Childhood parental bonding and depression in adulthood: A study of mothers in rural Pakistan.

BACKGROUND: Parent-child relationship quality can have long-term impacts on child mental health into adulthood. The impact of parental behaviors on the future mental health of children has been understudied in South Asia, where parenting approaches differ from the dominant western approaches often represented in the literature. METHODS: Mothers in rural Pakistan (N = 828) reported on their own mothers' parenting behaviors using the Parental Bonding Instrument (PBI) and were assessed for depression using the Structured Clinical Interview for DSM Disorders (SCID). The PBI includes scales for warmth (care scale) and over-control (protection scale), as well as subscales for behavioral control and psychological control. We used structural equation modeling to test the associations between depression and all PBI scales/subscales. RESULTS: Increased parental care was associated with lower probability of depression (B = -0.19, SE = 0.09). Parental protection was associated with higher probability of depression (B = 0.25, SE = 0.11). Among the protection subscales, behavioral control was associated with increased risk of depression (B = 0.24, 95 % SE = 0.11) and psychological control was associated with decreased risk of depression (B = -0.28, SE = 0.12). LIMITATIONS: This cross-sectional study used retrospective self-reports of parenting experiences. Participants only reported on their mothers, not fathers or other caregivers. CONCLUSIONS: In a rural Pakistani sample, maternal warmth was protective against adulthood depression. The association between maternal control and depression varied based on the type of control (behavioral or psychological), emphasizing the importance of nuanced measures of parental control in this context.

Non-linear associations between HPA axis activity during infancy and mental health difficulties during early childhood among children in rural Pakistan.

Hypothalamic pituitary adrenal (HPA) axis activity may be a mechanism linking early adversity to child mental health difficulties. However, there is a dearth of longitudinal evidence for the association between HPA axis activity and mental health among children in low-resource contexts. The goal of this study is to examine linear and curvilinear associations between HPA axis activity during infancy and mental health difficulties in early childhood among children in rural Pakistan. Participants included 104 children (46% male) from the Bachpan study, a longitudinal cohort embedded within a maternal depression trial in Pakistan. We examined the associations between hair-derived cortisol and dehydroepiandosterone (DHEA) at 12 months old and mental health difficulties, measured with the Strengths and Difficulties Questionnaire (SDQ), at 36 months old. There was a significant quadratic association between hair cortisol and SDQ scores, with results showing a U-shaped relationship (i.e., having relatively high or low cortisol predicted increased mental health difficulties). DHEA showed a quadratic association with SDQ scores with an inverted U-shaped relationship (i.e., high and low DHEA was associated with decreased mental health difficulties). Results provide evidence of longitudinal and curvilinear effects of cortisol and DHEA during infancy on mental health difficulties in early childhood.

Effects of a maternal psychosocial intervention on hair derived biomarkers of HPA axis function in mothers and children in rural Pakistan.

Objective: Disruptions in the hypothalamic-pituitary-adrenal (HPA) axis are thought to be key neuroendocrine mechanisms involved in psychopathology and may have intergenerational impacts. Hair-derived HPA hormones offer a measure of long-term HPA axis activity that may be useful in assessing maternal and infant health. Building on a community-based randomized control trial of a perinatal depression intervention in Pakistan, we examine intervention effects on HPA axis activity in a subsample of mothers and infants. Methods: HPA axis activity was assessed using hair-derived cortisol, cortisone, and dehydroepiandosterone (DHEA). Hair samples were collected from mother-child dyads at one year postpartum from prenatally depressed women randomized to a cognitive-behavioral intervention (n = 35 dyads) or to enhanced usual care (n = 37 dyads), and from a comparison sample of women who screened negative for depression in pregnancy (n = 35 dyads). Results: The intervention group had 38 percent (p=0.01) lower maternal cortisol levels and 45 percent (p < 0.01) lower maternal cortisone compared to the EUC group. Maternal DHEA levels were higher among women in the intervention group compared to the EUC group by 29 percent (p = 0.02). Intergenerational intervention effects show higher DHEA levels in infants by 43% (p = 0.03). Infant cortisol and cortisone did not differ across groups. Conclusions: Results suggest that the perinatal depression intervention has effects on HPA axis activity in both mothers and children, providing evidence that treating maternal depression may impact physiological stress system functioning intergenerationally. In addition, utilizing hair-derived biomarkers of HPA-axis activity is a potentially useful clinical indicator of intervention impacts on the neuroendocrine system.

Longitudinal effects of perinatal social support on maternal depression: a marginal structural modelling approach.

BACKGROUND: Depression in the perinatal period, during pregnancy or within 1 year of childbirth, imposes a high burden on women with rippling effects through her and her child's life course. Social support may be an important protective factor, but the complex bidirectional relationship with depression, alongside a paucity of longitudinal explorations, leaves much unknown about critical windows of social support exposure across the perinatal period and causal impacts on future depressive episodes. METHODS: This study leverages marginal structural models to evaluate associations between longitudinal patterns of perinatal social support and subsequent maternal depression at 6 and 12 months postpartum. In a cohort of women in rural Pakistan (n=780), recruited in the third trimester of pregnancy and followed up at 3, 6 and 12 months postpartum, we assessed social support using two well-validated measures: the Multidimensional Scale of Perceived Social Support (MSPSS) and the Maternal Social Support Index (MSSI). Major depressive disorder was assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM IV). RESULTS: High and sustained scores on the MSPSS through the perinatal period were associated with a decreased risk of depression at 12 months postpartum (0.35, 95% CI: 0.19 to 0.63). Evidence suggests the recency of support also matters, but estimates are imprecise. We did not find evidence of a protective effect for support based on the MSSI. CONCLUSIONS: This study highlights the protective effect of sustained social support, particularly emotional support, on perinatal depression. Interventions targeting, leveraging and maintaining this type of support may be particularly important for reducing postpartum depression.

Effectiveness of a peer-delivered, psychosocial intervention on maternal depression and child development at 3 years postnatal: a cluster randomised trial in Pakistan.

BACKGROUND: Maternal depression has a recurring course that can influence offspring outcomes. Evidence on how to treat maternal depression to improve longer-term maternal outcomes and reduce intergenerational transmission of psychopathology is scarce, particularly for task-shifted, low-intensity, and scalable psychosocial interventions. We evaluated the effects of a peer-delivered, psychosocial intervention on maternal depression and child development at 3 years postnatal. METHODS: 40 village clusters in Pakistan were randomly allocated using a computerised randomisation sequence to receive a group-based, psychosocial intervention and enhanced usual care for 36 months, or enhanced usual care alone. Pregnant women (≥18 years) were screened for moderate or severe symptoms of depression (patient health questionnaire-9 [PHQ-9] score ≥10) and were recruited into the trial (570 participants), and a cohort without depression (PHQ-9 score <10) was also enrolled (584 participants). Including the non-depressed dyads enabled us to determine how much of the excess risk due to maternal depression exposure the intervention could mitigate. Research teams responsible for identifying, obtaining consent, and recruiting trial participants were blind to the allocation status throughout the duration of the study, and principal investigators, site coordinators, statisticians, and members of the trial steering committee were also blinded to the allocation status until the analysis of 6-month data for the intervention. Primary outcomes were maternal depression symptoms and remission (PHQ-9 score <10) and child socioemotional skills (strengths and difficulties questionnaire [SDQ-TD]) at 36-months postnatal. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, NCT02658994. FINDINGS: From Oct 15, 2014 to Feb 25, 2016 46 village clusters were assessed for eligibility, of which 40 (including 1910 mothers were enrolled. After exclusions, 288 women were randomly assigned to the enhanced usual care group and 284 to the intervention group, and 1159 women were included in a group without prenatal depression. At 36-months postnatal, complete data were available from 889 mother-child dyads: 206 (72·5%) in the intervention group, 216 (75·3%) in the enhanced usual care group, and 467 (80·0%) women who did not have prenatal-depression. We did not observe significant outcome differences between the intervention group and the enhanced usual care group for the primary outcomes. The standardised mean difference of PHQ-9 total score was -0·13 (95% CI -0·33 to 0·07), relative risk of patient health questionnaire-9 remission was 1·00 (95% CI 0·88 to 1·14), and the SDQ-TD treatment estimate was -0·10 (95% CI -1·39 to 1·19). INTERPRETATION: Reduced symptom severity and high remission rates were seen across both the intervention and enhanced usual care groups, possibly masking any effects of the intervention. A multi-year, psychosocial intervention can be task-shifted via peers but might be susceptible to reductions in fidelity and dosage over time (which were not among the outcomes of this trial). Early intervention efforts might need to rely on multiple models (eg, collaborative care), be of greater intensity, and potentially targeted at mothers who are at high risk for depression to reduce the intergenerational transmission of psychopathology from mothers to children. FUNDING: National Institutes of Health.

Maternal depression in rural Pakistan: the protective associations with cultural postpartum practices.

BACKGROUND: Traditional postpartum practices are intended to provide care to mothers, but there is mixed evidence concerning their impact on postpartum depression (PPD). It remains unknown if there is a unique impact of postpartum practices on PPD separately from other types of social support, or if practices differentially affect those with existing prenatal depression. In Pakistan, chilla (چله) is a traditional postpartum practice in which women receive relief from household work, additional familial support, and supplemental food for up to 40 days postpartum. This study aims to understand if chilla protects against PPD independent of other support and whether this relationship varies by prenatal depression status. METHODS: Data come from the Bachpan cohort study in rural Pakistan. Chilla participation and social support (Multidimensional Scale of Perceived Social Support) were assessed at 3 months postpartum. Women were assessed for major depressive episodes (MDE) with the Structured Clinical Interview, DSM-IV and for depression symptom severity with the Patient Health Questionnaire (PHQ-9) in their third trimester and at 6 months postpartum. Adjusted linear mixed models were used to assess the relationship between chilla participation and PPD. RESULTS: Eighty-nine percent of women (N = 786) participated in chilla and almost 70% of those that participated took part in all of chilla's aspects. In adjusted models, chilla participation was inversely related to MDE (OR = 0.56;95%CI = 0.31,1.03) and symptom severity (Mean Difference (MD) = - 1.54;95%CI: - 2.94,-0.14). Chilla participation was associated with lower odds of MDE (OR = 0.44;95%CI = 0.20,0.97) among those not prenatally depressed and with lower symptom severity among those prenatally depressed (MD = -2.05;95%CI:-3.81,-0.49). CONCLUSIONS: Chilla is inversely associated with both MDE and symptom severity at 6 months postpartum above and beyond social support. Specifically, chilla is inversely associated with MDE among those not prenatally depressed and with lower symptom severity among those prenatally depressed. This relationship signals an opportunity for interventions aimed at preventing and treating PPD in this region to draw upon chilla and similar traditional postpartum practices in creating community-based, low-cost, sustainable interventions for maternal mental health. TRIAL REGISTRATION: NCT02111915. Registered 18 September 2015. NCT02658994. Registered 22 January 2016. Both trials were prospectively registered.

Psychosocial determinants of sustained maternal functional impairment: Longitudinal findings from a pregnancy-birth cohort study in rural Pakistan.

Function is an important marker of health throughout the life course, however, in low-and-middle-income-countries, little is known about the burden of functional impairment as women transition from pregnancy to the first year post-partum. Leveraging longitudinal data from 960 women participating in the Share Child Cohort in Pakistan, this study sought to (1) characterize functional trajectories over time among women in their perinatal period and (2) assess predictors of chronic poor functioning following childbirth. We used a group-based trajectory modeling approach to examine maternal patterns of function from the third trimester of pregnancy through 12 months post-partum. Three trajectory groups were found: persistently well-functioning (51% of women), poor functioning with recovery (39% of women), and chronically poor functioning (10% of women). When compared to mothers in the highest functioning group, psychosocial characteristics (e.g., depression, stress, and serious life events) were significantly associated with sustained poor functioning one-year following child-birth. Mothers living in nuclear households were more likely to experience chronic poor functioning. Higher education independently predicted maternal function recovery, even when controlling for psychosocial characteristics. Education, above and beyond socio-economic assets, appears to play an important protective role in maternal functional trajectories following childbirth. Public health implications related to maternal function and perinatal mental health are discussed.

Father involvement in the first year of life: Associations with maternal mental health and child development outcomes in rural Pakistan.

The contribution of fathers to child development and maternal mental health is increasingly acknowledged, although research on this topic outside of high income countries is limited. Using longitudinal data, we characterized father involvement in a rural setting in Pakistan and investigated the link between father involvement in the first year of life and child development and maternal depression. Data come from the Bachpan study, a birth cohort established in the context of a perinatal depression intervention. Father involvement was mother reported at 3 and 12 months postpartum and covered domains such as playing with or soothing the infant. Child outcomes included growth at 3, 6 and 12 months postpartum, socioemotional development at 6 months (Ages and Stages Questionnaire-socioemotional), and developmental milestones at 12 months (Bayley Scales of Infant and Toddler Development, BSID)). Maternal depression was assessed at 3, 6, and 12 months postpartum. Roughly 20% of the fathers were temporarily non-resident. Among the rest, most mothers reported that fathers were involved: for example, approximately 40% reported that the father plays with the baby on a typical day. We observed no clear pattern of association between 3-month father involvement and child growth at any time point; however, 12-month father involvement was cross-sectionally inversely associated with child growth. We observed a protective pattern of association between 3-month father involvement and 6-month child socioemotional development. For the BSID domains, while almost all effect estimates suggested a protective association with higher levels of father involvement/father being temporarily non-resident, the magnitude of the estimates was smaller and most 95% confidence intervals crossed the null. Finally, there was a trend toward greater father involvement/being temporary non-resident predicting lower levels of maternal depression. Using longitudinal data, these results provide new evidence about the association between father involvement, and both child development and maternal mental health.

Socioeconomic status indicators and common mental disorders: Evidence from a study of prenatal depression in Pakistan.

There is growing interest in the relationship between socioeconomic status (SES), poverty, and mental health in low and middle-income countries (LMIC). However, it is not clear whether a gradient approach focused on a wider SES distribution or a binary poverty approach is more salient for mental health in LMIC. Yet this distinction has implications for interventions aimed at improving population health. We contribute to the literature by examining how multiple indicators of socioeconomic status, including gradient SES and binary poverty indicators, contribute to prenatal depression symptoms in a LMIC context. Prenatal depression is an important public health concern with negative sequela for the mother and her children. We use data on assets, education, food insecurity, debt, and depression symptoms from a sample of 1154 pregnant women residing in rural Pakistan. Women who screened positive for depression participated in a cluster randomized controlled trial of a perinatal depression intervention; all women were interviewed October 2015-February 2016, prior to the start of the intervention. Cluster-specific sampling weights were used to approximate a random sample of pregnant women in the area. Findings indicate that fewer assets, experiencing food insecurity, and having household debt are independently associated with worse depression symptoms. The association with assets is linear with no evidence of a threshold effect, supporting the idea of a gradient in the association between levels of SES and depression symptoms. A gradient was also initially observed with woman's educational attainment, but this association was attenuated once other SES variables were included in the model. Together, the asset, food insecurity, and debt indicators explain 14% of the variance in depression symptoms, more than has been reported in high income country studies. These findings support the use of multiple SES indicators to better elucidate the complex relationship between socioeconomic status and mental health in LMIC.

Child mental health and maternal depression history in Pakistan.

PURPOSE: We address the significant gaps in knowledge of prevalence and correlates of child mental health (CMH) problems outside of high income countries. We describe the prevalence of CMH problems and their correlates with a focus on the association with maternal depression in a sample of seven-year-old children in rural Pakistan. METHODS: This study was nested in a long-term follow-up of a perinatal depression intervention together with a reference group of non-depressed women, yielding a population representative sample. The Total Difficulties (TD) and component scores of the Strength and Difficulties Questionnaire (SDQ) were used to measure emotional and behavioral difficulties. RESULTS: The mean SDQ TD score was 10.6 (standard deviation = 8.3), with 12.5 % of children categorized as "abnormal" using standard cutoffs. Boys had a roughly 1 point higher (worse) SDQ TD score than girls (p value = 0.04). Children of mothers who were depressed prenatally as well as currently had SDQ TD scores 2.87 points higher than children whose mothers were not depressed at either time point (p value < 0.01). This association was stronger for boys. There was no evidence of elevated SDQ TD score among children whose mothers were depressed only prenatally or only currently. Some deviations from this pattern were observed with specific components of the SDQ. CONCLUSIONS: In this low resource, South Asian setting, we found evidence of elevated levels of emotional and behavioral problems, highlighting the need for effective interventions. Given the strong association of CMH with maternal depression, any intervention efforts should give strong consideration to maternal mental health.

Effect of an early perinatal depression intervention on long-term child development outcomes: follow-up of the Thinking Healthy Programme randomised controlled trial.

BACKGROUND: Perinatal depression has been linked with deleterious child development outcomes, yet maternal depression interventions have not been shown to have lasting effects on child development, and evidence is not available from countries of low or middle income. In the Thinking Healthy Programme cluster-randomised controlled trial, a perinatal depression intervention was assessed in Pakistan in 2006-07. The intervention significantly reduced depression levels 12 months post partum compared with a control. We aimed to assess the effect of this same intervention on the cognitive, socioemotional, and physical development of children at around age 7 years. METHODS: Mother-child dyads who participated in the Thinking Healthy Programme cluster-randomised controlled trial were interviewed when the index child was about 7 years old. A reference group of 300 mothers who did not have prenatal depression and, therefore, did not receive the original intervention, was enrolled with their children at the same time. The primary cognitive outcome was the score on the Wechsler Preschool and Primary Scale of Intelligence (WPPSI-IV); primary socioemotional outcomes included scores on the Strengths and Difficulties Questionnaire (SDQ) and the Spence Children's Anxiety Scale (SCAS); and primary physical outcomes were height-for-age, weight-for-age, and body-mass index (BMI)-for-age Z scores. Generalised linear modelling with random effects to account for clustering was the main method of analysis. Analyses were by intention to treat. The Thinking Healthy Programme cluster-randomised trial was registered at ISRCTN.com, number ISRCTN65316374. FINDINGS: Of 705 participating mother-child dyads interviewed at the end of the Thinking Healthy Programme randomised controlled trial, 584 (83%) dyads were enrolled. 289 mothers had received the intervention and 295 had received a control consisting of enhanced usual care. The mean age of the children was 7·6 years (SD 0·1). Overall, cognitive, socioemotional, or physical development outcomes did not differ between children in the intervention or control groups whose mothers had prenatal depression. When compared with the reference group of children whose mothers did not have prenatal depression, the Thinking Healthy Programme trial children had worse socioemotional outcomes; mean scores were significantly higher on the SDQ for total difficulty (11·34 vs 10·35; mean difference 0·78, 95% CI 0·09-1·47; p=0·03) and on the SCAS for anxiety (21·33 vs 17·57; mean difference 2·93, 1·15-4·71; p=0·0013). Cognitive and physical outcomes did not differ. INTERPRETATION: Our findings show that cognitive, socioemotional, and physical developmental outcomes of children at age 7 years whose mother had prenatal depression did not differ between those who received the Thinking Healthy Programme intervention and those who received the control. Further investigation is needed to understand what types of complex interventions or approaches are needed for long-term gains in maternal and child wellbeing. Prolonged, detailed, and frequent follow-up is warranted for all interventions. FUNDING: Grand Challenges Canada (Government of Canada), Saving Brains programme.

The puzzle of Muslim advantage in child survival in India.

The socioeconomic status of Indian Muslims is, on average, considerably lower than that of upper-caste Hindus. Muslims nevertheless exhibit substantially higher child survival rates, and have done for decades. This paper analyses this seeming puzzle. A decomposition of the survival differential confirms that some compositional effects favour Muslims but that, overall, differences in characteristics and especially the Muslim deficit in parental education predict a Muslim disadvantage. The results of this study contribute to a recent literature that debates the importance of socioeconomic status (SES) in determining health and survival. They augment a growing literature on the role of religion or culture as encapsulating important unobservable behaviours or endowments that influence health, indeed, enough to reverse the SES gradient that is commonly observed.

The linked survival prospects of siblings: evidence for the Indian states.

This paper reports an analysis of micro-data for India that shows a high correlation in infant mortality among siblings. In 13 of 15 states, we identify a causal effect of infant death on the risk of infant death of the subsequent sibling (a scarring effect), after controlling for mother-level heterogeneity. The scarring effects are large, the only other covariate with a similarly large effect being mother's (secondary or higher) education. The two states in which evidence of scarring is weak are Punjab, the richest, and Kerala, the socially most progressive. The size of the scarring effect depends upon the sex of the previous child in three states, in a direction consistent with son-preference. Evidence of scarring implies that policies targeted at reducing infant mortality will have social multiplier effects by helping avoid the death of subsequent siblings. Comparison of other covariate effects across the states offers some interesting new insights.

Spending to save? State health expenditure and infant mortality in India.

There are severe inequalities in health in the world, poor health being concentrated amongst poor people in poor countries. Poor countries spend a much smaller share of national income on health expenditure than do richer countries. What potential lies in political or growth processes that raise this share? This depends upon how effective government health spending in developing countries is. Existing research presents little evidence of an impact on childhood mortality. Using specifications similar to those in the existing literature, this paper finds a similar result for India, which is that state health spending saves no lives. However, upon allowing lagged effects, controlling in a flexible way for trended unobservables and restricting the sample to rural households, a significant effect of health expenditure on infant mortality emerges, the long run elasticity being about -0.24. There are striking differences in the impact by social group. Slicing the data by gender, birth order, religion, maternal and paternal education and maternal age at birth, I find the weakest effects in the most vulnerable groups (with the exception of a large effect for scheduled tribes).