Over the past fifteen years there has been considerable interest in the subject of postnatal depression from the perspectives of both research and primary care.

During the 1980’s a number of prospective studies of community samples were conducted to examine the prevalence, nature and course of postnatal depression, and the pattern of variables associated with its occurrence (see Cooper et al., 1991, for a review). This work showed that about 10 - 15% women experience an episode of clinical depression in the early months following delivery. These episodes are indistinguishable in terms of their presentation from those occurring at other times in the life cycle. Thus, in addition to pervasive low mood, symptoms of anxiety, irritability, loss of energy, guilt and feelings of worthlessness may be present. Most episodes remit spontaneously within six months of onset, although a minority follow a chronic course. Factors that have been consistently identified as being associated with the disorder include a lack of a close confiding relationship and social support, financial hardship and housing problems, and a previous psychiatric history.

More recently, attention has turned to the possible impact of postnatal depression on the mother-child relationship. Most studies have focused on mother-infant face-to-face interactions, and these have shown depressed women to have difficulties in sensitively attuning their responses to the infant (Field, 1984; Field et al, 1988; Cohn et al, 1990; Murray et al, 1993). Rather little is known about the effects of postnatal mood disorder on general aspects of caretaking,

Further work indicates possible long term effects of postnatal depression and associated difficulties in the mother-child relationship on child development. For example, there have been reports of poorer cognitive outcome, behavioural difficulties and more insecure attachments in the one and a half to four year old children of postnatally depressed mothers (Cogill et al, 1986; Murray, 1992; Sharp et al, 1995). Notably, such associations with the postnatal mood disorder are found even when depression occurring beyond the postpartum period is taken into account.

This body of work clearly raises important questions about treatment. Previous reports suggest that, in the normal course of events, in spite of regular contacts between primary health care workers and postpartum women, postnatal depression often goes undetected ( Briscoe 1986; Marks et al, 1979). Furthermore, even when detected, there is no evidence that routine care, either in the form of health visitor contacts, or the psychotropic medication usually prescribed by general practitioners, is effective in alleviating either the depressive mood or the difficulties depressed mothers experience with their infants.

One of the most important areas for research in this area therefore concerns the evaluation of various interventions. Previous studies have shown that health visitors, given brief training in the detection and support of women suffering from depression, can have a significant impact on the course of the disorder ( Holden et al, 1989; Gerard et al, 1993). However, to date, there is no evidence of the impact of such intervention on depressed mothers' relationships with their infants, or on the adverse outcomes that are otherwise associated with this postpartum mood disorder.

A series of inter-related studies is presented here that were conducted to address the following questions:

i) Maternal experience of infant care: whether the experience of difficulties in the general care of the infant differs between postnatally depressed and well women

ii) Health visitor awareness of postnatal depression: whether, in the ordinary course of health visitor practice, women experiencing postnatal depression are identified as depressed and offered more help than non-depressed women; and

iii) Intervention study: whether training health visitors in the detection and management of postpartum depression has benefits, not only in terms of maternal mood, but also the mother’s experience of both caring for, and relating to, her infant.