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Objectives: Maternal health and well-being has been studied widely from the angle of postpartum depression and practical aspects of infant feeding. However, two kinds of difficulties, postpartum psychosis (PPP) and negative emotions experienced during breastfeeding, have received significantly less attention in the perinatal research field. Consequently, clinical guidelines and available support are limited for mothers with such experiences. Therefore the main objective of this thesis was to explore how experiences of PPP and negative emotions during breastfeeding influence the way mothers view themselves and their relationships, in order to identify recommendations for clinical practice. Method: A systematic literature review of 10 studies on PPP and an empirical qualitative study of 11 mothers experiencing negative emotions during breastfeeding were undertaken. Findings: Across both studies, themes captured how mothers’ negative experiences influenced the way they viewed themselves, their relationships with others and how they navigated the mother-child bond and breastfeeding. Mothers also felt disappointed with professionals’ lack of knowledge and understanding of their experiences. However, gaining insight into their own difficulties alleviated mothers’ distress and enabled them to develop and employ various coping strategies, such as seeking peer support. Discussion: Discussion of findings highlighted that the psychological nature of difficulties associated with PPP and breastfeeding problems is often given a secondary priority. In contrast, mothers experienced that relationships with others and increased understanding of their experiences was essential to their ability to cope and recover. In light of mothers’ disappointment with the care they received, clinical recommendations highlighted the importance of training and raising awareness about less common difficulties that mothers may experience in the perinatal period, which may affect how they feel about themselves and consequently, how well they adapt to the mothering role.

Postnatal depression (PND) is an episode of major depression which occurs within the postnatal period. It has major implications for maternal wellbeing, the mother-infant relationship and child development. Whilst there is considerable evidence demonstrating the impact of PND on parenting, there has been limited focus on parenting as an intervention target. Therefore, the foremost aim of this thesis was to assess the efficacy and acceptability of the Baby Positive Parenting Programme (Baby Triple P) in women with Postnatal Depression. In Chapter 1 a broad overview of the PND treatment literature is undertaken. The treatments represent a range including anti-depressant medication, antenatal group interventions, psychoeducation, cognitive behaviour therapy (CBT), interpersonal psychotherapy (IPT), interventions which focus on the mother-infant relationship and baby massage. Chapter 1 highlights the poverty of interventions focusing on parenting as well as limited assessment of dyadic and child developmental outcomes. Therefore, a systematic review in Chapter 2 sought to evaluate the quality and efficacy of treatments which did include the aforementioned outcomes. Having identified the little attention to parenting within the context of PND, Chapter 3 outlines the rationale for targeting parenting in PND and introduces the Triple P Positive Parenting Programme, its evidence base and details Baby Triple P. Self-regulation is also introduced as a possible mechanism for explaining the improvements and maintenance associated with Triple P programmes. Since there is no measure to assess self-regulation, one was designed for the purpose of this study. Chapter 4 presents the methodology for the two aforementioned empirical papers. Chapter 5 presents a Factor Analysis (FA) and psychometric properties of the Brief Parenting Beliefs Scale-baby version, designed to measure self-regulation in new parents. The result was a three-factor, brief reliable measure of self-regulation. Chapter 6 presents the findings from the pilot randomised controlled trial (RCT) of Baby Triple P, compared with treatment as usual (TAU) in a sample of women with PND. Twenty-seven women and their infants (under 12 months) from primary care services in Greater Manchester, UK, were randomised to either receive the eight-session Baby Triple P programme in addition to TAU or to TAU only. Participants were assessed prior to randomisation at Baseline (Time 1), post-treatment (eight weeks for TAU) (Time 2) and three-month follow-up (Time 3). Self-report measures were used to compare groups, including symptoms of depression, happiness, the parenting experience, subjective bonding and self-regulation. An assessor-rated observational measure of mother-infant interaction, the Care Index, and a measure of intervention acceptability were also included. Significant improvements from baseline to post-treatment and baseline to three-month follow-up were found across both Baby Triple P and TAU conditions. However, the present study failed to demonstrate an additive effect of Baby Triple P. Despite the non-significant findings Baby Triple P was found to be highly acceptable to women with PND.Reasons for the non-significant findings are explored. The final Chapter (7) is a general discussion summarising the preceding chapters and provides a critical analysis of the pilot RCT of Baby Triple P.

Introduction. Recent reports indicate inequalities for ethnic minority women in maternal health and a need for tailored maternity services to improve access to care. High rates of postnatal depression among British Pakistani women have been reported. These women tend to suffer from persistent depression and have both, poorer access to and outcomes from evidence based psychosocial interventions, compared to the majority of the population. Trials for Cognitive Behaviour Therapy based interventions for postnatal depression appear to improve clinical outcomes and patient satisfaction. However, no study to date has developed an intervention for this group of women that is culturally sensitive. The overall aim of this thesis was to explore a culturally adapted psychosocial intervention with British Pakistani women with persistent postnatal depression, and use the results of these investigations to develop a culturally adapted cognitive behavioural therapy (CBT) based intervention to the meet the needs of persistently depressed British Pakistani women. Methods. This thesis employed a two-phase design based on the Medical Research Council’s (MRC) complex intervention framework. In the first phase, qualitative interviews were conducted to explore the experiences of British Pakistani women with persistent postnatal depression and the type of help they would find acceptable. These interviews were analysed using framework analysis. Following the findings from phase 1, a culturally adapted CBT based manualised intervention was developed in phase 2, to target the British Pakistani women’s needs and measured participants’ satisfaction and engagement. Results. Three emergent themes from qualitative interviews with fifteen British Pakistani women with persistent postnatal depression were identified. These were: 1) causes of persistent postnatal depression; 2) impact of the depression; 3) past help sought and current treatment required for management of persistent postnatal depression. A feasibility study of a culturally adapted CBT based manualised intervention for persistent postnatal depression resulted in high levels of service user satisfaction and engagement. These women found the intervention, both accessible and acceptable for their needs. Fifteen women with persistent postnatal depression took part in the intervention. Significant improvements were found in depression, marital relationships, quality of parenting, and health. Significant improvements in perceived social support were not found. Conclusions. This systematic mixed method approach to the development and testing of a manualised culturally appropriate intervention will provide a framework for those developing culturally adapted interventions for British Pakistani women. A culturally adapted group CBT based intervention was acceptable to British Pakistani women with persistent postnatal depression. A larger trial is currently underway to investigate efficacy of this intervention in terms of reducing depression, and improving social functioning, marital and parental relations, and health.

Background: Perinatal mental illness, especially depression, is a leading cause of maternal morbidity and mortality in high-income countries. In the United Kingdom (UK), mental illness commonly presents to and is treated at primary care level; however there are no up-to-date estimates of the burden of different mental illnesses in women in and around pregnancy. The potential impact of mental illness with or without psychotropic medication on the risk of non-live pregnancy outcomes is unclear. In this context, the safety of psychotropic drugs, especially antidepressants, remains controversial. Aim and objectives: To estimate the clinical burden of depression, anxiety and serious mental illness (defined as bipolar disorder, schizophrenia and other related psychotic disorders) presenting to and/or being treated in UK primary care, and to investigate the effects on pregnancy outcomes while trying to differentiate the effects of psychotropic medication from mental illness itself. Methods: Women aged 15-45 years from 1990 to 2009 were identified from The Health Improvement Network, a UK primary care database. Coding of mental illness diagnoses and psychotropic drug prescriptions were examined by separately assessing the proportions of women with recordings of diagnoses, symptoms, and drug prescriptions over the study period. Three separate studies were then carried out. A cross-sectional study was firstly conducted to estimate the prevalence and diagnostic overlap of mental illnesses before, during and after pregnancy and the variation by maternal age, socioeconomic status and other maternal factors. The second study examined the risks of non-live pregnancy outcomes (defined as perinatal death, miscarriage, and termination) in women with no history of depression and anxiety, a diagnosis of such illness prior to pregnancy, illness during pregnancy or illness during pregnancy with use of medication (stratified by medication type). Multinomial logistic regression models were used to compare risks of non-live outcomes across these groups, adjusting for important socio-demographic and lifestyle characteristics. The third study examined the risks of major and system-specific congenital anomalies in children born to women with depression or anxiety that was untreated or treated with psychotropic medication. Logistic regression with a generalised estimating equation was used to compare risks of major congenital anomalies in children exposed and unexposed to psychotropic medication during the first trimester of pregnancy, adjusting for important socio-demographic, lifestyle and chronic comorbidity in the mother. Results: There were 344,042 women who had one or more singleton pregnancies identified between age 15 and 45 from 1990 to 2009. Recording of mental illness and prescriptions of psychotropic drugs increased considerably over the study period. There was high prevalence and overlap of different maternal mental illnesses, especially depression and anxiety, during and after pregnancy, and the prevalence was generally highest in younger, socioeconomically deprived women who had smoked before childbirth, were outside the normal range of BMI and had other chronic medical conditions, such as diabetes. Socioeconomic deprivation was associated with increased risk of all mental illnesses, although the impact of deprivation was more marked in older women. Those aged 35-45 in the most deprived group had 2.63 times the odds of antenatal depression (95% confidence interval [CI] 2.22-3.13) compared with the least deprived; in women aged 15-25 the increased odds associated with deprivation was more modest (odds ratio [OR]=1.35, 95%CI 1.07-1.70). Similar patterns were found for anxiety and serious mental illness. Women with antenatal exposure to antidepressant or anti-anxiety drugs showed the greatest increased risks for non-live pregnancy outcomes, relative to those with no history of depression or anxiety, although women with prior (but currently un-medicated) illness also showed modest increased risks. Compared with un-medicated antenatal morbidity, there was weak evidence of an excess risk in women taking tricyclic antidepressants (TCAs), and stronger evidence for other medications. The absolute risks of major and system-specific congenital anomalies were small in the general population (269 per 10,000 children for major congenital anomalies). Compared with un-medicated antenatal depression or anxiety (278 per 10,000 children for major congenital anomalies), the use of antidepressants during early pregnancy was associated with excess risks, especially for selective serotonin reuptake inhibitors (SSRIs) (290 per 10,000 children for major congenital anomalies). Compared with children born to women with no depression or anxiety, there was an increased risk of heart anomalies in children with antenatal exposure to SSRIs (adjusted OR=1.25, 95% 95%CI 1.02-1.53), particularly in those exposed to paroxetine (adjusted OR=1.89, 95%CI 1.24-2.88). Children exposed to sertraline and escitalopram also had similar increased risks, although fewer women were exposed to these drugs. No increased risks of major congenital anomalies were found in children exposed to TCAs or benzodiazepines; however, the risks of right ventricular outflow tract anomalies were notably higher for all drug classes. Conclusion: Strong socioeconomic inequalities in perinatal mental illnesses occur and persist with increasing maternal age. Women with depression or anxiety have higher risks of miscarriage, perinatal death and therapeutic terminations than women without these diagnoses and the risks are even higher if prescribed psychotropic medication during early pregnancy than if not. There is also an increased risk of congenital heart anomalies in children exposed to paroxetine and other SSRIs during the first trimester compared with those who are unexposed, although the absolute risk is small. There could be other associated factors also related to depression, anxiety or use of medications, which yet unlikely fully explain the observed excess risks. Whilst medicated depression or anxiety could be a marker of more severe illness than un-medicated ones, my findings indicate there may be some specific drug effects Targeting detection and effective interventions to women at risk of mental illness during pregnancy may reduce inequity and avoid substantial psychiatric morbidity, and subsequently reduce the need for further psychotropic treatment. GPs and other health care professionals should take a cautious approach when managing mental illness in pregnant women. The findings in this thesis provide vital information for this purpose, namely helping communicate the magnitude of risk of major congenital anomalies to women with the use of different psychotropic drugs in the context of the baseline risk in the general population.

Research has suggested that a bi-directional relationship exists between sleep disruption and depression. Not only is poor sleep a commonly reported symptom in those with depression, some aspects of sleep have also been shown to predict the onset of depression. Despite sleep problems being a commonly reported occurrence throughout the perinatal period, the field of perinatal sleep research remains in its relative infancy. However, recent studies suggest that sleep disturbances during this time may increase the risk of developing postpartum depression. Currently, research in this area is limited by studies that have failed to control for depressive symptoms at baseline, relied upon subjective, often retrospective, measures of sleep, and have only measured symptoms of postpartum depression in the early postpartum period. Few studies have used polysomnography, considered the ‘gold standard’ of sleep, and no studies to date have specifically compared the relationship between subjective and objective sleep. Therefore, the major aim of this thesis was to gain a better understanding of the specific aspects of sleep that were most relevant to postpartum depression. In order to address this aim, studies were carried out to: explore the aspects of sleep most relevant to major depressive disorder; examine differences in sleep between pregnant and non-pregnant women; investigate the relationships between subjective and objective measures of sleep; explore longitudinal changes in sleep, fatigue and depression throughout the perinatal period, and finally; examine which aspects of sleep at which time-point were most relevant to the development of postpartum depression. Overall this thesis found that women experience significant changes to their sleep throughout the perinatal period. While the sleep of third trimester women is considerably poorer than that of non-pregnant women (both objectively and subjectively), the most significant changes occur in the transition between late pregnancy and the early postpartum period. Furthermore, increased amounts of sleep and reports of difficulty falling asleep during late pregnancy predicted the development of postpartum depressive symptoms. This suggests that certain aspects of sleep during late pregnancy may serve as markers for women at risk of developing postpartum depression.

The research question “What does it mean for a woman to be diagnosed with postnatal depression?” indicates three main overlapping areas of investigation: women, including issues of gender, discourses around womanhood and the roles and expectations being a woman carries; diagnosis, which is the categorising of experiences deemed to be outside of what is considered normal and includes discourses around mental health and mental illness; and mothers, including expectations of mothers and motherhood. All of these areas interlink and are arguably socially and culturally specific. There is also an underlying concept of identity as a woman, a mother and a mentally ill person, both separately and as an intersection of the three. It is therefore an important area of investigation within counselling psychology, a discipline that concerns itself with subjective experience and is therefore well placed to interrogate the process of medicalised diagnoses. The social and cultural influence also suggests Charmaz’s constructivist grounded theory as the appropriate method as it uses ideas of social constructionism. In this study semistructured interviews were carried out with eight women who believed they had been given a diagnosis of postnatal depression. They were asked about the circumstances leading up to their diagnosis and what they felt the impact was. These interviews were transcribed and analysed using a Grounded Theory methodology (Charmaz, e.g. 2006). A theory of how women view their experience of being diagnosed with postnatal depression, as well as how social factors influence the way the women make sense of this experience, is proposed. This theory takes the form of a process in which women described a dissonance between their expectations of motherhood and their lived experience. They understood this as a lack in themselves and as a result hid their struggles to a point at which they felt they could no longer avoid seeking professional help. The subsequent diagnosis of postnatal depression led to an opening of a dialogue around the difficulties they were experiencing as well as options of possible treatments. The implications of this process are discussed.

Purpose: An unsatisfactory couple relationship is consistently considered a risk factor for postnatal depression. This systematic review aimed to critically evaluate the evidence regarding relationship factors which are predictive, maintaining or protective of maternal and paternal postnatal depression. Methods: Following database, reference and citation searches, seventeen articles meeting the inclusion criteria were identified. The findings of these studies were reviewed and critically appraised. Results: Findings suggested depressive symptoms were associated with perceived poor quality partner support, relationship dissatisfaction, conflict and discord. The relationships between depressive symptoms, reduced partner support and relationship dissatisfaction were broadly similar for women and men, however conflict appeared to play a stronger role in depressive symptoms for men than women. Conclusions: Several relationship factors were consistently implicated in postnatal depressive symptoms. Conclusions regarding the direction and strength of relationships between variables remain tentative due to limitations of the reviewed studies. Despite this, heightened understanding of relationship factors’ roles in postnatal depression can improve screening and intervention. Further involvement of couples in research and interventions for postnatal depression is warranted.