Perinatal Depression: Preventive Interventions --Pregnant and postpartum persons


General

Grade: B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Offer or provide this service.

Specific Recommendations

The USPSTF recommends that clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions.

Frequency of Service

No information available.

Risk Factor Information

Include a past history of depression. Current depressive symptoms (that do not reach a diagnostic threshold), history of physical or sexual abuse, unplanned or unwanted pregnancy, stressful life events, lack of social and financial support, intimate partner violence,pregestational or gestational diabetes,and complications during pregnancy. Additional risk factors include adolescent parenthood, low socioeconomic status, and lack of social support. Genetic factors are also suspected to contribute to women’s risk of developing perinatal depression.


Clinical

Patient Population Under Consideration

This recommendation applies to pregnant persons and persons who are less than 1 year postpartum who do not have a current diagnosis of depression but are at increased risk of developing depression.

Assessment of Risk

Clinical risk factors that may be associated with the development of perinatal depression include a personal or family history of depression, history of physical or sexual abuse, having an unplanned or unwanted pregnancy, current stressful life events, pregestational or gestational diabetes, and complications during pregnancy (eg, preterm delivery or pregnancy loss). In addition, social factors such as low socioeconomic status, lack of social or financial support, and adolescent parenthood have also been shown to increase the risk of developing perinatal depression. However, there is no accurate screening tool for identifying women at risk of perinatal depression and who might benefit from preventive interventions.

A pragmatic approach, based on the populations included in the systematic evidence review, would be to provide counseling interventions to women with 1 or more of the following: a history of depression, current depressive symptoms (that do not reach a diagnostic threshold), certain socioeconomic risk factors such as low income or adolescent or single parenthood, recent intimate partner violence, or mental health–related factors such as elevated anxiety symptoms or a history of significant negative life events.

Counseling Interventions

Studies on counseling interventions to prevent perinatal depression mainly included cognitive behavioral therapy and interpersonal therapy.

Cognitive behavioral therapy focuses on the concept that positive changes in mood and behavior can be achieved by addressing and managing negative thoughts, beliefs, and attitudes and by increasing positive events and activities.23 Common therapeutic techniques include patient education, goal-setting, interventions to identify and modify maladaptive thought patterns, and behavioral activation. Interpersonal therapy focuses on treating interpersonal issues thought to contribute to the development or maintenance of psychological disorders.4 Common therapeutic techniques include the use of exploratory questions (ie, open-ended and clarifying questions), role-playing, decision analysis, and communication analysis.25 The interventions reviewed by the USPSTF varied in setting, intensity, format, and intervention staff. Counseling intervention trials included a mixture of populations at increased risk of perinatal depression and not at increased risk.2

The USPSTF found limited or mixed evidence that other studied interventions such as physical activity, education, pharmacotherapy, dietary supplements, and health system interventions were effective in preventing perinatal depression.

Implementation

There are no data on the ideal timing for offering or referral to counseling interventions; however, most were initiated during the second trimester of pregnancy. Ongoing assessment of risks that develop in pregnancy and the immediate postpartum period would be reasonable, and referral could occur at any time.

Counseling sessions reviewed for this recommendation ranged from 4 to 20 meetings (median, 8 meetings) lasting for 4 to 70 weeks.6 The format of counseling consisted mainly of group and individual sessions, with the majority involving in-person visits. Intervention staff included psychologists, midwives, nurses, and other mental health professionals.2

One example of a cognitive behavioral approach was the “Mothers and Babies” program.7-10 It involved 6 to 12 weekly 1- to 2-hour group sessions during pregnancy and 2 to 5 postpartum booster sessions. The program included modules on the cognitive behavioral theory of mood and health; physiological effects of stress; the importance of pleasant and rewarding activities; how to reduce cognitive distortions and automatic thoughts; and the importance of social networks, positive mother-child attachment, and parenting strategies to promote child development and secure attachment in infants.

The Reach Out, Stand Strong, Essentials for New Mothers (ROSE) program is an example of an interpersonal therapy approach reviewed by the USPSTF.4511-13 It involved 4 or 5 prenatal group sessions lasting 60 to 90 minutes and 1 individual 50-minute postpartum session. Course content included psychoeducation on the “baby blues” and postpartum depression, stress management, development of a social support system, identification of role transitions, discussion of types of interpersonal conflicts common around childbirth and techniques for resolving them, and role-playing exercises with feedback from other group members.

Additional Approaches to Prevention of Depression

The Substance Abuse and Mental Health Administration—Health Resources and Services Administration Center for Integrated Health Solutions promotes the development of, and provides resources for, integrating primary and behavioral health services.14 The Substance Abuse and Mental Health Administration provides resources for locating mental health services.15

The Mothers and Babies program, which is based on cognitive behavioral therapy, also provides web-based resources for families and clinicians.16

The USPSTF has a related recommendation on screening for depression in adults, including pregnant and postpartum women (B recommendation).17 The USPSTF also recommends screening for depression in adolescents aged 12 to 18 years (B recommendation) and found insufficient evidence to recommend for or against screening in children 11 years or younger (I statement).18


Rationale

Importance

Perinatal depression, which is the occurrence of a depressive disorder during pregnancy or following childbirth, affects as many as 1 in 7 women and is one of the most common complications of pregnancy and the postpartum period.1 It is well established that perinatal depression can result in negative short- and long-term effects on both the woman and child.2

Benefits of Counseling Interventions

The USPSTF found convincing evidence that counseling interventions, such as cognitive behavioral therapy and interpersonal therapy, are effective in preventing perinatal depression in those at increased risk.

Harms of Counseling Interventions

The USPSTF found adequate evidence to bound the potential harms of counseling interventions as no greater than small, based on the nature of the interventions and the low likelihood of serious harms.

USPSTF Assessment

The USPSTF concludes with moderate certainty that counseling interventions to prevent perinatal depression have a moderate net benefit for persons at increased risk.


Others

Research Gaps and Needs Further research could address important gaps in several areas. Good-quality evidence is lacking on the best way to identify women at increased risk of perinatal depression who would most benefit from preventive interventions. Measures of depression symptoms are useful in predicting future perinatal depression, although more data are needed on how to incorporate other perinatal risk factors into these depression screening tools. A small number of trials examined several potentially valuable depression prevention interventions, such as physical activity, infant sleep education, in-hospital perinatal education, and peer counseling. More and larger-scale trials of these types of interventions are needed to expand the evidence base. Similarly, large-scale trials of cognitive behavioral therapy and interpersonal therapy interventions are needed to demonstrate whether these strategies are scalable and applicable to persons at lower risk. Several interventions related to improved health systems, such as developing clinical pathways, training health care practitioners, and facilitating access to embedded behavioral health specialists, show promise and have been implemented on a limited basis in US-based primary care settings. Further research is needed to evaluate the potential benefits and harms of these types of interventions. Data are lacking on the benefits and harms of antidepressant medications for the prevention of perinatal depression. Likewise, dietary supplements, such as selenium and vitamin D, have shown promise, but more research is needed to explore these interventions.   Recommendations by Others The USPSTF found no other guidelines on the prevention of perinatal depression. The American College of Obstetricians and Gynecologists recommends early postpartum follow-up care, including screening for depression and anxiety, for all postpartum women.19,59


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