Identify the signs and symptoms ofcommon perinatal mood disorders Identify local and national resources tosupport those with perinatal mentalhealth concerns

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Introduction: The perinatal period, which consists of pregnancy and up to one year postpartum, is considered a period of vulnerability. During this time, women are at higher risk than at other times in their lives of developing a mental health disorder, particularly anxiety and depressive disorders. Perinatal mental health disorders have a tremendous negative impact on not only the mother, but also their children who may develop cognitive, behavioural, and emotional problems that last well into adulthood. Emotion dysregulation has been implicated in both anxiety and depressive disorders and, due to endocrine changes during the perinatal period, may play an important role in perinatal mental health. Perinatal emotion dysregulation has yet to be explored. The purpose of this thesis was to 1) better understand the link between emotion dysregulation and perinatal mental health, 2) assess whether current perinatal treatments effectively target emotion dysregulation, and 3) develop an effective psychological treatment protocol for perinatal emotion dysregulation. Methods: We designed and conducted three studies to meet our research aims. The first study compared emotion reactivity and emotion regulation, two aspects of emotion dysregulation, in perinatal women with an anxiety and/or depressive disorder to better understand perinatal emotion dysregulation. The second study examined the bidirectional relationship between Cognitive Behavioural Therapy (CBT) for perinatal anxiety and emotion dysregulation to examine whether emotion dysregulation moderates CBT treatment outcomes and whether CBT is an effective treatment modality for perinatal emotion dysregulation. This was examined in two samples of participants: participants from a randomized controlled trial and routine clinical care. In the third study, we developed a novel Dialectical Behavioural Therapy (DBT) informed treatment program for perinatal emotion dysregulation and examined the effectiveness of the program through a pilot study. Results: Our research revealed several important findings. First, heightened emotional reactivity may be a protective factor during the perinatal period; less flexibility in emotional reactivity and difficulties with emotion regulation were associated with worse perinatal mental health, and relationship dissatisfaction. Second, CBT was an effective treatment for low levels of emotion dysregulation but not for moderate or severe perinatal emotion dysregulation. Only 16% of routine clinical care participants and 28% of participants from the randomized controlled trial demonstrated clinically reliable change in emotion dysregulation. Emotion dysregulation did not moderate CBT treatment outcomes on anxiety or depression. This suggest that emotion dysregulation appears to be a distinct factor that may warrant more specialized treatment. Third, our short term, DBT informed, skills group was effective in significantly reducing perinatal emotion dysregulation. The DBT informed treatment may be more effective in targeting perinatal emotion dysregulation than CBT as illustrated by 48% of participants demonstrating clinically reliable change compared to the 16%-28% in the CBT treatment. Conclusions: This line of research allows us to have a better understanding of perinatal emotion dysregulation and may aid in the development of best practice assessment and treatment guidelines for emotion dysregulation during the perinatal period. Limitations and future directions are discussed. / Dissertation / Doctor of Philosophy (PhD)

The perinatal period is increasingly recognized as a vulnerable time for the development and exacerbation of psychopathology symptoms. Research has often focused on perinatal depression, with limited information on perinatal anxiety. This study examined the psychometric structure of all anxiety and depressive disorder symptoms as well as explored the relation between perinatal internalizing symptoms and sociodemographic, obstetric, and psychological risk factors. Obsessive-Compulsive Disorder (OCD) is a common perinatal anxiety disorder that is now classified with the Obsessive-Compulsive Spectrum (OCS) (hoarding, body dysmorphic, trichotillomania, and excoriation disorders). This study also aimed to determine the prevalence of clinically significant OCS symptoms and their association with postpartum adjustment. Participants recruited from the University of Iowa Hospitals and Clinics (N =246) completed an online questionnaire and a structured clinical interview during pregnancy (28-32 weeks gestation) and the postpartum (6-8 weeks). Questionnaires assessed demographics, pregnancy complications, anxiety sensitivity, coping strategies, maternal attitudes and experiential avoidance. Clinical interviews dimensionally assessed all anxiety and depressive symptoms as well as past psychiatric diagnoses. Confirmatory factor analyses identified three factors: Distress (depression, GAD, irritability, and panic); Fear (social anxiety, agoraphobia, specfic phobia, and OCD); and Bipolar (mania and OCD) during pregnancy and the postpartum. During pregnancy, structural equation modeling demonstrated that past psychiatric history predicted Distress and Fear symptoms. Experiential avoidance mediated the relation between negative coping strategies and Fear symptoms. In the postpartum, negative maternal attitudes predicted Distress symptoms. Experiential avoidance mediated the relation between negative coping strategies and Fear symptoms as well as between anxiety sensitivity and Fear symptoms. There were low rates of clinically significant OCS symptoms, except for body dysmorphic disorder symptoms. Elevations in all OCS disorder symptoms were significantly associated with more difficulty adjusting to the postpartum. Past psychiatric history, negative maternal attitudes, and experiential avoidance are particularly important risk factors for perinatal anxiety. Future clinical research should be aimed at identifying at-risk women and modifying experiential avoidance during the perinatal period. Elevated OCS symptoms, particularly body dysmorphic disorder symptoms, affect postpartum adjustment. Future intervention work should focus on assessing and treating perinatal body dysmorphic disorder symptoms.

<b>Background:</b> Perinatal depression is a significant contributor to maternal morbidity and mortality worldwide. Left untreated, perinatal depression has severe and far-reaching consequences for women, their families and wider society. Migrant women, including labour migrants and refugees, may be particularly prone to developing perinatal depression as a result of multiple stressors associated with displacement. Despite the vast majority of global migration flows occurring within low- and middle-income countries, evidence from these regions is severely lacking. This research addresses this imbalance by examining perinatal depression in migrant women living on the Thai-Myanmar border: a resource-poor setting of political tension and socio-economic disadvantage. <b>Aims:</b> This research aims to review the existing evidence around perinatal depression among migrant women from low- and middle-income settings; identify an appropriate tool to detect perinatal depression in migrant women on the Thai-Myanmar border; determine the prevalence of, and risk factors for, perinatal depression in this setting; explore women's experiences of perinatal depression; and develop recommendations for policy and practice. <b>Methods:</b> A sequential-exploratory mixed-methods design was used. The research included the following five study components: a systematic literature review; a validation study to identify a culturally-acceptable and appropriate assessment tool; a prospective cohort study of migrant women on the Thai-Myanmar border followed-up from the first trimester of pregnancy to one month post-partum; in-depth interviews with a subgroup of women with severe perinatal depression; and an informal exploration of stakeholder views. <b>Findings:</b> The systematic review found a wide range in prevalence of perinatal depression among migrant women and confirmed the absence of studies conducted in low-and middle-income destination countries. A total of 568 migrant women on the Thai-Myanmar border participated in the prospective cohort study, of whom 18.5% experienced moderate-severe depression and 39.8% experienced depression of any severity during the perinatal period. Almost a third (29%) of women reported suicidal ideation. Interpersonal violence (OR 4.5), experience of trauma (OR 2.4), a self-reported history of depression (OR 2.3) and perceived insufficiency of social support (OR 2.1) were significantly associated with perinatal depression. Lives of women with severe perinatal depression were characterised by difficult partner relationships, alcohol use among partners and interpersonal violence. A lack of mental health services currently limits the effective management of perinatal depression in this setting. Alongside training of health staff, primary, secondary and tertiary prevention efforts are required to effectively address perinatal depression on the Thai-Myanmar border.

Introduction: Borderline personality disorder (BPD) is a severe psychiatric disorder characterized by emotion dysregulation, interpersonal dysfunction, and poor impulse control. Little research has investigated BPD in the context of major life events. The perinatal period (pregnancy until 12 months postpartum) is an important milestone that involves major role transitions and novel challenges. This thesis examined the associations between borderline personality features (BPF) and depressive and generalized anxiety symptoms in a sample of treatment-seeking perinatal women. Methods: 74 perinatal women were recruited from the Women’s Health Concerns Clinic (WHCC) at St. Joseph’s Healthcare Hamilton, Canada, and enrolled in the WHCC Registry study. Participants were sent online intake questionnaires to collect data about demographic, personality, and other psychosocial variables. They also completed three self-report mental health measures: the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD), the Edinburgh Postnatal Depression Scale (EPDS), and the Generalized Anxiety Disorder Scale (GAD-7). Logistic regression was used to determine whether a positive MSI-BPD screen (score ≥ 7) was associated with a higher likelihood of screening positive on the EPDS or GAD-7 (score ≥ 13). Results: A positive screen on the MSI-BPD was significantly associated with an almost eighteen-fold increase in the odds of screening positive on the EPDS in our treatment-seeking perinatal sample (OR 17.84, 95% CI[2.11, 218.80], p<0.05). A positive screen on the MSI-BPD was not associated with higher odds of screening positive on the GAD-7, rather only childhood trauma and a positive screen on the EPDS emerged as significant predictor variables. Our findings may reflect the greater symptomatic overlap observed between BPD and perinatal depression as well as the comparatively lower comorbidity observed between GAD and BPD in non-perinatal research. Conclusions and Future Directions: The use of self-report measures, low statistical power, and a treatment-seeking sample are limitations to consider when interpreting our findings. To our knowledge, this research study offers one of the first explorations into the relationship between BPD and generalized anxiety symptoms during the perinatal period. Future research should aim to better characterize perinatal BPD and investigate its relationship with other mental health conditions. / Thesis / Master of Science (MSc) / The perinatal period (pregnancy until 12 months postpartum) represents a time of heightened vulnerability to poor mental health. Prior research has mainly focused on perinatal depression and anxiety, while perinatal personality disorders have received comparably less attention. Borderline personality disorder (BPD) is a severe psychiatric disorder associated with diminished ability to regulate emotions, disturbances in self-image, troubled interpersonal relationships, and impulsive behaviour. This thesis investigated the relationship between self-reported borderline personality features (BPF) and depressive and generalized anxiety symptoms in a sample of perinatal women seeking treatment at a psychiatric clinic. We hope that this research sheds light on the nature of perinatal BPD, as well as its associations with other mental health conditions, to improve both immediate and multi-generational maternal and infant well-being.

Aufmerksamkeit ist eine wichtige kognitive Operation, die mehrere Prozesse betrifft, zu welchen Konzentration, Orientierung, Filterung und Verarbeitung von Inputs, das Aufrechterhalten des Fokus und endogene Kontrolle gehören (Colombo, 2001; Hendry et al., 2019). Es wird angenommen, dass Aufmerksamkeit die Allokation von kognitiven Ressourcen, die Priorisierung und Aktualisierung eintreffender Informationen und die Regulierung von Verhalten in der frühkindlichen Entwicklung unterstützen kann (Colombo et al., 2011; Esterman & Rothlein, 2019). Die Fähigkeit zur Steuerung von Aufmerksamkeit in frühen Jahren wird häufig als entscheidend für die spätere Entwicklung von Selbstregulation angesehen (Posner et al., 2016; Rueda, Posner, et al., 2005), welche verbunden ist mit der akademischen Leistung und Lernleistung im späteren Leben (Best et al., 2011; Morgan et al., 2019). Beeinträchtigungen von Aufmerksamkeit und Selbstregulation sind oft mit neurologischen Entwicklungsstörungen verbunden, wie beispielsweise einer Aufmerksamkeitsdefizits- oder einer Hyperaktivitätsstörung (Barkley, 1997; Sjöwall et al., 2013; Sonuga-Barke et al., 2010) oder einer Autismus-Spektrum-Störung (Gilotty et al., 2002; Matson et al., 2013; Samson et al., 2014). Der Blick nach vorn – vom Säugling zum Kleinkind Die Entwicklungsliteratur verlässt sich zur Messung der Aufmerksamkeitssteuerung stark auf die Messung unterschiedlichen Blickverhaltens (Bornstein, 1985; Colombo et al., 1999; Gredebäck et al., 2009). Verschiedene Parameter des Blickverhaltens wurden verwendet, um unterschiedliche Aspekte der Aufmerksamkeitssteuerung zu erfassen, wie beispielsweise die Latenz der Ausrichtung zu Stimuli (Pyykkö et al., 2020), die Blickdauer auf Stimuli (Johansson et al., 2015) oder die Verarbeitungsgeschwindigkeit visueller Stimuli (Blankenship et al., 2019). Obwohl berichtet wurde, dass verschiedene Aspekte der Entwicklung der Aufmerksamkeitssteuerung über die ersten 2 Lebensjahre stabil sind (Brandes-Aitken et al., 2019; Colombo et al., 2004; Rose & Feldman, 1987; Rose et al., 2001), basieren die meisten Ergebnisse auf einem einzelnen und kurzen Beobachtungszeitraum (z. B. 5 Minuten). In dieser Arbeit wird eine datengetriebene Methodik eingesetzt, um einen longitudinalen Datensatz zu untersuchen, der Daten zum Blickverhalten im Alter von 6, 10 und 18 Monaten enthält. Auf diese Weise sind wir im Stande, Entwicklungsänderungen der Aufmerksamkeitssteuerung aus verschiedenen Perspektiven zu beobachten. Vor allem konnte auf diese Weise eine stabile und robuste Messgröße identifiziert und etabliert werden, die verwendet werden kann, um zu anderen Variablen in Bezug gesetzt zu werden, beispielsweise in der vorliegenden Arbeit zur Selbstregulation und zur mütterlichen psychischen Gesundheit. Aufmerksamkeit im Säuglingsalter wird oft als Frühindikator oder Prädiktor für Selbstregulationsfunktionen genutzt. Selbstregulationsfunktionen wiederum, häufig unter Betonung von Effortful Control und exekutiven Funktionen (Posner & Rothbart, 2000; Rothbart & Rueda, 2005; Rothbart, Sheese, et al., 2011), korreliert mit individuellen akademischen Leistungen, der Lebenszufriedenheit und dem Arbeitsmarkterfolg (Ahmed et al., 2019; Best et al., 2011; Brock et al., 2009; Morgan et al., 2019). Es wurde vorgeschlagen, dass Aufmerksamkeit grundlegend für die Entwicklung von Selbstregulationsfunktionen ist (Colombo & Cheatham, 2006; Posner & Rothbart, 2009; Rueda, Posner, et al., 2004). Auf dieser Basis haben mehrere jüngere Studien einen positiven Zusammenhang zwischen Aufmerksamkeit und Selbstregulation in den frühen Lebensjahren festgestellt (Blankenship et al., 2019; Cuevas & Bell, 2014; Geeraerts et al., 2019; Papageorgiou et al., 2014). In der vorliegenden Arbeit wurde die Literatur gesichtet, die diesen Zusammenhang aufstellt, und die Gesamtevidenz geprüft. Obwohl zwar empirische Hinweise darauf existieren, die diese Feststellung unterstützen, sind die Ergebnisse nicht konsistent. Des Weiteren werden basierend auf den gleichen Annahmen experimentelle Ergebnisse präsentiert, welche den Zusammenhang zwischen Messgrößen der Aufmerksamkeit im Säuglingsalter (auf Basis der datengetriebenen Methodik) und der Selbstregulationsfunktionen im Alter von 18 und 30 Monaten untersuchen. Die vorliegenden Resultate, ebenso wie der Literaturüberblick unterstützen die Behauptung eines Zusammenhangs zwischen Aufmerksamkeit und Selbstregulation nicht, zumindest nicht im Kleinkindalter. Der Blick zurück – vom Säugling zu Schwangerschaft und Kindheit der Mutter Vor dem Hintergrund der Wichtigkeit von Aufmerksamkeit im Säuglingsalter und der zuvor beschriebenen Rolle in der späteren Entwicklung haben Studien zu Säuglingsalter und Kindheit versucht, diejenigen Risikofaktoren zu identifizieren, welche die Aufmerksamkeitsentwicklung beeinträchtigen könnten. Dies legt den nachträglichen Fokus der Betrachtung auf die In-Utero-Periode und sogar Kindheitserfahrungen der Mutter. Es existieren substantielle Hinweise darauf, dass mütterliche Stressfaktoren kortikale und subkortikale Verknüpfungen von Säuglingen beeinflussen (Rifkin-Graboi et al., 2013; Scheinost et al., 2020) und negative Auswirkungen auf die kognitive Entwicklung von Kindern haben kann (Keim et al., 2011; Kingston et al., 2015; Laplante et al., 2004; Tarabulsy et al., 2014). Des Weiteren wurde in jüngeren Studien berichtet, dass negative mütterliche Kindheitserfahrungen einen kumulativen Effekt auf die mütterliche psychische Gesundheit haben kann (Sacchi et al., 2020; Weltz et al., 2016) und wiederum zu strukturellen Konsequenzen für die neuronale Entwicklung in-utero führen kann (Andescavage et al., 2017; Moog et al., 2018). Im Einklang mit diesen Ergebnissen haben mehrere umfangreiche Studien einen negativen Zusammenhang zwischen mütterlichem Stress und Kindheitstraumata, aufmerksamkeitsbezogenen Problemen (Ross et al., 2020; Wang & Dix, 2017), Aufmerksamkeitsdefizits-/Hyperaktivitätssymptomen (Moon et al., 2021; Mulraney et al., 2019; Vizzini et al., 2019) und einem erhöhten Autismusrisiko (Roberts et al., 2013) ihrer Kinder gezeigt. Obgleich eine umfangreiche Literatur zeigt, dass mütterlicher Stress die Aufmerksamkeit von Kindern beeinflusst, sind die zugrundeliegenden Mechanismen weiterhin unbekannt. In der vorliegenden Arbeit wurden die theoretischen Erklärungsansätze und die empirische Beweislage zum Zusammenhang von mütterlichen Stressfaktoren und Aufmerksamkeit des Nachwuchses untersucht. Im nächsten Schritt wurden, um ein besseres Verständnis für die zugrundeliegenden Mechanismen zu entwickeln, verschiedene Aspekte der mütterlichen psychischen Gesundheit (z. B. depressive Symptome, Symptome von Angstgefühlen und negative mütterliche Kindheitserfahrungen) und ihr Zusammenhang mit der Aufmerksamkeit von Säuglingen untersucht, basierend auf der gleichen Stichprobe anhand der Aufmerksamkeitsmessgrößen und unter Hinzufügen mütterlichen Daten von der Schwangerschaft bis 12 Monate nach der Geburt. Im Gesamten behandelt die vorliegende Arbeit drei Hauptthesen, welche in zwei verbundenen Veröffentlichungen untersucht werden. Erstens wurde die Entwicklung von Aufmerksamkeit im Alter von 6, 10 und 18 Monaten unter Verwendung von etwa 0,5 Millionen Fixierungen von Eye-Tracking-Messungen untersucht und mittels einer datengetriebenen Methode analysiert. Nach der Entwicklung von stabilen und robusten Aufmerksamkeitsmessgrößen, wurde das zweite Ziel umgesetzt, den Zusammenhang mit Selbstregulationsfunktionen zu untersuchen. Drittens wurde unter Verwendung der robusten Aufmerksamkeitsmessgrößen untersucht, ob rückblickend negative mütterliche Kindheitserfahrungen und mütterliche Stressfaktoren während der Schwangerschaft die Aufmerksamkeit von Säuglingen beeinflussen (Tu et al., 2021). Im Ergebnis zeigt sich (1) ein hoher Grad an Stabilität und interne Konsistenz zweier Aspekte der Aufmerksamkeitssteuerung von 6 bis 18 Monaten unter Verwendung einer datengetriebenen Methodik; (2) die Abwesenheit eines signifikanten Zusammenhangs zwischen Aufmerksamkeitssteuerung im Säuglingsalter und Selbstregulation im Kleinkindalter, welche eine weithin angenommene Verbindung zumindest im Kleinkindalter nicht bestätigt; und (3) einen signifikanten Einfluss von mütterlichen psychologischen Stressfaktoren, die in Verbindung zu negativen mütterlichen Kindheitserfahrungen stehen, auf die dauerhafte Aufmerksamkeit von Säuglingen. Zusammenfassend bietet die vorliegende Arbeit tiefere Einblicke in die Entwicklung von Aufmerksamkeit im Säuglingsalter und trägt zu einer wachsenden Literatur bei, die nahelegt, dass Prävention und Intervention sowohl für Mütter als auch für Säuglinge bereits vor der Schwangerschaft ansetzen sollten. Gleichzeitig zeigt die vorliegende Arbeit auf, dass das Forschungsfeld dringend weitere Untersuchungen zu den Entwicklungspfaden benötigen, die zu Selbstregulation führen. Dies unterstreicht die mehrstufige Natur von Entwicklungsprozessen. Zum jetzigen Zeitpunkt besteht nur wenig Evidenz, dass Aufmerksamkeit im frühen Säuglingsalter stark und auf besondere Weise mit Selbstregulation in der Kindheit in Zusammenhang stünde. Eine Theoriebasis und überprüfbare Modelle, die spezifisch für die Bewertung von früh entstehenden Grundlagen der Selbstregulation entwickelt werden, wären essenzielle Modelle, die der Komplexität der Aufgabe gerecht werden können.:1. Introduction p.7 1.1 Attentional Control in Infancy p.10 1.1.1 Development of Attentional Control in Infancy p.10 1.1.2 The Application of a Data-driven Method for Attention Measures Using Eye-tracking Data p.13 1.2 Attention and Self-regulatory Functions p.19 1.2.1 Distinct yet Approximate Aspects of Self-regulatory Functions in Early Years of Life p.19 1.2.2 The Relation between Attentional Control and Self-regulatory Functions p.20 1.3 Maternal Distress and Infants’ Attention p.26 1.3.1 Cross-generational Effects on Offspring’s Attention p.26 1.3.2 A Multi-dimensional Investigation of the Impact of Maternal Distress on Infants’ Attention p.27 2. Experimental Work p.33 2.1 Publication 1 – Experimental Work: Tu et al., (2022) p.35 2.2 Publication 2 – Experimental Work: Tu et al., (2021) p.51 3. General Discussion and Outlook p.67 3.1 Implications and Questions from the Experimental Work p.67 3.2 Optimizing the Design for Future Studies p.70 4. Summary p.73 3.1 English Summary p.73 3.2 Deutsche Zusammenfassung p.76 References p.80 Appendix p.96 A.1 Supplementary Information p.96 A.2 Author Contributions to the Publications p.97 A.3 Declaration of Authenticity p.99 A.4 Curriculum Vitae p.100 A.5 List of Publications p.102 A.6 Conference Contributions p.102 A.7 Acknowledgements p.103

<b>Introduction</b>: Maternal antenatal depression has been associated with an increased risk of offspring psychopathology and more recently with disturbed infant sleep; in particular, shorter sleep duration, more awakenings and sleep problems. The exact mechanisms through which risk may be transmitted remain unknown, as does the question of whether all infants are equally susceptible to the effects of antenatal depression. The primary objectives of this thesis were to examine: i) The role of two potential moderators on the association between antenatal depression and infant sleep: infant reactive temperament and the serotonin transporter polymorphism 5-HTTLPR ii) The association between antenatal depression and infant sleep using objective behavioural and physiological measures. iii) Infant sleep and temperament in a pilot randomised controlled trial (RCT) following treatment of antenatal depression <b>Methods</b> i) The role of infant reactivity and 5-HTTLPR as potential moderators was examined in two large longitudinal cohorts: the Avon Longitudinal Study of Parents And Children (ALSPAC) and the Generation R study, based in the UK and The Netherlands respectively (n=8,991 and n=2,441). ii) An Oxford based pilot longitudinal family study (n=16) iii) A pilot randomised controlled trial of women with antenatal depression who received Cognitive Behavioural Therapy (CBT) or Care as Usual (n=25). <b>Results</b> i) There was evidence that reactive temperament moderated the association between antenatal depression and infant sleep; boys seemed to be most affected exhibiting more awakenings, sleep problems and shorter sleep duration. 5-HTTLPR did not moderate this association. ii) Antenatal depression was associated with shorter infant sleep duration 5 months postpartum iii) Improvement in depression was associated with shorter infant sleep duration and easier temperament 2 months postpartum <b>Conclusion</b>: This thesis suggests that not all infants are equally susceptible to environmental influences and this may prove important in targeting interventions. The role of genetic factors in conferring any susceptibility remains unclear. Actigraphy offering accurate representation of activity levels and timing during the day and night was a significant methodological advantage, but recruitment to a study incorporating these proved challenging. Finally, psychological interventions during pregnancy appear to have beneficial effects for child development.

Thesis (MA)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: The topic of perinatal depression (i.e. depression during and after pregnancy) remains a subject of continued research interest, as a broad literature body reports that a large proportion of women suffering from this mental disorder do not receive appropriate treatment. This is worrisome, firstly, because mental health treatment is often readily available to the public and at no cost. Secondly, untreated perinatal depression not only holds dangerous consequences for the mother but also for the infant and the rest of the family. It is therefore important to identify those factors that act as barriers to mental health care utilization for perinatal depression. Although this is a persistent problem within the South African context, to date, little is known about the barriers to the utilization of available mental health services experienced among pregnant South African women. For this reason, the Perinatal Mental Health Project (PMHP) aims to provide mental health services at the same location where women receive obstetric services. However, despite their efforts, the number of women who decline available treatment is still of great concern. The present study offers a unique perspective on counselling for perinatal depression appointment-keeping barriers as it provides a holistic view of these barriers that exist not only within the women but also in their multi-levelled environments. Secondly, it addresses the problem of nonattendance to mental health care treatment offered by the PMHP and consequently also addresses the gap in South African research on the topic. The sample for this study was selected from PMHP files of those patients who failed to attend scheduled counselling appointments. The participants included in this study were selected by means of purposeful sampling to participate in face-to-face and telephonic semi-structured interviews. Participants were assured of confidentiality and anonymity. The semi-structured interviews were audio-recorded and transcribed after which transcriptions were entered into MS Word for textual analysis. Transcriptions were thematically analysed. The main themes that emerged from the present study included individual-related barriers, social-related barriers, institution-related barriers, community-related barriers and poverty-related barriers. The results of the present study reflect the motivations for depressive pregnant women to decline available and free mental health services provided by the PMHP, according to five main themes. These themes were then discussed according to Bronfenbrenner’s (1977; 1979) Ecological Systems Theory, which categorised the main themes identified according to the different systems operating within the patient’s environment, i.e. the individual-, micro-, meso-, exo-, and macrosystem. The individual system comprised the individual-related barriers, which included poor mental health, and ambivalent feelings toward the pregnancy. The microsystem comprised the social-related barriers, which included low social support and self-help strategies. Community-related barriers were considered within the mesosystem of the patient’s ecological environment, with stigma and pity as sub-barrier. The exosystem comprised the institution-related barriers, including referral protocol barriers, lack of information provided by the nurses, and nurses’ attitudes as experienced by participants. Lastly, poverty-related barriers were considered within the macrosystem, with financial life hardship, constant child-care demands, and transportation barriers as sub-barriers. The significance of this study lies in the original perspective offered on mental health care appointment-keeping behaviour within the South African context. Future research could, in addition to conducting interviews with hospital patients, include health care professionals and focus groups as this will allow for triangulation of the perspectives of all significant players. Also, having identified the problems and concerns with regards to attending counselling appointments, future research direction may be aimed at creating interventions designed to reduce the identified barriers to mental health care service use. / AFRIKAANSE OPSOMMING: Perinatale depressie (d.w.s. depressie voor en na swangerskap) bly ʼn onderwerp van voortdurende navorsings belang, aangesien ʼn breë navorsingsveld aandui dat ʼn groot proporsie van vroue wat aan hierdie geestesversteuring lei, nie die gepaste behandeling ontvang nie. Dit is kommerwekkend, eerstens, aangesien behandeling vir geestesgesondheid meestal openlik verkrygbaar is aan almal sonder enige koste. Tweedens, onbehandelde perinatale depressie hou nie slegs gevaarlike gevolge vir die moeder in nie, maar ook vir die baba en die res van die gesin. Dit is daarom belangrik om daardie faktore te identifiseer wat as hindernisse optree tot geestesgesondheid sorg diensgebruik vir perinatale depressie. Alhoewel dit ʼn voortdurende probleem binne die Suid-Afrikaanse konteks is, is daar tot op hede geen navorsing wat hindernisse tot gebruik van beskikbare geestesgesondheidsdienste bekend gemaak nie, veral wat ervaar word onder swanger Suid-Afrikaanse vroue nie. Vir hierdie rede, beoog die Perinatal Geestesgesondheid Projek (Perinatal Mental Health Project - PMHP) om geestesgesondheidsdienste te lewer by dieselfde plek waar vroue verloskundige dienste kan ontvang. Nietemin, ten spyte van hul pogings, is die getal vroue wat beskikbare behandeling van die hand wys steeds van groot kommer. Dié studie bied ʼn unieke perspektief op hindernisse tot berading vir perinatale depressie afspraak-ooreenkoms gedrag, aangesien dit ʼn algehele uitkyk bied op hindernisse wat nie slegs binne die vroue bestaan nie, maar ook in hul veelvlakkige omgewings bestaan. Tweedens, spreek dit die probleem van nie-bywoning van geestesgesondheidsbehandelingsdienste wat aangebied word deur die PMHP aan en gevolglik ook die gaping wat binne Suid-Afrikaanse navorsing rakende dié onderwerp bestaan. Die steekproef vir die studie was gekies van PMHP lêers van daardie pasiënte wat nie hul geskeduleerde terapie afsprake bygewoon het nie. Die deelnemers ingesluit in die studie is deur middel van doelgerigte-steekproefneming geselekteer om aan aangesig-tot-aangesig of telefoniese semi-gestruktureerde onderhoude deel te neem. Deelnemers is van hul vertroulikheid en anonimiteit van die proses verseker. Die semi-gestruktureerde onderhoude was oudio-opgeneem en transkripsies is daarvan gemaak, waarna die transkripsies in MS Word gelaai is vir tekstuele analise. Transkripsies is tematies geanaliseer. Die hooftemas wat na vore gekom het, sluit in individuele-verwante hindernisse, sosiale-verwante hindernisse, institusie-verwante hindernisse, gemeenskapsverwante hindernisse en armoede-verwante hindernisse. Resultate van dié studie reflekteer die motiverings van depressiewe swanger vroue om beskikbare en gratis geestesgesondheidsdienste wat verskaf is deur die PMHP van die hand te wys, volgens die vyf hooftemas. Hierdie temas is toe volgens Bronfenbrenner (1972) se Ekologiese Sisteemteorie verdeel in die verskillende sisteme teenwoording in die pasiënt se omgewing, naamlik die individuele-, mikro-, meso-, ekso-, en makrosisteem. Die individuele sisteem het die individuele-verwante hindernisse ingesluit, wat swak geestesgesondheid, en teenstrydige gevoelens teenoor die swangerskap omvat het. Die mikrosisteem het die sosiale-verwante hindernisse ingesluit, wat swak sosiale ondersteuning, en self-help strategieë omvat het. Gemeenskapsverwante hindernisse is binne die mesosisteem van die pasiënt se ekologiese omgewing beskou, en het stigma en jammerte as sub-hindernisse ingesluit. Die eksosisteem het die institusie-verwante hindernisse ingesluit, wat verwysing protokol hindernisse, gebrek aan inligting verskaf deur die verpleegsters, en verpleegsters se houdings soos ervaar deur die deelnemers omvat het. Laastens is die armoede-verwante hindernisse binne die makrosisteem beskou, en het finansiële lewens swaarkry, konstante kindersorg eise, en vervoer-verwante struikelblokke as sub-hindernisse ingesluit het. Die belang van dié studie lê in die oorspronklike perspektief van geestesgesondheidsbehandeling dienste afspraak-ooreenkoms gedrag binne die Suid-Afrikaanse konteks, wat aangebied is. Toekomstige navorsing kan, bykomend tot die voer van onderhoude met hospitaal pasiënte, fokus daarop om gesondheidsorg kenners en fokus groepe in te sluit, aangesien dit die triangulasie van perspektiewe moontlik maak van al die belangrike rolspelers. Ook, aangesien die probleem en bekommernisse rakende bywoning van terapie afsprake reeds geïdentifiseer is, mag toekomstige navorsing in die rigting beweeg met die doel om intervensies te omskep wat beoog om die geïdentifiseerde hindernisse tot geestesgesondheidsorg diensgebruik te verminder.