Postnatal depression can affect up to one in four (24%) mothers in the UK. This has profound effects on mothers’ levels of maternal wellbeing and can lead to symptoms such as stress, anxiety, fatigue and persistent low mood. Feelings of guilt and hopelessness are other common signs of the condition.
It can be hard for many women to recognise they have postnatal depression, as symptoms can appear gradually. There are impacts on the mother-baby relationship and on infant development, so it’s important that the condition is recognised and mothers and babies are supported.
Uptake of treatments can be low among this population. While psychotherapy and antidepressants are often considered to be standard interventions for mothers with postnatal depression, there are barriers to this type of support. Challenges include mothers experiencing stigma when accessing care and delays in accessing conventional types of treatment.
There has been growing interest in the potential of community-based art interventions for postnatal depression. One of three interventions funded by the Wellcome Trust looking at how to upscale arts-in-health activities, the SHAPER-PND randomised clinical trial studied Melodies for Mums, an activity run by Breathe Arts Health Research. Prior to this study, research had shown the effectiveness of 10-week music and singing sessions in reducing symptoms of postnatal depression (Fancourt & Perkins, 2018).
This larger-scale, hybrid study (Bind et al., 2025) has examined the clinical effectiveness and cost-effectiveness of a community singing intervention, and critically, it also set out to consider how group singing could work in practice. On this question of implementation, consideration was given to whether Melodies for Mums would be deemed acceptable, appropriate and feasible for the mothers taking part. Core to this new study was a lengthened timeframe to study changes in symptoms of postnatal depression.
A large-scale randomised trial examines whether group singing can offer mothers with postnatal depression an effective, acceptable and cost-effective alternative to conventional community activities.
Methods
Postnatal mothers were screened to assess whether they had baseline symptoms of possible depression (a score greater than 10) using the Edinburgh Postnatal Depression Scale (EPDS). With their babies aged 0-9 months, they were randomly assigned to either the Melodies for Mums singing intervention or to a control group. Eligible Mums were assigned using a 2:1 intervention-to-control allocation process. When the intervention period got underway, 133 mothers were allocated to the singing group and 66 were assigned to the control group.
The singing group included between eight to twelve pairs of mothers with their babies. They met in person, weekly for one hour, for a period of ten weeks. They were led by a specialist trained by Breathe Arts Health Research, who introduced them to a repertoire of songs from a range of cultural traditions. Singing experience was not required, and anyone involved in any other singing groups was excluded. The mothers placed in the ‘active’ control group were signposted to other mother-and-baby groups where music wasn’t the point of the activity.
Recruitment took place across multiple children’s and community centres in three London boroughs (Lewisham, Lambeth and Southwark). A range of health and care professionals were active in drawing postnatal mothers’ attention to the opportunity, including general practitioners, midwives and mental health professionals. The research took place over a period of just under three years, and in total, seven cohorts were recruited to the study.
To ensure a balance across the control and intervention groups, participants had first been stratified by Edinburgh Postnatal Depression Scores (EPDS) scores so there wouldn’t be a clustering of participants with higher scores in one group compared to another. Participants were also stratified by infant age (0–3, 3–6, and 6–9 months), for operational reasons: groups ran more smoothly with a spread of infant ages.
The protocol was to first undertake assessments of postnatal depression at six weeks, again when the study ended at ten weeks, and to subsequently assess the mothers for any changes in postnatal depression at weeks 20 and 36; a full six months after the intervention had ended. At every stage, from baseline onwards, the EPDS scale was used, which consisted of an online questionnaire, with self-reported scores inputted. Compared to baseline assessments, changes in the severity of symptoms were assessed at 10 weeks, and thereafter, the control and intervention groups continued to be compared using an intention-to-treat approach. Participants were ‘unblinded’ to which group they were assigned. To ensure equality of treatment, those mothers initially signposted to a control activity were later offered Melodies for Mums.
Results
When the intervention ended at ten weeks, mothers in both the singing group and the control group experienced reductions in depressive symptoms. Importantly, between-group differences in EPDS scores were not statistically significant at weeks 6 or 10 (mid- and end-of-intervention); Only the Melodies for Mums group showed significant reductions in depressive symptoms at follow-up at weeks 20 and 36.
There was no difference in mean EPDS scores when the two groups were first assigned for the study, but the results reveal a statistically significant overall treatment effect of the singing intervention relative to the control activity of non-music activity. Of note, where a crucial difference in postnatal depression scores starts to be observed across the groups is not during the intervention period itself, but at weeks 20 and 36, meaning there was a sustained effect on depressive symptoms of participating in the singing group. It should be noted that this treatment effect was statistically significant under the intention-to-treat analysis, but not in the available-data analysis; a caveat the authors themselves acknowledge.
Retention was an issue for both groups, but throughout the study, retention rates were higher for the singing group. The research also highlights that mothers involved in Melodies for Mums found the activity significantly more acceptable, appropriate and feasible (so more manageable to take part in), relative to how Mums experienced other community activities. Qualitative evidence underpins the extent to which Mums valued the singing, not just for the activity itself, but because they felt they were in a safe, socially supportive, inclusive environment. Participants in Melodies for Mums appreciated being placed in a group designed to include other Mums experiencing postnatal difficulties. Four mothers in the control group withdrew due to mental health deterioration, compared to none in the singing group.
With regards to cost-effectiveness, looked at across the 36-week study period, mothers in the singing group gained around 15 additional days in full health compared to mothers allocated to the control group. The estimated costs of the singing intervention ranged from a lower limit of £126 to an upper limit of £539, depending on which delivery costs were factored in.
The range in total costs per maternal Quality Adjusted Life Year (QALY) almost entirely fell below the maximum range in spending recommended by NICE (£20,000 to £30,000 per QALY gain). These are total costs per additional QALY that bear equivalence to telephone-based peer support and compare favourably to interventions such as group therapies or home-based support. Specifically, the incremental cost per QALY gained ranged from £11,122 to £21,215 depending on whether a lower or upper estimate of intervention costs was applied.
Mothers in the singing group showed sustained reductions in depressive symptoms at six and nine months and were more likely to stay engaged.
Conclusions
A Melodies for Mums intervention is not only effective in reducing symptoms of depression in the ten-week period it is delivered, but it also has a significant and long-lasting effect for mothers with postnatal depression beyond this period. At weeks 20 and 36, mothers participating in Melodies for Mums experienced a notable further reduction in depressive symptoms.
The SHAPER-PND study also demonstrates the acceptability and appropriateness of a singing intervention, with higher levels of regular participation and retention observed, in contrast with mother and baby activities that see lower attendance and lower levels of engagement. Recognising that differences in participants’ clinical histories didn’t account for differences in attrition across the two groups, mothers see a value in group singing and what it offers beyond the four walls within which the singing activity takes place. Mums highlight how they benefit from being in a bespoke singing group where the focus is on maternal mental health, and the bonds that can be created between them and their child.
The cost-effectiveness of the singing intervention makes it scalable at a reasonable cost to the NHS and local authority public health departments. Noting the impacts observed in a UK context, the World Health Organisation has recently adapted and delivered singing interventions for postnatal depression in other European countries (Music and Motherhood).
Group singing is well-accepted by mothers and represents a cost-efficient investment for NHS and local authority commissioners seeking scalable perinatal mental health support.
Strengths and limitations
While there are many strengths to this study, a couple of questions remain.
In an earlier study, also focusing on the same Melodies for Mums group intervention (Fancourt D, Perkins R, 2018), a randomised controlled trial involved three arms. Participants with postnatal depression were allocated to the intervention group, or else they were placed in a bespoke creative play-based group, where music wasn’t included. The control in this instance saw remaining participants offered neither intervention.
This previous study had shown that whilst group singing had led to reduced depressive symptoms for mothers with postnatal depression, the alternative activity that saw mothers placed in a creative play group had not achieved quite the same effects, and certainly not at the same pace. This seems a meaningful comparator, so even though participants weren’t to receive the same intervention, they nevertheless found themselves allocated to a specific activity – something creative for mothers to engage in that wasn’t too generic. The control activity that was also a feature of that study meant very distinctive conditions were being examined throughout, ranging from a singing intervention to mothers getting “usual” care, which, in practice, means receiving no arts-based community activities.
Turning to the present study, participants allocated to the control group were signposted to non-music-based activities, but it is not entirely clear what that amounted to. Since they weren’t actively allocated to a community group (so, for example, a play group) but were instead offered telephone-based communications that merely encouraged them to take up an offer of community activities, mothers in the control group might have been less disposed to the ‘activities’ they had to choose from, from the very start.
It’s worth noting however that at first glance, this raises design questions about whether mothers in the control activity were less likely to engage with it or view it as sufficiently meaningful or bespoke. They weren’t placed, but trusted, it seems, to follow up and act on a lead for themselves. What is being compared across the singing intervention and the control activity might have been coloured somewhat, and perhaps even distorted, by this differential approach to participants actively being placed in a group, or not.
In addition, these alternative community offerings were open to all mothers with infants, and not only those with postnatal depression. The research exercise of comparing treatment effects in a sample that is split in this way merits further discussion: including why, during this larger study, no comparison ‘play-based’ group was included, when in fact it had been in the earlier study.
The study’s rigorous design and long follow-up are notable strengths, but questions about the comparability of the control condition and the broad symptom threshold warrant careful consideration before generalising findings.
Implications for practice
A key point noted by the researchers was that an earlier feature of the research protocol was for a much stricter threshold to be in place, meaning that to be eligible, participants would have needed to have had a clinical diagnosis of a major depressive disorder, but this criterion was removed. Since this study was broad in scope and included mothers with moderate-to-severe depression, commissioners and clinicians would need to reflect on the transferability of a singing intervention for a population of mothers with major depressive disorders.
Continuing to ensure diverse groups can be established, and socioeconomic and demographic differences don’t unduly skew Mums’ levels of engagement with community singing groups in different geographic areas, remains a key consideration for health practitioners. It will also be important to examine in what ways a community singing intervention can remain benchmarked in terms of consistency of approach and the quality of the intervention, especially if it were scaled at pace and not all leads could be trained directly by Breathe Arts Health Research.
One possibility would be for clinicians, together with allied health and care professionals, to socially prescribe community singing, but this will of course first depend on services being available at neighbourhood level, with community assets in place to provide these activities for Mums and their infants.
Community health teams and mental health professionals should consider this research as they agree Neighbourhood Plans. Local authorities and partners working in the NHS can use integrated care planning to determine what capacity exists, if any, to provide Melodies for Mums interventions.
For commissioners and clinicians, the evidence supports social prescribing of community singing for postnatal depression, provided consistent quality, equitable access and neighbourhood-level infrastructure can be assured.
Statement of interests
Andrew Kaye Kauffman has no interests to declare.
Edited by
Dr Dafni Katsampa
Links
Primary Paper
Bind RH, Lawrence AJ, Estevao C, et al. Clinical effectiveness, implementation effectiveness and cost-effectiveness of a community singing intervention for postnatal depressive symptoms, SHAPER-PND: randomised controlled trial. The British Journal of Psychiatry. 2025;227(6):836-845. doi:10.1192/bjp.2025.10377
Other References
Fancourt D, Perkins R. Effect of singing interventions on symptoms of postnatal depression: three-arm randomised controlled trial. The British Journal of Psychiatry. 2018;212(2):119-121. doi:10.1192/bjp.2017.29