Beyond Postnatal Depression
What the PRAM Studies Reveal About Mothers and Children
Author's Note: This piece has previously been published on IoPPN's LinkedIn Page.
Maternal mental health is often framed through a single question: does postnatal depression affect the baby?
And intuitively, this makes sense. It seems obvious that experiencing poor mental health while caring for a newborn could have negative impacts on the baby.
But emerging evidence suggests this framing is too narrow. It may not simply be the presence of symptoms after birth that matters, but when they occur - and what they reflect about longer-term vulnerability.
Maternal mental health also extends beyond depression alone, including conditions such as bipolar disorder and postpartum psychosis (a rare but severe disorder considered a psychiatric emergency). These areas have historically received far less attention but are now beginning to be studied in more depth.
To address this gap, the Psychiatry Research and Motherhood (PRAM) studies were born. PRAM is a set of longitudinal cohort studies that recruited women during pregnancy and followed them and their children into middle childhood, up to 6–12 years. The cohort is comprised of two complementary arms.
The first, PRAM-D, began in 2007 and focuses on women at risk of depression during pregnancy (antenatal depression). The Principal Investigator, Professor Carmine Pariante, explained the rationale: “In the early 2000s, it became clear that depression in pregnancy may have a greater impact on both mothers and babies than postnatal depression, despite being less widely recognised.” So, PRAM-D was created to “look at the possible biological and psychological mechanisms underpinning this association”.
Following the success of PRAM-D, a second study, PRAM-P, began in 2013, focusing on women at risk of postpartum psychosis. The Principal Investigator, Professor Paola Dazzan notes, “we wanted to understand whether the same biological mechanisms identified in PRAM-D were also operating in postpartum psychosis - and whether they could predict illness after birth.”
Having co-led the PRAM-P follow-up into middle childhood alongside Dr Catriona Curl, I wanted to share an update on where the PRAM studies are now and what we have learned so far.
Looking at the Whole Picture
Across PRAM, we have collected a wide range of clinical, behavioural, and biological data on mothers and their children, from pregnancy through to middle childhood. This includes measures of stress biology, maternal mental health, family relationships, and the home environment, alongside children’s behaviour and development. More recently, we have also begun to include fathers and co-parents, recognising the importance of the wider family context.
As the lead researchers for the original PRAM-P study said, “it has been a privilege to follow families from pregnancy through to middle childhood, providing a unique opportunity to understand how maternal mental health and early relationships shape outcomes over time.”
What Have We Learned So Far
Early Mother-Infant Interactions
Confirming the data that inspired PRAM, we found that it is not only mothers who are unwell after birth who experience difficulties. One of the key findings from the PRAM-D cohort is that both depression during pregnancy and a history of depression before pregnancy are associated with differences in the quality of the mother–infant relationship, including reduced synchrony and responsiveness within the interaction.
A similar pattern is seen in the PRAM-P cohort, where mothers at risk of postpartum psychosis were also more likely to show less connected interactions with their infants. In both cohorts, these differences are observed regardless of whether mothers were unwell after the birth of their babies. Importantly, these findings reflect group-level trends, and many mothers continue to form strong, positive relationships with their babies. They also highlight the perinatal period as an important opportunity to provide support and promote positive outcomes for both mother and child.
In the PRAM studies, factors such as maternal anxiety and socioeconomic stress during pregnancy, as well as earlier experiences like childhood adversity, were found to contribute to differences in how mothers and babies interacted. In the postpartum psychosis cohort, difficulties in recognising emotional cues (such as fear), for example, were also linked to less connected interactions.
Alongside observed interaction, PRAM-P also showed that women at risk of postpartum psychosis reported more negative bonding experiences with their infants, particularly when parenting stress and psychiatric symptoms were higher.
PRAM-D also showed that these differences were reflected in mothers’ speech, with mothers experiencing antenatal depression, or with a history of depression, making fewer comments focused on their infant’s experience and showing less positive affection.
These findings suggest that maternal mental health matters not only after birth, but also during pregnancy, with early experiences and circumstances shaping how the mother–child relationship develops.
Early Differences in Babies’ Behaviour and Responses to Stress
In the PRAM-D cohort, we identified early differences in infant behaviour from birth. Babies of mothers who were depressed in pregnancy tended to be less alert, show more physiological signs of stress, and need more support in consoling in the first days of life. Similar patterns were also observed in infants of mothers with a history of depression.
In the PRAM-P cohort, developmental differences were observed over the first year of life, including in learning, movement and emotional development. There was also some indication that these patterns may differ by sex, although further research is needed.
Furthermore, babies exposed to depression during pregnancy have been found to show stronger biological responses to mild stress in their first year of life, measured through changes in cortisol, a hormone involved in the body’s stress response.
Together, these findings suggest that maternal mental health may influence child development in different ways, depending on the type and timing of the difficulties.
Early Biological Influences
The PRAM studies have also investigated what happens biologically during pregnancy. In the PRAM-D cohort, mothers experiencing depression during pregnancy were found to have differences in the body’s stress system and in signals from the immune system, including higher levels of stress hormones and inflammatory markers. Inflammation during pregnancy was linked to babies’ early behaviour at birth, while changes in the body’s stress system were linked to how babies responded to stress later in infancy.
These findings suggest that biological processes during pregnancy may play an important role in shaping both early child development and maternal mental health outcomes.
What Predicts Who Struggles?
Of course, not everyone at risk of perinatal mental health difficulties goes on to experience challenges in the same way. One of the strengths of the PRAM studies is that they help us understand why.
Across the cohorts, several factors have been linked to poorer outcomes. In the PRAM-P cohort, higher levels of stress during pregnancy (including earlier life experiences such as childhood adversity) were associated with an increased risk of postpartum relapse. Biological factors also appear to play a role. Higher levels of stress hormones during pregnancy were associated with an increased likelihood of becoming unwell after birth, suggesting that some aspects of vulnerability may be detectable before the onset of illness and therefore could be helped by support during this period.
We also found that women at risk of postpartum psychosis who later became unwell showed differences during pregnancy in areas such as memory, processing speed and executive function, suggesting that some differences in how the brain processes information may already be present during pregnancy, before illness begins.
Importantly, these findings suggest that outcomes are not fixed. Instead, they highlight potential areas where support could be targeted, such as reducing stress and identifying those at higher risk earlier in pregnancy.
What’s Next?
Ongoing work, including mine and Dr Catriona Curl’s, is bringing together data from both PRAM-D and PRAM-P. With middle childhood follow-up now complete, we are linking data from pregnancy through to later childhood to understand how early differences develop into longer-term outcomes.
My work focuses on the early mother–child relationship and its links to children’s later attachment and emotional development, while Dr Curl’s work investigates how biological, psychological, and social factors link maternal mental health to later child outcomes, taking a broader family perspective that includes the role of co-parents.
Alongside this, we are examining biological pathways in more detail, including ongoing work on cortisol data collected across pregnancy and the postnatal period.
The Gratitude
The PRAM studies highlight the value of longitudinal research in understanding how risk progresses over time and where opportunities for support may lie.
Over the years, PRAM has contributed to more than 10 PhD theses and supported countless undergraduate and master’s research projects. This reflects not only the richness of the data, but the collaborative effort involved in building and sustaining a study of this scale.
The impact of this work extends beyond academia. Findings from the PRAM studies have contributed to policy discussions around perinatal mental health, including being cited in a recent UK Parliament research briefing on mental health during and after pregnancy.
Above all, this research would not have been possible without the women, their children, and their families who have generously given their time over many years. Their contribution underpins everything we have learned - and everything we hope to understand in the future.
