Evidence Base

Studies in: Infancy; Antenatal & Postnatal Depression; Screening; Prematurity

PIRI has conducted research in the areas of perinatal depression and prematurity since 2001. Our key findings include:

Beating the Blues Before Birth

This paper aimed to evaluate the efficacy of a brief CBT treatment for maternal depression and anxiety in pregnancy. Both the feasibility study and RCT yielded promising results for adherence, acceptability and improvements in depression and anxiety. Strong reductions in anxiety were observed during pregnancy and improvements in depression were maintained at nine months. Infant outcomes showed effects favouring the intervention in domains including problem solving, self-regulation, and stress reactivity, which were independent of maternal postnatal mood.

Milgrom J, Holt C, Holt CJ, et al. (2015) Feasibility study and pilot randomised trial of an antenatal depression treatment with infant follow-up. Arch Womens Ment Health 18: 717-730.

Subsequent papers have focused on the epigenetic effects of antenatal depression and the effects on children’s brain development:

Bleker LS, Milgrom J, Gemmill AW, et al. (2019a) A 7-year follow-up of antenatal depression treatment with cognitive behavioral therapy: A case report of maternal and child outcomes: SAGE Open Med Case Rep. 2019 Apr 9;7:2050313X19841463. doi: 10.1177/2050313X19841463. eCollection 2019.

Bleker LS, Milgrom J, Parker D, et al. (2019b) Brain Magnetic Resonance Imaging Findings in Children after Antenatal Maternal Depression Treatment, a Longitudinal Study Built on a Pilot Randomized Controlled Trial. Int J Environ Res Public Health 16.

Bleker LS, Milgrom J, Sexton-Oates A, et al. (2019c) Exploring the effect of antenatal depression treatment on children’s epigenetic profiles: findings from a pilot randomized controlled trial. Clin Epigenetics 11: 019-0616.

Milgrom J, Holt CJ, Bleker LS, et al. (2019d) Maternal antenatal mood and child development: an exploratory study of treatment effects on child outcomes up to 5 years. J Dev Orig Health Dis 10: 221-231.

Bleker LS, Milgrom J, Sexton-Oates A, et al. (2020) Cognitive Behavioral Therapy for Antenatal Depression in a Pilot Randomized Controlled Trial and Effects on Neurobiological, Behavioral and Cognitive Outcomes in Offspring 3-7 Years Postpartum: A Perspective Article on Study Findings, Limitations and Future Aims. Front Psychiatry 11.

MumMoodBooster – Online Treatment for PND

Our previous research with MumMoodBooster has established the usability, feasibility and clinical effectiveness of this internet program. Poor uptake of traditional treatment relates to fear of stigma, poor accessibility of clinic-based programs and expense. Potential strengths of a Web-based intervention for PND are accessibility, privacy and low cost. The potential public health impact of Web-based treatment is therefore enormous given the 300,000 annual births in Australia. Our ongoing work continues to evaluate this validated internet intervention for postnatal depression by comparing it to traditional face-to-face psychological treatment. A large randomised controlled trial has been completed and is awaiting publication.

Jeannette Milgrom, PhD; Brian G Danaher, PhD; John R Seeley, PhD; Christopher J Holt PhD; Charlene Holt, PsyD; Jennifer Ericksen, MPsych; Milagra S Tyler, MA; Jeff M Gau , MS; Alan W Gemmill, PhD. Internet and Face-to-face Cognitive Behavioral Therapy for Postnatal Depression Compared With Treatment as Usual: Randomized Controlled Trial of MumMoodBooster. Published on  in Vol 23, No 12 (2021): December  https://www.jmir.org/2021/12/e17185/

Milgrom, J., Danaher, B. G., Holt, C., Holt, C. J., Seeley, J., Tyler, M. S., . . . Gemmill, A. W. (2016). Internet Cognitive Behavioural Therapy for Women with Postnatal Depression: a randomised controlled trial of MumMoodBooster. Journal of Medical Internet Research, 18(3), e54. doi: doi:10.2196/jmir.4993

Danaher, B., Milgrom, J., Seeley, J., Stuart, S., Schembri, C., Tyler, M. et al. (2013). MomMoodBooster Web-Based Intervention for Postpartum Depression: Feasibility Trial Results. Journal of Medical Internet Research, 15(11), e242. https://www.jmir.org/2013/11/e242/

Danaher, B. G., Milgrom, J., Seeley, J. R., Stuart, S., Schembri, C., Tyler, M. et al. (2012). Web-based Intervention for Postpartum Depression: Formative Research and Design of the MomMoodBooster Program. JMIR Research Protocols, 1(2), e13. https://dx.doi.org/10.2196/resprot.2329

We continue to work with collaborators around the world to establish the effectiveness of internet-based psychological treatments for depression:

Furukawa TA, Suganuma A, Ostinelli EG, et al. (2021) Dismantling, optimising, and personalising internet cognitive behavioural therapy for depression: a systematic review and component network meta-analysis using individual participant data. Lancet Psychiatry 8: 500-511.

Karyotaki E, Efthimiou O, Miguel C, et al. (2021) Internet-Based Cognitive Behavioral Therapy for Depression: A Systematic Review and Individual Patient Data Network Meta-analysis. JAMA Psychiatry 78: 361-371.

PremieStart: Protecting the Neurological Development of Premature Infants through Stress-Reduction

The primary aim is evaluate the long-term effectiveness of a simple, inexpensive program of stress-reduction for preterm infants (n=123) on measures of cognition and behaviour. We have already demonstrated some early advantages of the PremieStart program in infant development at 6 months and have now compared developmental outcomes at 4 years in intervention and control preterm children, alongside a matched full-term cohort (funded by NHMRC).

Milgrom, J., Newnham, C., Martin, P. R., Anderson, P. J., Doyle, L. W., Hunt, R. W., Gemmill, A. W. (2013). Early communication in preterm infants following intervention in the NICU. Early Human Development, 89(9), 755-762. https://dx.doi.org/10.1016/j.earlhumdev.2013.06.001

Milgrom J, Martin PR, Newnham C, et al. (2019) Behavioural and cognitive outcomes following an early stress-reduction intervention for very preterm and extremely preterm infants. Pediatr Res 86: 92-99.

We are currently preparing the results of the 6-year and 9-year follow-ups of this preterm cohort.

Beautiful Beginnings: Early Intervention to Facilitate Brain Development in Preterm Infants

The neurological development of premature infants is severely compromised leading to a high prevalence of long-term neurobehavioural problems. In this work we showed that training parents to minimize stress on their premature neonates results in significant enhancements of early brain development, which are observable on cranial MRI scans. Specifically, white matter microstructure and connectivity were improved by this early intervention.

Milgrom, J., Newnham, C., Anderson, P. J., Doyle, L. W., Gemmill, A. W., Lee, K., Inder, T. (2010). Early sensitivity training for parents of preterm infants: impact on the developing brain. Paediatric Research, 67(3), 330-335.

Newnham, C. A., Inder, T. E., & Milgrom, J. (2009). Measuring preterm cumulative stressors within the NICU: the Neonatal Infant Stressor Scale. Early Human Development, 85(9), 549-555. https://dx.doi.org/10.1016/j.earlhumdev.2009.05.002

Newnham, C. A., Milgrom, J., & Skouteris, H. (2009). Effectiveness of a Modified Mother-Infant Transaction Program on Outcomes for Preterm Infants from 3 to 24 months of age. Infant Behavior & Development, 32(1), 17-26. https://dx.doi.org/10.1016/j.infbeh.2008.09.004

Depression, the Stress of Parenthood & Mother-Infant Interaction

With this paper, we are the first researchers to show that even when PND is treated effectively, this does not reverse the accompanying stress that mediates many of the negative effects of PND on the mother-infant relationship and ultimately infant development. Pilot data suggested that our HUGS mother-infant interaction intervention may be beneficial.

Milgrom, J., Ericksen, J., McCarthy, R., & Gemmill, A. (2006). Stressful impact of depression on early mother-infant relations. Stress and Health, 22(4), 229-238. https://dx.doi.org/10.1002/smi.1101

Following on from this work we have now completed 2 RCTs of our HUGS programs which have shown a positive impact of the interventions:

Milgrom J and Holt C. (2014) Early intervention to protect the mother-infant relationship following postnatal depression: study protocol for a randomised controlled trial. Trials 15: 1745-6215.

Ericksen J, Loughlin E, Holt C, et al. (2018) A Therapeutic Playgroup for Depressed Mothers and Their Infants: Feasibility Study and Pilot Randomized Trial of Community Hugs. Infant Ment Health J 39: 396-409.

Holt C, Gentilleau C, Gemmill AW, et al. (2021) Improving the mother-infant relationship following postnatal depression: a randomised controlled trial of a brief intervention (HUGS). Arch Womens Ment Health 19: 021-01116.

Effective Psychological Treatment for PND

This paper was an RCT comparing cognitive therapy with less specialized psychological interventions. All were demonstrated as superior to conventional routine care. There are relatively few such studies and this one had the added strengths of a broad community sample, formal clinical diagnosis of depression, manualised interventions and well-validated rating instruments.

Milgrom, J., Negri, L. M., Gemmill, A. W., McNeil, M., & Martin, P. R. (2005). A randomised controlled trial of psychological interventions for postnatal depression. British Journal of Clinical Psychology, 44( 4), 529-542. https://www.ncbi.nlm.nih.gov

We subsequently demonstrated in a RCT that our specialised CBT program is at least as effective as treatment with antidepressant medication and can be successfully adapted for delivery by non-specialist health professionals.

Milgrom J, Gemmill AW, Ericksen J, et al. (2015) Treatment of postnatal depression with cognitive behavioural therapy, sertraline and combination therapy: a randomised controlled trial. Aust N Z J Psychiatry 49: 236-245.

Today, we continue to work to progress the evidence base in this area

Hirshler Y, Gemmill AW and Milgrom J. (2021) An Australian perspective on treating perinatal depression and anxiety: a brief review of efficacy and evidence-based practice in screening, psychosocial assessment and management. Ann Ist Super Sanita 57: 40-50.

Milgrom, J., Holt, C., Gemmill, A., Ericksen, J., Leigh, B., Buist, A., & Schembri. (2011). Treating Postnatal Depressive Symptoms in Primary Care: A Randomised Controlled Trial of GP Management, with and without Adjunctive Counselling. BMC Psychiatry, 11(1), 95. https://www.biomedcentral.com/1471-244X/11/95

Reliable and Acceptable Screening for PND

Before this 2005 paper there had been large screening studies of PND on the one hand and there had been validation studies for PND screening tools on the other. This was the first study to validate a widely used tool in a large representative Australian population against gold-standard diagnostic criteria.

Milgrom, J., Ericksen, J., Negri, L., & Gemmill, A. (2005). Screening for postnatal depression in routine primary care: Properties of the Edinburgh Postnatal Depression Scale in an Australian sample. ANZJ Psychiatry, 39, 833 – 839. https://dx.doi.org/10.1111/j.1440-1614.2005.01660.x

We also published 3 articles evaluating the acceptability of screening. Well-informed Cost-Utility decisions about healthcare screening procedures require several crucial pieces of information including information on the acceptability to patients. This longstanding and important gap in research into perinatal depression screening was addressed comprehensively by the following papers:

Leigh, B., Milgrom, J., Leigh, B., & Milgrom, J. (2007). Acceptability of antenatal screening for depression in routine antenatal care. Australian Journal of Advanced Nursing, 24(3), 14-18. https://www.ncbi.nlm.nih.gov/pubmed/17518160

Gemmill, A. W., Leigh, B., Ericksen, J., & Milgrom, J. (2006). A survey of the clinical acceptability of screening for postnatal depression in depressed and non-depressed women. BMC Public Health, 6, 211. https://dx.doi.org/10.1186/1471-2458-6-211

Buist, A., Condon, J., Brooks, J., Speelman, C., Milgrom, J., Hayes, B., Bilszta, J. (2006). Acceptability of routine screening for postnatal depression: An Australia-wide study. J Affect Disorders, 93, 233 – 237. https://www.sciencedirect.com/science/article/abs/pii/S0165032706000966

Implementation of effective screening programs continues to be a strong focus of our research.

Milgrom J and Gemmill AW. (2014) Screening for perinatal depression. Best Pract Res Clin Obstet Gynaecol 28: 13-23.

Gemmill AW. (2014) The long gestation of screening programmes for perinatal depressive disorders. Journal of Psychosomatic Research 77: 242-243.

Milgrom J and Gemmill AW. (2015) Identifying Perinatal Depression and Anxiety: Evidence-based Practice in Screening, Psychosocial Assessment and Management. Chichester: Wiley-Blackwell, 288.

Women’s experience of depression and overcoming barriers to seeking help.

This qualitative project was a series of focus groups with women who had been experiencing depression and it concentrated on their acknowledgement of the condition and their journey towards recovery. This is a population that has been shown to be very difficult to engage in services. Of particular relevance were their attitudes and beliefs about their diagnosis and their perceived barriers to care which provide new insight into service design and delivery for women with depression.

Bilszta, J., Ericksen, J., Buist, A., & Milgrom, J. (2010). Women’s experiences of postnatal depression – beliefs and attitudes as barriers to care. Australian Journal of Advanced Nursing, 27(3), 44-54. https://search.informit.com.au/documentSummary;dn=909929185761432;res=IELHEA

Subsequently, we designed and successfully tested a motivational interviewing program that increases rates of help-seeking when delivered by Maternal and Child health Nurses at routine visits:

Holt C, Milgrom J and Gemmill AW. (2017) Improving help-seeking for postnatal depression and anxiety: a cluster randomised controlled trial of motivational interviewing. Arch Womens Ment Health 20: 791-801.

Towards parenthood: An antenatal intervention to reduce depression, anxiety and parenting difficulties

This paper describes the effectiveness of an antenatal intervention which targeted risk factors for poor postnatal adjustment, with the dual aim of reducing both postnatal symptoms of depression/anxiety and parenting difficulties.

Milgrom, J., Schembri, C., Ericksen, J., Ross, J., & Gemmill, A. W. (2011). Towards parenthood: an antenatal intervention to reduce depression, anxiety and parenting difficulties. Journal of Affective Disorders, 130: 385-394 doi:10.1016/j.jad.2010.10.045