Introduction
Perinatal mental health conditions, such as depression and anxiety, are common and significantly impact both parents and infants. Effective interventions are critical to mitigate adverse long-term outcomes. The Circle of Security-Parenting (COS-P) program, an attachment-based parenting intervention, has shown promise in preliminary studies; however, its efficacy in real-world NHS settings remained unconfirmed. This article critically reviews the findings from a rigorous, multicentre randomized controlled trial (RCT) assessing the clinical effectiveness of COS-P when combined with treatment-as-usual in improving parental psychopathology and bonding.
Study Background and Rationale
Perinatal mental health difficulties affect approximately 10-15% of new parents, with potential consequences such as impaired parent-infant bonding, adverse child development, and increased healthcare utilization. Despite the availability of treatments like psychological therapies and pharmacotherapy, there remains a gap regarding the added value of structured parent-infant interventions within routine NHS services. COS-P, rooted in attachment theory, aims to enhance parental sensitivity and secure attachment, theoretically improving mental health and bonding. Prior smaller or less methodologically rigorous studies suggested benefits, but definitive evidence was lacking.
Study Design and Methods
This pragmatic, multicentre, assessor-masked, randomized controlled trial was conducted across ten NHS Trusts in England. Participants were birthing parents aged 18 or older, with clinical levels of psychological distress (CORE-OM ≥1.1) and bonding difficulties (Postpartum Bonding Questionnaire ≥12), less than one year postpartum. Exclusion criteria included active psychosis. Participants were randomly assigned in a 2:1 ratio to either the COS-P plus treatment-as-usual group or to treatment-as-usual alone, with stratification by site and recruitment cohort.
The intervention involved ten 90-minute online group sessions of COS-P, delivered over approximately five weeks. The primary outcome was parental psychopathology, measured through the averaged CORE-OM scores at 3, 7, and 12 months post-baseline. Secondary outcomes included measures of bonding, parental sensitivity, and infant wellbeing. Data analysis adhered to the intention-to-treat principle, with multiple imputation addressing missing data.
Findings and Results
Between January 2022 and October 2023, 3,171 individuals were screened, 371 randomized (248 to COS-P + treatment-as-usual; 123 to treatment-as-usual). All participants identified as female at birth; most (89%) were of White ethnicity, with a mean age of approximately 31 years.
The primary outcome analysis revealed an adjusted mean difference in CORE-OM scores of -1.41 (95% CI -5.11 to 2.28; p=0.45) between the intervention and control groups, indicating no statistically or clinically significant benefit from adding COS-P. Secondary outcomes, including measures of bonding and parenting behavior, similarly showed no significant differences. Safety assessments identified some adverse events, including increases in mental health difficulties and instances of self-harm, but these occurred comparably across groups.
Discussion and Critical Appraisal
The trial robustly demonstrates that COS-P, when added to standard NHS care, does not confer additional benefit for reducing parental psychopathology or improving bonding in a routine clinical setting. This finding contrasts with some earlier preliminary studies and underscores the importance of large, pragmatic trials in informing clinical practice. The lack of observed efficacy may be attributable to factors such as the online delivery modality, variability in implementation, or the heterogeneity of the study population.
Limitations of the study include potential selection biases, reliance on self-report measures, and the challenge of engaging participants in online group formats during the pandemic era. Nonetheless, the comprehensive multicentre design enhances the generalizability of findings.
Implications for Clinical Practice and Future Research
Current evidence does not support routine implementation of COS-P in NHS perinatal mental health services for the targeted outcomes. Resources may be better allocated to evidence-based treatments with demonstrated efficacy. Further research should explore alternative or adjunctive interventions, possibly integrating individualized approaches or focusing on different outcomes such as infant development or parental well-being.
Conclusion
This large-scale, methodologically rigorous trial indicates that adding COS-P to usual care does not offer measurable benefits for parental mental health or bonding in NHS community settings. Clinicians should consider these findings in their service planning and prioritize interventions supported by robust evidence.
Funding and Registration
This study was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme. It is registered on ISRCTN (ISRCTN18308962).For further insights, clinicians and policymakers should critically evaluate alternative strategies that are evidence-based and tailored to the needs of diverse populations.
References
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4. National Institute for Health and Care Excellence. Postnatal mental health: treatment and management. NICE guideline NG195. 2023.