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 depression, it is possible to identify certain subgroups of women who are at increased risk for postpartum affective illness. For example, women who have had one episode of postpartum depression have about a 50% chance of experiencing PPD again after a subsequent pregnancy. Women with a history of depression (prior to pregnancy) are also at increased risk for PPD, with previous studies indicating that between 30% and 50% of women with histories of major depression will experience PPD.
In 2019, the US Preventive Services Task Force (USPSTF) issued recommendations that all pregnant and postpartum women should be evaluated in order to determine risk for depressive illness and recommended that women at increased risk should be referred for counseling interventions. Ultimately the goal is to identify women at highest risk for depressive illness during pregnancy and the postpartum period, so that we can introduce interventions designed to prevent depression in this setting.
Of utmost importance is the selection of an effective intervention. The medical literature reports on a wide array of interventions designed to prevent PPD; however, many of these interventions have not been tested in multiple settings.
Prevention of PPD in High-Risk Populations: USPSTF Recommendations
In 2019, the USPSTF reviewed 50 studies evaluating interventions delivered to pregnant and postpartum women in order to prevent perinatal depression (US Preventive Services Task Force, 2019; O’Connor et al, 2019). Twenty of those studies, including a total of 4107 participants, reported on counseling interventions. Based on this review of the literature, the USPSTF found convincing evidence to support the use of counseling interventions, specifically those using cognitive behavioral therapy and interpersonal therapy, as an effective means of preventing perinatal depression.
The majority of the interventions in this report (n=15) targeted women at high risk for perinatal depression, including women with a history of depression, women with current depressive symptoms (usually subsyndromal), and women with psychosocial risk factors for perinatal depression, including low socioeconomic status, recent intimate partner violence, or younger age. However, most of the interventions (n=13, 65%) excluded women meeting criteria for a current depressive episode. Most trials initiated interventions during pregnancy (17/20, 85%).
In this analysis, counseling interventions were associated with a 39% reduction in the likelihood of perinatal depression (pooled relative risk [RR] 0.61, 95% CI, 0.47 to 0.78). Although many different interventions had beneficial effects, there is the most evidence supporting interventions using cognitive behavioral therapy (CBT) and interpersonal therapy (IPT), with a total of 13 studies. A subgroup analysis of trials using the CBT-based Mothers and Babies program and the IPT-based ROSE program showed pooled reductions in risk of 53% and 50%, respectively. In general, interventions targeting high risk populations demonstrated a larger positive effect than trials enrolling women at lower risk for perinatal depression.
The Mothers and Babies Program: A CBT-Based Intervention
One example of an intervention utilizing cognitive behavioral techniques is the Mothers and Babies Program. This program consists of 6 to 12 weekly 1- to 2-hour group sessions during pregnancy and 2 to 5 postpartum booster sessions. The program includes modules covering the following topics: basic cognitive behavioral theories of mood, understanding the physiological effects of stress, learning how to reduce cognitive distortions and automatic thoughts which contribute to depression and anxiety, appreciating the importance of pleasurable and rewarding activities and social networks, and parenting strategies to promote secure attachment and child development.
The ROSE Program: An IPT-Based Intervention
The Reach Out, Stand Strong, Essentials for New Mothers (ROSE) program is an example of an intervention using an interpersonal therapy approach. This program involves 4 or 5 group sessions during pregnancy lasting 60 to 90 minutes and one individual 50-minute postpartum session. This program provides psychoeducation on the “baby blues” and postpartum depression, stress management, how to develop of a social support system, identification of role transitions, increasing awareness of types of interpersonal conflicts common to the transition to parenthood and techniques for resolving them, and role-playing exercises with feedback from other group members.
Mindfulness-Based Cognitive Therapy (MBCT)
In a pilot randomized clinical trial, researchers evaluated the acceptability and efficacy of MBCT specifically designed to prevent postpartum depression (MBCT-PD) as compared to treatment as usual (TAU) in a group of pregnant women with depression histories recruited from obstetric clinics at 2 sites. The women were randomized to MBCT-PD (N = 43) or TAU (N = 43). The subjects were evaluated through 6 months postpartum.
MBCT-PD for at-risk pregnant women was acceptable based on rates of completion of sessions and at-home practice assignments. Not surprisingly, satisfaction with services was significantly higher for MBCT-PD than TAU. Most importantly, at-risk women receiving MBCT-PD experienced a 74% reduction in the rate of relapse compared to treatment as usual across the duration of the entire study period (18.4% relapse for MBCT-PD vs. 50.2% for TAU). If the analysis was restricted to relapse during the postpartum period, the protective effect was even greater (4.6% relapse for MBCT-PD vs. 34.6% for TAU). In addition, participants receiving MBCT-PD reported, on average, significantly lower levels of depressive severity than participants in TAU.
Other Types of Psychosocial Interventions
What is notable in the USPSTF recommendations is that the report emphasizes interventions based on psychotherapeutic techniques delivered by highly trained specialists. While these interventions may be highly effective, it continues to be difficult for women to access specialized treatment for perinatal mood and anxiety disorder. Less obvious in the USPSTF report is that some of the most successful interventions are relatively simple and could be more easily implemented in settings with limited resources. These interventions were not specifically recommended by the USPSTF because they were not evaluated in multiple studies (in contrast to the interventions utilizing CBT and IPT).
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 infant sleeping and crying patterns and provides them with techniques for infant settling improved new mothers’ depression scores. Another intervention using videotaped materials to teach mothers how to facilitate positive interactions with their baby reduced the risk of postpartum depression.
In a randomized clinical trial including 230 Head Start mothers, those receiving a problem-solving educational intervention were 60% less likely to develop postpartum depression than those receiving standard care. One of the most exciting aspects of this study is the simplicity of this intervention; problem-solving sessions lasting 30 to 60 minutes were conducted as home visits or in Head Start centers for 6 to 8 weeks by non-licensed, community care–based providers.
Another study of an educational intervention for Black and Latinx mothers, was similarly effective in reducing risk for PPD. The first part of the intervention, administered in the hospital shortly after delivery consisted of a 15-minute review of a pamphlet outlining potential triggers of depressive symptoms (e.g., infant colic, episiotomy site pain, urinary incontinence), labeling these events as “normal” aspects of the postpartum experience and providing specific and practical suggestions for their management and stressing the importance of social supports for the mother.
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.Mothers who received the intervention were less likely to screen positive for depression at 3 weeks than those who received usual care (8.8% vs. 15.3%). At six months postpartum, women who received this intervention were less likely to be depressed than women receiving usual care (odds ratio, 0.67). These findings persisted even after adjusting for baseline depression.
Peer Support Interventions
A peer support intervention is defined as “the provision of emotional assistance (e.g., attentive listening), appraisal assistance (communication of information that is pertinent to self-evaluation), and informational assistance (provision of knowledge relevant to problem-solving) by a created social network member who possesses experiential knowledge of a specific behavior or stressor and similar characteristics as the target population” (Huang et al, 2020).
In a recent review, Huang and colleagues review the effectiveness and feasibility of peer support interventions in pregnant and postpartum populations. Ten randomized controlled trials were included in the analysis, with a total of 3064 participants (1468 in the peer-delivered intervention groups and 1596 controls). The risk of PPD in the intervention group was significantly lower than in the control group (OR= 0.69, 95% CI 0.49 to 0.96) which represents a moderate effect size.
It is noteworthy that many of the most effective interventions for the prevention of PPD occur in a group setting, including the Mothers and Babies Program and the ROSE Program. While these programs offer psychotherapeutic components, it is important to consider that one of the essential “active ingredients” of these interventions may be having the support of peers.
Prophylactic Treatment with Antidepressants
Most interventions thus far studied offer non-pharmacologic treatments; however, pharmacologic treatment may decrease risk for postpartum illness in women with a history of depression. These studies have included prophylactic treatment with SSRIs and tricycle antidepressants.
In a group of women at high risk for postpartum depression, Wisner and colleagues described a beneficial effect of prophylactic treatment with the selective serotonin reuptake inhibitor (SSRI), sertraline. In this double blind, placebo-controlled study, 22 women (ages 21 to 45 years) with histories of postpartum depression were randomized to receive treatment with either sertraline (Zoloft) or placebo. 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.
Choosing the Right Intervention
It is clear that there are a number of interventions which can be used to reduce risk for postpartum depression in certain populations; however, we cannot use a one-size-fits-all kind of approach when making decisions regarding the care of women at increased risk for perinatal depression. While a counseling intervention may be appropriate for a woman with a history of depression who is currently not taking antidepressants, it may not be ideal for a woman with recurrent, severe depression who is currently treated with an antidepressant.
In addition, which factors contribute to increased risk may influence the choice of intervention. For example, a married woman with a history of recurrent depression and a teen mother living in the inner city are both at increased risk for perinatal depression; however, they are likely to need different types of support.
Access to these programs is also a problem. While many different types of approaches may decrease risk for perinatal depression, they are not standard care. We have a number of interventions which reduce risk by 40% to 50%, yet most women in the United States will not be able to access these programs.
Ruta Nonacs, MD PhD
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