance maternal and child health (MCH) status. N Misconceptions regarding maternal depression are obstacles to the integration of mental health initiatives in MCH programmes. N Myths about maternal mental health include the beliefs that: maternal depression is rare, not relevant to MCH programmes, can only be treated by specialists, and its incorporation into MCH programmes is difficult. N Collaboration between policy makers in mental health and those in MCH is imperative for action that will advance maternal and child health status. N Strategies to improve maternal mental health have to be linked to broader development goals, including poverty reduction and gender empowerment. N This paper is the second in a series of five articles providing a global perspective on integrating mental health. Box 1. Public Health Dimensions of Maternal Depression N The second leading cause of disease burden in women worldwide, following infections and parasitic diseases N Presents with low mood, loss of interest or pleasure, feelings of guilt or low self- worth, disturbed sleep or appetite, low energy, and poor concentration – symptoms that profoundly affect maternal functioning and role N Can become chronic or recurrent and leads to substantial impairments in the mother’s ability for child care N Has long-term negative effects on infant physical and cognitive development N Can lead to suicide – a leading cause of mortality in women of child-bearing age PLOS Medicine | www.plosmedicine.org 2 May 2013 | Volume 10 | Issue 5 | e1001442 Table1.EffectiveInterventionsforMaternalMentalHealthIntegratedintoMaternalandChildHealth. LevelofIntegrationAuthor/LocationInterventionDesignandParticipantsOutcomeMeasuresMainFindings Integratedintoanutrition andpositiveparenting programme Baker-Henninghametal.2005 Location:Innutritionclinicsin Kingston,StAndrew,andSt Catherine,Jamaica. NHalf-hourweeklyhomevisiting interventiontoimprovemothers’ knowledgeandchild-rearing practicesandparenting self-esteem;encourageage- appropriateplayactivitiesand responsivefeeding;empathic listeningandpraise. NControlgroupreceivedstandard healthandnutritioncareatthe clinics. Randomisedcontrolledtrial.139 mother–infantdyads-child aged9to30months;weight forage21.5z-scoresof nationalreferenceand22 z-scoresinprior3months. Measuredat1yearpost intervention. Maternalmood:Culturally modifiedversionoftheCES-Dto assessmaternaldepression. Childdevelopment:GriffithsMental DevelopmentScalesubscales assessing:locomotor,hearingand speech,hand–eyecoordination, andperformancedevelopmentto giveaglobaldevelopmental quotient(DQ). Maternalmood:Declinein depressivesymptomsin intervention,butnotcontrolgroup mothers(b=20.98;95%CI21.53to 20.41);mothersreceiving40–50 homevisitshadgreatestdeclinein depressivesymptoms(b=21.84; 95%CI22.97to20.72). Childdevelopment:Finalmaternal depressionandfinalDQcorrelated inboys(p,0.05),butnotingirls. Integratedintoa communityhealth programme Rahmanetal.2008 Location:UnionCouncilclustersin twosub-districts:GujarKhanand KallarSyedaninaruralarea65km southeastofRawalpindicityin Pakistan. N16homevisits:4antenatally and12until1yearpostnatally usingtheThinkingHealth Programme(THP),amanualised interventionincorporating cognitiveandbehavioural techniques. NControlgroupreceived enhancedroutinecare:thesame numberandscheduleofhome visits,butfromanuntrained communityhealthworker. NClusterrandomisedcontrolled trial. NWomenaged16–45years,in thethirdtrimesterofpregnancy, meetingSCIDcriteriaforDSM-IV majordepressiveepisode (n=903). Measuredat6monthsand1year postintervention. Maternalmood HDRSandSCIDat6and12 monthspostpartumtoassess maternaldepression. Infanthealthanddevelopment: Infantanthropometry:weightand length;numberofdiarrhoeal episodesinpreviousfortnightand immunisationstatusoftheinfant; timededicatedtoinfantplay. Maternalmood:Afteradjustingfor covariates,mothersinthe interventiongroup(a)Wereless likelytobedepressedat6months postpartum(23%vs53%,AOR0.22, 95%CI0.14to0.36,p,0.0001);(b) werelesslikelytobedepressedat 12monthspostpartum(27%vs59%, AOR0.23,95%CI0.15to0.36, p,0.0001);and(c)hadbetter perceivedsocialsupportat6(AMD 6.71,95%CI3.93to9.48,p,0.0001) and12months(AMD7.85,95%CI 5.43to10.27,p,0.0001). Infanthealthanddevelopment:(a) Infantsofinterventiongroup mothershadfewerepisodesof diarrhoeaat12months(AOR0.6, 95%CI0.39to0.98,p=0.04);and weremorelikelytobefully immunised(AOR2.5,95%CI1.47to 4.72,p=0.001);(b)Bothparents dedicatedtimetoplayingwiththe baby(AORmothers2.4,95%CI2.07 to4.01,p,0.0001;AORfathers1.9, 95%CI1.59to4.15,p=0.0001). PLOS Medicine | www.plosmedicine.org 3 May 2013 | Volume 10 | Issue 5 | e1001442 Table1.Cont. LevelofIntegrationAuthor/LocationInterventionDesignandParticipantsOutcomeMeasuresMainFindings Integratedintoachild developmentprogramme Cooperetal.2009 Location:Khayelitsha,aperiurban settlementoutsideCapeTown, SouthAfrica. 16homevisits–2antenatally and14until5months postnatally–usinganadaptation oftheHealthVisitorIntervention Programmeincorporatingprinciples ofWHO’sImprovingthe PsychosocialDevelopmentof Childrenprogrammeto:(a) Enhancematernalsensitivityand responsivenesstoandinteractions withherbaby;and(b)compare withgroupthatreceivedonly standardhealthcare. Allwomen,inthirdpregnancy trimester,identified systematicallyinregular homevisits(n=449). Mother-infantinteraction: Atinfantage6months,video tapesof10minutesoffreeplay independentlyscoredtoassess maternalsensitivityandintrusiveness. Infantattachment:Atinfantage18 months,theStrangeSituation Procedure. Maternaldepression:6months postpartumSCIDinterviews,which incorporatedtheEPDS. Maternaldepression:Lower prevalenceofdepressionin interventionthanincontrolgroupat 6and12months,butdifferences notsignificant;EPDSscoreslowerin interventionthancontrolgroupsat bothassessmentpoints,but differenceonlysignificant(p=0.04) at6months. Mother–infantinteraction: Interventiongroupsignificantly moresensitiveandlessintrusivein interactionswiththeirinfantsat both6and12months,allp,0.05. Infantattachment:Moreinfantsin theinterventionthaninthecontrol groupweresecurelyattached(OR 1.70,p,0.029). RahmanA,FisherJ,WaheedW.(2009).Maternalmentalhealthinterventionsinlowandmiddleincomecountries:Asystematicreviewoftheevidence.Unpublishedmanuscript.DepartmentofMentalHealthandSubstanceAbuse, WorldHealthOrganization,Geneva. AMD,adjustedmeandifference;AOR,adjustedoddsratio;CES-D,CenterforEpidemiologicStudiesDepressionScale;DQ,developmentalquotient;EPDS,EdinburghPostnatalDepressionScale;HDRS,HamiltonDepression. RatingScale;OR,oddsratio;PPVT-R,PeabodyPictureVocabularyTest–Revised;SCID,StructuredClinicalInterviewsforDSMIVDiagnoses;NBAS,NeonatalBehaviouralAssessmentScale. doi:10.1371/journal.pmed.1001442.t001 PLOS Medicine | www.plosmedicine.org 4 May 2013 | Volume 10 | Issue 5 | e1001442 professionals as of the communities they serve. The Way Forward In 2011, the Grand Challenges in Global Mental Health, an initiative of a consor- tium of researchers, advocates, and clini- cians, announced priorities for improving the lives of people with mental illness around the world and called for urgent action and investment . The principles underlining the setting of such priorities are to use a life-course approach, system-wide approaches to address suffering, and evi- dence-based interventions, and to under- stand the environmental context in which illness occurs and services are delivered. We believe these principles are not limited to mental health but are of direct relevance to all of MCH. Long-term follow-up studies from high-income countries show that the offspring of depressed mothers are at a higher risk of poor mental health and social impairment from early childhood through to adolescence and adulthood, and have an increased risk of mortality from medical causes . While such studies have not been conducted in LMICs, the impact of maternal depression through the life course is likely be even greater, given the strong associations with infant low birthweight and undernutrition. This paper highlights evidence-based interventions that can serve as models for integration into existing health systems to improve not only mater- nal depression but also immediate perinatal and long-term infant health and develop- mental outcomes, with likely benefits throughout the life course. The immediate needs are to make policy makers, planners, and politicians aware of the missed oppor- tunity of integrating these interventions into mainstream MCH programmes and to direct both research and implementation funds to meet the challenges of scaling up these promising approaches. The exercise of defining Grand Chal- lenges provides a framework for future steps in this direction . The Challenges especially relevant to maternal depression in the global MCH context are: N Enhance collaboration between MCH and mental health programmes, re- searchers, and practitioners N Develop ways to integrate screening and core packages of mental health services into routine primary health care (e.g., antenatal visits) and establish effective referral mechanisms N Further develop effective treatments for use by non-specialists, including lay health workers with minimal training N Address stigma related to mental illness that could impede the integra- tion of mental health into MCH programmes N Increase capacity in low- and middle- income countries by creating regional centers for mental health research, education, training, and practice that incorporate the views and needs of local people N Develop sustainable models to train and increase the number of culturally and ethnically diverse lay and specialist providers to deliver evidence-based services N Strengthen the mental health compo- nent in the training of all health care personnel N Redesign health systems to integrate maternal depression with other chron- ic disease care, and create parity between mental and physical illness in terms of investment into research, training, treatment, and prevention N Incorporate a mental health compo- nent into international MCH aid and development programmes The responsibility to meet these chal- lenges is not the sole duty of the mental health community, but rather it should be shared equally by the MCH researchers and funders. But where does one begin? Firstly, gain recognition at the highest international and national policy forums that mental health and well-being is a generic component of MCH that does not compete with MCH programmes but instead complements them. Secondly, enhance the training and supervision of MCH community and primary care personnel so that they can recognise and treat psychosocial distress and depression in women, enabling them to be more effective health workers. Thirdly, adapt effective interventions to local contexts and strengthen systems of supervision, referral, and continued training at the primary, secondary, and tertiary levels so that the community component is well supported. Finally, it is imperative to invest in research and implementation programmes so that these approaches are refined and scaled-up, leading to improved outcomes of all MCH programmes. Along with efforts to integrate maternal mental health care into MCH pro- Box 2. Case Study of Integration of a Stepped Care Intervention with a Facility-based MCH Programme in Urban South Africa  Neither routine screening nor treatment of maternal mental disorders are available in primary care settings in South Africa. The Perinatal Mental Health Project, based at the Mowbray Maternity Hospital in the Western Cape Province of South Africa, developed a stepped care intervention for maternal mental health that is integrated into antenatal care. Mowbray Maternity Hospital is a secondary level maternity hospital, linked to the University of Cape Town, and is located centrally within the city. The Perinatal Mental Health Project services are based at the hospital within the Midwife Obstetric Unit, which provides a primary level antenatal clinic. Midwives at the Midwife Obstetric Unit are trained to screen women routinely for maternal mood disorders during their antenatal visits. Women in whom screening yields positive findings are referred to on-site counsellors who also act as case managers. When specialist intervention is indicated, women are referred to an on-site psychiatrist. The Perinatal Mental Health Project works directly with facility managers and health workers through collaborative partnerships, focusing on problem solving and capacity develop- ment in the primary health care system. Over a 3-year period, 90% of all women attending antenatal care in the maternity clinic were offered mental health screening with 95% uptake. Of those screened, 32% qualified, of which 47% received counselling through the programme. A number of important lessons have been learned from this programme: (a) maternity health workers may be trained to screen for and refer women with mental distress in low-resource primary care settings; (b) training programmes that address and support the mental health needs of health workers may help staff to manage their workload and prevent compassion fatigue and ‘‘burn out’’; (c) on-site screening and counselling fosters the establishment of efficient referral mechanisms and access to mental health care often lacking in maternity settings in LMICS; (d) on-site, integrated mental health services increase access for women who have scarce resources and competing health, family, and economic priorities; e) coordinating mental health visits with subsequent antenatal visits further facilitates access for women with insufficient resources. PLOS Medicine | www.plosmedicine.org 5 May 2013 | Volume 10 | Issue 5 | e1001442 grammes comes the need to pay attention to factors contributing to the high rates of maternal depression, especially in re- source-poor settings. Epidemiologic data indicate that the origins of depression in women can be traced to the social circumstances of their lives [6,9]. As Desjarlais and colleagues  eloquently pointed out: ‘‘hopelessness, exhaustion, anger and fear grow out of hunger, overwork, violence and economic depen- dence. Understanding the sources of ill health for women means understanding how cultural and economic forces interact to undermine their social status. If the goal of improving women’s well-being from childhood through old age is to be achieved, healthy policies aimed at improv- ing the social status of women are needed along with health policies targeting the entire spectrum of women’s health needs’’. Integration of maternal mental health into the MCH agenda can provide a univer- sally acceptable ‘‘window of opportunity’’ for creating healthy policies, from education to economic empowerment to legal and political mechanisms that enhance the status of women. The evidence presented in this paper shows that many outcomes that contribute to infant mortality, such as undernutrition, diarrhoeal disease, immunization, and breastfeeding uptake, have direct associa- tions with maternal mental health. By narrowly fixating on mortality and mor- bidity targets, and relegating psychosocial well-being to be a peripheral goal, the MCH community is missing an important opportunity and, in the process, depriving millions of mothers and children of their basic right to health. This situation needs to be remedied immediately and urgently. Author Contributions Wrote the first draft of the manuscript: AR. Contributed to the writing of the manuscript: AR PJS CEC PR KED. 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