For the purposes of today,
I would think since very briefly only cover the context and the background objectives and methods and spend most of my time talking about
the key lessons that we learnt from that work to pull out the messages that I think may be transferable to other resource settings.
So that's the outgoing. After talking about the key lessons, I'm also going to talk very briefly about upcoming work, which I'm just embarking on,
which will be looking at perinatal mental disorders in India within the three network, which I'll describe later.
So I don't need to convince this audience about the importance of mental health and perinatal depression,
but like depression in all other walks of life, it's common and the burden is in equitably distributed.
So it's a low and middle income countries bear the significant bulk of the burden, perhaps different from depression at other times of life.
Depression during pregnancy or the perinatal period has, I would argue, more far reaching consequences.
And not only does it affect women themselves and their relationships and their ability to work and function in society.
But there's a lot of evidence now that depression and in mothers during pregnancy and after the very can have adverse effects on their infants,
and that physical adverse physical effects and stunting increased risk of diarrhoeal disorder,
diarrhoeal infections and other infections, but also cognitive impairments, emotional impairment.
And there's even evidence now that children of depressed mothers are more likely to have emotional problems as adolescents themselves.
So, especially in low income settings, there's a real risk of intergenerational effects of depression.
And it's a treatable condition so many people are very worried about, you know,
treating women who are pregnant or breastfeeding, but there are actually safe ways of of treating this condition.
So to give a little bit of context to the geographic setting.
So Myanmar has had civil conflict since 1984, and that's mainly between the UM, the central government,
which consists mainly of the ethnic majority Burman Group and multiple smaller ethnic groups.
Very. So this shows all the different ethnic groups that are all fighting, either for autonomy or some degree of independence,
and many of them are armed, so this has led to displacement of populations to all the surrounding countries.
And where I was based in this town called myself and I work with a group with a research unit called SMI, the Shukla Malaria Research Unit.
And along this border, it's estimated so between Myanmar and Thailand.
It's estimated that those 200000 migrants and about 150000 refugees.
And these were the populations that I was working with. So they were two distinct groups of the population.
So they were refugees who live in an established refugee camps.
And this is an example of one of the biggest refugee camps, which is home to about 40000 people.
And refugee camps offer a certain degree of safety.
Because everybody gets a house, everybody gets food ration, their NGOs that provide education and health services.
But you give up a lot of freedom of movement.
So once you within these camps, you're not you're not really allowed to leave until you get formally resettled to another country.
The migrant population is slightly different, so they don't live within these refugee camps.
They live in villages along the border, making a living in agriculture or in service industries or in manufacturing.
And they make the trips. This is some migrant women arriving to the smart health clinic, and they often commute back and forth.
So this river that you see here is the Mighty River, which is the border between Thailand and Myanmar.
So you can see on that side is already Myanmar. So it's physically not a long distance.
So they are very mobile group the migrants. So the objective is the work that I did was to find a tool that we could use to assess
perinatal depression in the setting because mental health in general was is very,
very much neglected in this area hasn't really been assessed before.
So the first objective was to find a tool that we could actually use then to use that
tool to look at to find the prevalence and risk factors for perinatal depression.
I also wanted very much to add a qualitative component,
so we wanted to explore women's own experiences and then look at treatment options for this setting.
So it was a mixed methods study. The big part the first part of it was a cohort study where we recruited women in pregnancy and then followed
them up to one month postpartum and assessed depression status at multiple time points throughout.
We had five hundred and sixty eight women for that part,
and then I did an in-depth qualitative component with 11 women who had very severe depression.
OK, so that's very briefly just providing the context, and I know I've skipped over the methods,
so please ask if you want to know more, but I thought I'd spend most of the time just talking about what we found.
So the things I wanted to talk about here are the prevalence that we found, the risk factors, the importance of qualitative narratives,
which I think is an area that, especially for people from medical or public health backgrounds, is quite a neglected area.
The importance of finding the right tool to use and then putting screening or some kind of case identification into practise.
So our first finding was that prenatal depression was very common in this setting.
Um, this is the prevalence of depression across the different time points that we looked at.
If you just look at one months postpartum. This is the cumulative prevalence that I'm showing here.
So it goes up over time. So at the at the time point of one month's postpartum,
so by the time we'd followed women up from the first trimester of pregnancy through to one month postpartum,
seventeen point three percent of women have experienced moderate to severe depression and moderate to severe depression.
We defined as mild, sorry, minor or major depression using the DSM criteria.
But one of our big findings, and that was quite interesting to me was that.
So the difference between these two bars is that this is just moderate to severe depression and the yellow bars is any form of depression.
So the difference in the column height is basically those people who are experiencing a mild severity of depression.
And it was striking to me that if you look at most kind of psychiatric research, this group of women, so the mild,
mildly depressed people with mild mild depression are completely neglected when actually the women we spoke to,
even if they were in that mild category, were having significant difficulties in their lives.
Another interesting finding, which was which was somewhat unexpected,
or at least something that we hadn't set out to look at systematically was that suicidal ideation was very common.
So almost a third of women that we spoke to had suicidal ideation and five percent had made first attempts.
And actually, when we went back and looked at data, we found that over the past five years,
half of all maternal deaths had been due to suicide, and that was something that had.
Despite it being so common,
had never really been picked up in the in a systematic way or highlighted as being one of the major causes of maternal deaths.
And what we found was that. So this so when we looked at those women who were having who had suicidal ideation,
this is looking at all the women in the first trimester of pregnancy who said who
who had suicidal ideation and looking at what depression category they fell into.
And the key message of this pie chart is that.
A quarter of the women who had suicidal ideation fell into this moderate or severe depression category, actually,
three quarters of women who are experiencing suicidal thoughts have either only very mild depression
as per the diagnosis or are completely negative in the interview for any depressive symptoms.
So it made us think,
is there something happening around suicidal ideation that is completely separate from the notion of depression as a as a disorder?
Risk factors only go briefly the main.
So this was a multivariable regression analysis, these were the factors that remained significantly associated with perinatal depression.
The main message here was that like and this was just alluding to a lot of the
factors that were associated with perinatal depression were psychosocial factors,
and they were things outside the remit of kind of biomedicine.
So not having enough social support, having experienced trauma, having experienced interpersonal or domestic violence.
So, yeah, that just made it clear to us that actually we're working within a whole social system of issues.
Qualitative narrative, so we spoke in depth to women who had experienced severe depression and.
I'll read you some quotes. Every day, my children ask me to buy them sweets, but I cannot because I have no money.
I cannot buy shoes for them. It makes me feel sad and pity for them.
It's about violence, so there was a high there was a lot of interpersonal violence between couples.
When I fight with my husband, I feel sad for a whole day. He hits me a lot.
Even without drinking alcohol, he hits me. So men drinking alcohol and then that leading to domestic violence was extremely common.
I worry about my children and their future. I feel so sad I can't breathe.
I cry when I think about my daughter in Burma, but I cannot cry, I lock it up inside and then I get chest pain.
My husband is in Bangkok, I cannot contact him every night, I cry for him.
Sometimes I think I don't want to stay in this world anymore. Sometimes I just want to close my eyes forever.
I feel weak. I have no more strength. I don't have the energy to even open my eyes.
So I wanted to highlight Anna's presentation by video.
Earlier, she said something about numbers not doing justice to the depth of the unmet need.
And I feel very strongly that often when you read quotes like this, they mean a lot more than seeing what the prevalence is in terms of percentages.
And that I think it's very important in these contexts to actually get the participants,
the people who are experiencing mental health issues to express in their own words and get across what they're feeling and what they're experiencing.
So finding the right tool, I could talk for a whole hour just on this, and I will try to keep it brief,
but we had a very difficult time figuring out what tool we would actually use to identify depression amongst people.
So the most commonly used tool, as you may know in perinatal women, is the Edinburgh postnatal depression scale.
It's been used widely translated into many, many different languages.
We found it just didn't work, so our population was a very low literacy population.
It's a very oral culture. And these tick boxes and these criteria of.
You know, asking someone to distinguish between hardly ever and sometimes, and it just it didn't work, it was very confusing.
Women just didn't like it and it was extremely time consuming.
We tried the Q9 nine, which has a bit of a more structured and and slightly more simplified scoring system,
but that also was not did not go down well.
And in the end, what was a real game changer to us was that we tried administering the structured clinical interview,
which is an open ended diagnostic tool, which is something that is not a screening tool.
It's a diagnostic instrument, and it's classically seen as the gold standard with which you validate screening tools.
But this completely changed everything for us because suddenly, instead of.
You know, myself and one of the local councillors kind of interrogating women,
it felt like almost all of these other parts were these screening tools and trying to get them to pick one tick box.
We were actually starting to have conversations and suddenly getting so much more information,
and it was like putting flesh on the bones of this conversation.
So in the end, unconventionally we stuck with this structured clinical interview for assessing depression throughout our study.
But I thought this was an important point to make, just because I think it's really essential that you get the right tool before you go out and
start trying to identify depression and or other mental disorders in different settings.
So putting screening into practise in a way,
the perinatal period is an ideal time at which to identify depression and other mental disorders
because it's a time when there is increased contact between women and health care services,
whether that's in primary care or antenatal or in hospital.
But even in low income settings, there tends to be more contact between health professionals and women at that point in time.
In Thailand, where I was,
the way it worked was that the women would all arrive to the clinic en masse in a big truck that would pick them up from different locations,
bring them to the clinic, and they would sit there for four or five hours before the truck would then take them back home again,
so they would wait for everybody to be seen.
And then they would all go home, be taken home again so that those that four or five hours was a perfect window of opportunity.
To not only do the study that we did, but more generally to do health promotion about mental health and to potentially introduce screening.
So this is another picture of the setting,
so people sitting around waiting and because they're not doing anything else is just a convenient time to introduce screening programmes.
OK, so very, very briefly, the project that I'm now embarking on is with the Mazzarri platform,
which is the maternal and perinatal health research collaboration India.
It's a collaboration that was established by Manisha Now, who works at the National Perinatal Epidemiology Unit here in Oxford.
And it's a network of 14 hospitals across four states in India.
And the primary aim of the network was to look at severe complications of pregnancy.
So not mental health related, but looking at things like anaemia and pregnancy and heart failure and pregnancy.
And I will be sorry. This is the this is the.
The institutions that are involved in the network and the project that I will be working on will be using that platform,
but looking at mental health in women during pregnancy and after delivery.
And again, we're hoping we're hoping to identify and validate a screening tool and then determine
prevalence and risk factors for the perinatal from perinatal mental disorders.
We're still liaising with a different partner hospitals to see which sites I'm going to be using,
and we're planning to start that in the middle of next year.
And she.