Postpartum depression (PPD) is a relatively common problem, affecting between 10% and 15% of women after delivery. Although it is difficult to reliably predict which women in the general population will experience postpartum mood disturbance, it is possible to identify certain subgroups of women who are more vulnerable to postpartum affective illness. For example, women who have had one episode of postpartum depression have about a 50% chance of experiencing another episode of PPD after a subsequent pregnancy. The extent to which a history of depression (prior to pregnancy) influences risk is less clear, but some studies indicate that between 30% and 50% of women with histories of major depression will experience recurrent illness during the postpartum period.
But being able to identify women at risk for postpartum depression is just the tip of the iceberg. The big question is: What can we do to reduce the risk of PPD in women at risk?
In a group of women with histories of postpartum depression, Wisner and colleagues described a beneficial effect of prophylactic treatment with a selective serotonin reuptake inhibitor (SSRI) antidepressant . In a double blind, placebo-controlled study, 22 women (ages 21 to 45 years) who had histories of postpartum depression were randomized to receive treatment with either sertraline (Zoloft) of placebo. Dosing was 50 mg a day for the first four weeks, 75 mg for week 5 through week 17, then a tapering over the next three weeks for a total of 20 weeks of treatment. The women began taking the drug an average of 15 hours after delivery. Of the 14 women who received Zoloft, only one woman had recurrence of depression. In contrast, four (50%) of the eight women in the placebo group developed PPD.
Other studies have explored the potential efficacy of non-pharmacologic interventions in these populations of women at risk. The most recent of these examined the effectiveness of PREPP, Practical Resources for Effective Postpartum Parenting. PREPP is a novel PPD prevention protocol which focuses on the mother-infant dyad. (This article is also an excellent review of the literature on behavioral interventions for PPD.)
PREPP consists of several infant behavioral interventions and targeted psychotherapy techniques. The sessions are described as “coaching” sessions to minimize the stigma that many women associate with receiving mental health care. The intervention used the following research-derived infant behavioral techniques with the goal of reducing infant fussing and crying behaviors and promoting sleep:
(1) Feeding between 10 PM and midnight, even if the baby must be awakened (“a focal feed”);
(2) Accentuating the difference between day and night by providing higher levels of stimulation during the day;
(3) Lengthening the wait for feeding time in the middle of the night by engaging in other attentive activities such as walking with the baby and diapering in order to extinguishing the association between night time waking and feeding
(4) Carrying infants for at least 3 hours a day in addition to the carrying that occurs in response to crying and feeding;
(5) Learning to swaddle the baby.
The PREPP intervention also provided (1) supportive psychological interviewing that encouraged exploration of the mother’s childhood and how it informs parental identity, (2) psychoeducation about the postpartum period, and (3) various mindfulness techniques aimed at helping mothers to cope better when their babies are distressed and/or unsoothable.
Women at risk for PPD were identified using the Predictive Index of Postnatal Depression (Cooper et al. 1996) between 34 and 38 weeks’ gestation. At this time, eligible participants (n=54) were assigned to the PREPP group or the enhanced treatment as usual (ETAU) group. ETAU consisted of an information session about PPD, a brief clinical mood assessment, and a referral for treatment if indicated or if requested by the participant. Between 18 and 36 hours of delivery, women in the PREPP group received their second treatment session with a psychologist. At 2 weeks postpartum, participants in the PREPP group received a check-in telephone call from the psychologist. At 6 weeks postpartum, all participants completed mood assessments. Women in the PREPP group received their final session, while those in the ETAU group were again given information about PPD. Mood was again assessed at 10 and 16 weeks.
The researchers observed that mothers who received the PREPP intervention, on average, experienced lower levels of depressive symptoms and anxiety than women receiving treatment as usual at 6 weeks postpartum. In addition, the study also found that mothers who received PREPP reported having infants who fussed and cried fewer times per day than infants of the ETAU mothers. No women in the PREPP group dropped out, whereas mothers in the ETAU group did not finish the study.
Although this study was small in size, it provides preliminary evidence that this intervention is well-tolerated and reduces the risk of depressive symptoms and anxiety in women at increased risk for PPD. This is a relatively brief intervention, consisting of only three visits (one of which is conducted while the mother is in the hospital after delivery). Although this intervention was delivered by a psychologist, it appears that many components of this intervention — particularly the infant behavior techniques — could be provided by caregivers who are not mental health providers, which may make this intervention easier to implement in many different settings.
Over the last several years, we have seen a number of studies which have shown the effectiveness of relatively simple and practical interventions for reducing the risk of postpartum depressive symptoms. One study demonstrated that an intervention which teaches new parents about normal infant sleeping and crying patterns and provides them with techniques for infant settling improved new mothers’ depression scores. An intervention which used videotaped material to help new mothers learn about how to facilitate positive interactions with their baby reduced the risk of postpartum depression. Another study demonstrated that an action-oriented behavioral educational intervention addressing modifiable risk factors for depression (such as social isolation, lack of support, low self-esteem) reduced the prevalence of postpartum depressive symptoms in a group of low-income mothers.
What all of these studies tell us is that we can make a tremendous difference by increasing support for and by providing practical childcare education to new mothers. None of the interventions described above require specially trained clinicians and can be carried out in variety of settings. In a society where new mothers are often geographically separated from their own families and may not have adequate supports or experience with childcare, we need to offer more support and guidance to new mothers.
Ruta Nonacs, MD PhD
Hiscock H, Cook F, Bayer J, Le HN, Mensah F, Cann W, Symon B, St James-Roberts I. Preventing Early Infant Sleep and Crying Problems and Postnatal Depression: A Randomized Trial. Pediatrics. 2014 Jan 6. [Epub ahead of print]
Werner EA, Gustafsson HC, Lee S, Feng T, Jiang N, Desai P, Monk C. PREPP: postpartum depression prevention through the mother–infant dyad.Arch Womens Ment Health. 2015 Aug 2. [Epub ahead of print]
Wisner K, et al. Prevention of Postpartum Depression: A Pilot Randomized Clinical Trial. Am J Psychiatry 2004; 161: 1290-1292.
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