The Cambridge Health Authority approved a training programme for all health visitors which comprised six half days over a period of six weeks. All health visitors in post at the time of the start of the study attended at least five of the sessions. The course was run 3 times. The course was led by a British Association for Counselling-accredited counsellor who was an experienced trainer, already familiar with working with postnatally depressed women, together with a health visitor (SS).

Before formal training started all the health visitors were invited to an introductory meeting at which their knowledge of, and attitude to, postnatal depression was explored.

The aims of the training course were :

• to provide education on the nature and prevalence of postnatal depression;
  and:
• to raise awareness of the value to the mother and infant of providing treatment.

In addition, training was provided in the assessment of mood to enable detection of postpartum depression, and in the management of postpartum depression by use of simple counselling and cognitive behavioural techniques.

The details of the training course can be obtained from the first author.

Briefly, training in the detection of depression involved instruction in the use of the Edinburgh Postnatal Depression Scale, together with guidelines on specific areas which need to be addressed in interview with those identified by the questionnaire as potentially depressed.

Training in the management of postnatal depression and associated difficulties with the infant proceeded on two fronts:

• basic counselling skills were imparted, using Egan’s (1982) model of ‘active reflective listening’
  and:
• basic cognitive behavioural skills were presented derived from Cognitive Behaviour Therapy for Adult Psychiatric Disorders (Hawton et al, 1989). The focus here concerned the mother’s depressive thoughts, as well as any problems she was experiencing either in managing her infant and/or difficulties she was experiencing in her relationship with her infant.

For practical reasons it was not possible to carry out a controlled clinical trial. Instead, information was collected in the period before the health visitor training, when women were receiving routine primary care (i.e. the control group), and then again after training (i.e. the health visitor treated group).

For each of these groups assessment of maternal mood was made using the EPDS, followed by further enquiries to confirm a diagnosis of depression. These concerned the extent of the mother’s low mood over the past two weeks, her interest in activities she previously enjoyed, and any feelings of worthlessness or guilt. Where more disturbance was present permission was sought from the mother for referral, either to the GP or Community Psychiatric Nurse.

In addition to the assessment of maternal mood, an evaluation of the mother’s experience of infant care was made using a self-report questionnaire (the problem sheet) covering infant behaviour problems (feeding and sleeping problems, excessive infant crying) and difficulties in the mother-infant relationship (infant demands for attention, separation problems, play and affection).

The level of depressed mood and the rate of infant behavioural and relationship problems was compared for these two groups of women at six weeks postpartum and again eight to ten weeks later. For the group identified as depressed after the health visitor training, regular supportive visits were negotiated with the mother. Usually hour-long, weekly visits were made by the mother's health visitor at the mother’s home for up to eight weeks. Depressed women declining supportive help at this time nevertheless had, at the time when the EPDS was administered, the opportunity to express their feelings and have them acknowledged (as did well women). Following a two month induction period, formal evaluation of the treatment programme was conducted over six months.

During these visits the mother was encouraged to explore her feelings, often about her changed role as a mother (whether or not for the first time), while the health visitor maintained a non-judgmental and uncritical stance, using the counselling skills of active reflective listening. Conventional health visitor advice was withheld during these visits. Where appropriate, simple cognitive techniques such as problem solving were introduced, for instance where the mother was overwhelmed by the practical problems of caring for the baby.

In the period before health visitor training, 90% of women delivering at the Cambridge maternity hospital were screened at six weeks using the EPDS, and where diagnosed as depressed they also completed the problem sheet. These two items were also completed at four months postpartum. Those resident in the city of Cambridge (n=30) comprise the control group for the present study.

Following training, 92% mothers were screened postpartum using the EPDS, of whom 9.3% were found to be suffering from postpartum depression. All these women were offered the programme of supportive visits from their health visitor. During the two month induction period 72% women accepted the offer of intervention; whereas in the last month of the study 95% of those offered help accepted it. Data are presented for the 70 depressed women who were seen by their health visitors during the evaluation period.