Draft Recommendation Statement
Perinatal Depression: Preventive Interventions
Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Aug 28, 2018Return to Recommendation
|Pregnant and postpartum women||The USPSTF recommends that clinicians provide or refer pregnant and postpartum women who are at increased risk of perinatal depression to counseling interventions.||B|
The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms.
It bases its recommendations on the evidence of both the benefits and harms of the service, and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.
The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decisionmaking to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.
Perinatal depression 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 women at increased risk.
Harms of Counseling Interventions
The USPSTF found adequate evidence to bound the potential harms of counseling interventions to no greater than small, based on the nature of the interventions and the low likelihood of serious harms.
The USPSTF concludes with moderate certainty that counseling interventions to prevent perinatal depression have a moderate net benefit for women at increased risk.
Patient Population Under Consideration
This recommendation applies to pregnant women and women 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
No accurate screening tool is available to identify women at risk of perinatal depression. 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/unwanted pregnancy, current stressful life events, pregestational or gestational diabetes, and complications during pregnancy (e.g., premature contractions or hyperemesis). In addition, social factors such as low socioeconomic status, lack of social or financial support, and adolescent parenthood have also been shown to increase women’s risk of developing perinatal depression.
There are limited data on the best way to identify women at increased risk of perinatal depression. A pragmatic approach, based on the populations included in the systematic evidence review, would be to provide counseling interventions to women with one or more of the following: a history of depression, current depressive symptoms (that do not reach a diagnostic threshold), or certain socioeconomic risk factors (e.g., low income or young or single parenthood).
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.2,3 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 that are thought to contribute to the development or maintenance of psychological disorders.4 Common therapeutic techniques include the use of exploratory questions (i.e., open-ended and clarifying questions), role-playing, decision analysis, and communication analysis.2,5
The interventions reviewed by the USPSTF varied in setting, intensity, format, and intervention staff. Overall, counseling sessions ranged from four to 20 meetings (median, 8 meeting) lasting for 4 to 70 weeks.6 Most sessions were initiated during pregnancy. 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 Counseling intervention trials included a mixture of populations at increased risk of perinatal depression and those not at increased risk.2
One cognitive behavioral approach used in four studies7-10 was the “Mothers and Babies” program. It involved six to 12 weekly 1- to 2-hour group sessions during pregnancy and two to five 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, cognitive distortions and automatic thoughts, social networks, positive mother-child attachment, and parenting strategies to promote child development and secure attachment in infants. The interpersonal therapy–based Reach Out, Stand Strong, Essentials for New Mothers (ROSE) program was studied in five trials.4,5,11-13 It involved four or five 60- to 90-minute prenatal group sessions and one 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.
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.
The USPSTF recommends screening for depression in adults, including pregnant and postpartum women (B recommendation).14 The USPSTF recommends screening for depression in adolescents ages 12 to 18 years (B recommendation) and found insufficient evidence to recommend for or against screening in children age 11 years or younger (I statement).15
Research Gaps and Needs
There are several areas where further research could address important gaps. There is a lack of good-quality evidence on the best way to identify women at increased risk of perinatal depression who would most benefit from preventive interventions. Measures of depression symptoms have shown use in predicting future perinatal depression, although more data are needed on how to incorporate perinatal risk factors into these depression screening tools.
There were a small number of trials examining several potentially valuable 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 and interpersonal therapy interventions are needed to demonstrate whether these strategies are scalable and applicable to lower-risk women.
Several interventions related to improved health systems, such as developing clinical pathways, training health care providers, and facilitating access to embedded behavioral health specialists, show promise and have been implemented (on a limited basis) in U.S.-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.
Burden of Disease
Perinatal depression is defined as the occurrence of a depressive disorder during pregnancy or following childbirth.16 Symptoms include loss of interest and energy, depressed mood, fluctuations in sleep or eating patterns, reduced ability to think or concentrate, feelings of worthlessness, and recurrent suicidal ideation. Symptoms of depressed mood or loss of interest are required and must be present for a minimum of 2 weeks.17 The diagnosis should not be confused with the less severe postpartum “baby blues,” which is a commonly experienced transient mood disturbance consisting of crying, irritability, fatigue, and anxiety that usually resolves within 10 days of delivery.18
In the United States, the estimated prevalence of major depressive disorder in postpartum women ranges from 8.9% among pregnant women to 37% at any point in the first year postpartum.19 Rates vary by age, race/ethnicity, and other sociodemographic characteristics. For example, women age 19 years or younger, American Indian/Alaska Native women, women with less than 12 years of education, unmarried women, or women with six or more stressful life events in the previous 12 months have higher reported rates of perinatal depression.20
It is well established that depression during the postpartum period can lead to negative effects on the mother and infant. Although acts of harming oneself or others are rare, perinatal depression increases the risk of suicide and suicidal ideation, and mothers with depression report more thoughts of harming their infants than mothers without depression.21 Women with perinatal depression exhibit significantly higher levels of negative maternal behaviors (i.e., hostile/coercive behaviors) and disengagement from their infants than women without perinatal depression.22 Women with perinatal depression are also more likely to exhibit significantly lower levels of positive maternal behaviors, such as praising and playing with their child.22 Perinatal depression is linked to an increased risk of preterm birth, small for gestational age newborns, and low birth weight.23 Infants whose mothers have perinatal depression are at increased risk of early cessation of breastfeeding24 and have been shown to receive fewer preventive health services (i.e., vaccinations) compared to mothers without depressive symptoms.25 Perinatal depression can also affect a child’s cognition and emotional development. Children of mothers who had perinatal depression demonstrate more behavior problems, lower cognitive functioning, and increased risk of developing psychiatric disorders.26,27
A number of risk factors are thought to be associated with the development of perinatal depression. These include a past history of depression,28 current depressive symptoms (that do not reach a diagnostic threshold),29 history of physical or sexual abuse,30,31 unplanned/unwanted pregnancy,32 stressful life events,20,28 lack of social and financial support,28,32 intimate partner violence,30,31 pregestational or gestational diabetes,33 and complications during pregnancy (e.g., hyperemesis or premature contractions).34 Additional risk factors include adolescent parenthood, low socioeconomic status, and lack of social support.35 Genetic factors are also suspected to contribute to women’s risk of developing perinatal depression.36
Scope of the Review
The USPSTF commissioned a systematic evidence review2 to evaluate the evidence on the potential benefits and harms of preventive interventions in pregnant or postpartum women or their children. The review focused on studies of interventions involving pregnant women and new mothers of any age who were both selected and unselected based on known risk factors. The review included studies of women with mental health symptoms or disorders, although studies targeting women with a depression diagnosis, women with high levels of depressive symptoms, or women currently being treated for a depressive disorder were excluded, as were studies of women with psychotic or developmental disorders. The USPSTF reviewed contextual information on the accuracy of tools used to identify women at increased risk of perinatal depression and the most effective timing for preventive interventions. Interventions reviewed included counseling, health system interventions, physical activity, education, supportive interventions, and other behavioral interventions, such as infant sleep training and expressive writing. Pharmacological approaches included the use of nortriptyline, sertraline, and omega-3 fatty acids.
Effectiveness of Preventive Interventions
The USPSTF reviewed studies of pregnant and postpartum women who received interventions to prevent perinatal depression delivered in or referred from primary care. The main reported outcomes were depression status (measured as cumulative incidence, point prevalence, or scoring above a cutoff on a symptom severity scale) and continuous depression symptom scale scores. Other health outcomes such as quality of life, infant/child outcomes, and functioning were also reported by trials and considered by the USPSTF. The USPSTF reviewed a total of 50 trials of good or fair quality. The trials were divided between those that targeted pregnant (26/50 [52%]) or postpartum (22/50 [44%]) women. Two trials recruited women who were pregnant as well as women up to 26 weeks postpartum.2 Most trials (42/50 [84%]) were limited to women age 18 years or older, and the average age across trials was 28.6 years. Twenty-six of the trials (52%) selected women with risk factors for perinatal depression. These included a personal or family history of depression (or perinatal depression), elevated depressive symptoms, socioeconomic factors (e.g., low income, single/without partner, young age, or recent intimate partner violence), and other mental health factors (elevated anxiety symptoms and history or significant negative life events).2 The majority of participants in the included trials were non-Hispanic white women, although two trials were limited to Latina women and eight trials had a majority black and Latina population. Nearly a quarter of trials (13/50 [26%]) were primarily or entirely composed of economically-disadvantaged women.2
Twenty trials (n=4,107) reported on counseling interventions. More than half were conducted in the United States (12/20 [60%]), most were limited to adults (older than age 18 years) (17/20 [85%]), and most initiated interventions during pregnancy (17/20 [85%]).2 Three-quarters of the trials were limited to women who were known to be at increased risk of perinatal depression because of depression history or symptoms (6/20 [30%]); nondepression-related risk factors such as low socioeconomic status, recent intimate partner violence, or young age (3/20 [15%]); or depression-related or other risk factors (6/20 [30%]). Almost two-thirds (13/20 [65%]) of the trials excluded women who met diagnostic criteria for current major depression or scored above the cutoff on a symptom severity scale. Most of the interventions (13/20 [65%]) used cognitive behavioral or interpersonal therapy approaches. Counseling interventions lasted a median of 8 weeks and had a median of 12 hours of total contact time.2 The interventions consisted of both group (15/20 [75%]) and individual (11/20 [55%]) sessions, with some involving both types.2 Settings included in-person (19/20) or phone-based meetings (two trials), and four trials included home visits. Across all counseling interventions, half to three-quarters of sessions were attended by participants.2
When the outcomes of incidence, prevalence, and scoring above the cutoff on a symptom severity scale were combined, 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]).2 Assuming a 19% baseline risk of perinatal depression (i.e., the median percentage of women with depression in control groups at 3- to 6-months postpartum across all included studies), this corresponds to a number needed to treat of 13.5 women (95% CI, 9.9 to 23.9). Compared to the overall effect of counseling interventions, studies reporting the use of cognitive behavioral or interpersonal therapy approaches showed similar effects.2 Subgroup analysis of trials using the “Mothers and Babies” and ROSE programs showed pooled RR reductions of 53% and 50%, respectively.2 When analyzing the effect of counseling interventions by study population, trials that selected women at increased risk of perinatal depression (based on symptoms, history of depression, or social/socioeconomic risk factors) demonstrated a larger positive effect compared to lower-risk, unselected populations (45% vs. 21% risk reduction, respectively), although this difference was not statistically significant.2
Thirteen trials reported continuous symptom score measures, with five trials demonstrating statistically significant group differences.7,8,11,37,38 Counseling interventions were associated with a small beneficial effect in symptom scores, resulting in a pooled standardized effect size of 0.2, or an average 1.5-point greater reduction in depression symptom severity compared to control groups.2 Trials reported other maternal or child outcomes; however, outcome measures widely varied and there was little consistency across studies. Stress (four trials)37,39-41 and anxiety (four trials)39,40,42,43 were the most common other reported outcomes, although most trials did not demonstrate statistically significant findings.2
Three trials (n=5,321)44-46 examined health system–level interventions consisting of screening, counseling, and patient navigation services conducted by midwives and nurses.2 In all three trials, usual care included home visitation.2 Individually, each trial showed a statistically significant risk reduction in the likelihood of scoring above the cutoff on the Edinburgh Postnatal Depression Scale (RR, 0.33 to 0.71). However, pooled analysis did not demonstrate statistical significance (RR, 0.58 [95% CI, 0.22 to 1.53]). Three trials (n=1,200)47-49 examined physical activity programs consisting of group or individual exercise sessions (with or without dietary advice or educational sessions). Two trials48,49 found statistically significant reductions in depression symptoms (weighted mean difference, -3.45 [95% CI, -5.0 to -1.9])2, although pooled analysis failed to demonstrate statistically significant reductions in depression diagnosis (RR, 0.54 [95% CI, 0.18 to 1.57]).2
Three trials (n=980) focusing on improving infant sleep demonstrated mixed results. One trial found a 39% reduction in the likelihood of scoring 10 or higher on the Edinburgh Postnatal Depression Scale at 6-month followup (adjusted odds ratio, 0.57 [95% CI, 0.34 to 0.94]).50 Two other trials reported statistically significant or near significant reductions in symptom severity scores at one (but not all) time point on one (but not all) depression screening instrument.51,52 Educational interventions and other supportive interventions, such as telephone-based peer support and nondirective group sessions, demonstrated inconsistent findings, with 1/6 and 3/7 trials, respectively, reporting statistically significant reductions in depression status or depression symptom scores. Yoga classes, debriefing exercises, and expressive writing failed to demonstrate statistically significant reductions in depression symptoms or status.2
Four trials of chemoprevention of perinatal depression assessed the effects of sertraline (n=22),53 nortriptyline (n=58),54 and omega-3 fatty acids (n=219).55,56 The sertraline trial found that at 20 weeks postpartum, women taking sertraline had decreased depression recurrence compared to those taking placebo (7% vs. 50%, respectively; p=0.04). In addition, the time to depression recurrence was faster in participants receiving placebo (p=0.02).53 Neither nortriptyline54 or omega-3 fatty acids55,56 showed preventive benefits for perinatal depression compared to placebo, although omega-3 fatty acids demonstrated small statistically significant improvements in gestational length, mean birth weight, and 5-minute Apgar scores.56
Potential Harms of Preventive Interventions
The nortriptyline study54 reported only the number of events for one of 11 side effects, with 78% of women taking nortriptyline reporting constipation (vs. 22% of women taking placebo). Participants receiving sertraline were more likely than those receiving placebo to report dizziness (57% vs. 13%, respectively; p=0.05) and drowsiness (100% vs. 50%, respectively; p=0.02).53 One woman taking nortriptyline and one woman taking sertraline developed mania or hypomania, but there were no cases among women taking placebo.53,54 No harms were associated with omega-3 fatty acids. None of the other included intervention trials reported harms outcomes.
Estimate of Magnitude of Net Benefit
The USPSTF found convincing evidence that counseling interventions, such as cognitive behavioral therapy and interpersonal therapy, are effective in preventing perinatal depression. Based on the population of women included in the studies, women with a history of depression, current depressive symptoms, or certain socioeconomic risk factors (e.g., low income or young or single parenthood) would benefit from counseling interventions and could be considered at increased risk. The USPSTF found adequate evidence to bound the potential harms of counseling interventions as no greater than small, based on the nature of the intervention and the low likelihood of serious harms. The USPSTF found inadequate evidence to assess the benefits and harms of other noncounseling interventions. The USPSTF concludes with moderate certainty that counseling interventions to prevent perinatal depression have a moderate net benefit for pregnant or postpartum women at increased risk.
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