Interventions to Prevent Perinatal Depression
by Anne Eglash MD, IBCLC, FABM
Perinatal depression is the occurrence of depression during pregnancy or during the first year postpartum. Depression during pregnancy is associated with decreased intent to breastfeed, along with increased risk of preterm birth, low birth weight, and fetal growth restriction. Women with postpartum depression are at risk of decreased breastfeeding and impaired mother-infant bonding, as well as an increased risk of suicide and thoughts of harming their infants. Perinatal depression can also affect an infant’s cognitive and emotional development.
The USPSTF states that there is no accurate screening tool to identify women at risk for perinatal depression. Therefore, they recommend providing counseling interventions for women with risk factors, including a history of depression, current symptoms that do not compromise a depression diagnosis, anxiety, and/or socioeconomic risk factors such as low income, adolescent or single parenthood, recent intimate partner violence, or significant negative life events.
- Home visitation is strongly associated with less perinatal depression.
- Gestational diabetes is a risk factor for perinatal depression.
- Baby blues typically resolves by 10 days postpartum.
- Infants whose mothers have perinatal depression are at increased risk for fewer preventive services such as vaccinations.
- Women at higher risk for perinatal depression have a greater response to counseling interventions than women at lower risk for perinatal depression.
- Physical activity programs consistently show strong prevention of perinatal depression.
- Omega fatty acids, such as fish oil, can prevent perinatal depression.
See the Answer
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. It is well established that perinatal depression can result in adverse short- and long-term effects on both the woman and child.
Objective
To issue a new US Preventive Services Task Force (USPSTF) recommendation on interventions to prevent perinatal depression.
Evidence Review
The USPSTF reviewed the evidence on the benefits and harms of preventive interventions for perinatal depression in pregnant or postpartum women or their children. 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.
Findings
The USPSTF found convincing evidence that counseling interventions, such as cognitive behavioral therapy and interpersonal therapy, are effective in preventing perinatal depression. 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 providing or referring pregnant or postpartum women at increased risk to counseling interventions has a moderate net benefit in preventing perinatal depression.
Conclusions and Recommendation
The USPSTF recommends that clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions. (B recommendation)
Physical activity, fish oil, and patient navigation services by health systems such as home visitation were not found to significantly prevent perinatal depression. However, I wonder about the quality of the home visitation in the studies evaluated, because if it includes counseling, then home visitation should help prevent perinatal depression. They did cite research showing that sertraline (Zoloft) decreases depression recurrence, but it was more harmful than counseling as a prevention.
Cognitive behavior therapy and interpersonal therapy, as group or individual sessions, have been found to decrease the risk of perinatal depression by approximately 50% among high risk women. The USPSTF does not delineate the best time to refer for counseling services, but in most studies women were referred in the second trimester of pregnancy. They highlight 2 programs that have been successful, the ROSE program, and the Mothers and Babies Program.
Kathleen Kendall-Tackett, PhD, IBCLC, FAPA
I agree with most of what Anne said about prevention, but there have been several good studies showing that exercise for depressed pregnant women does help lower depressive symptoms and increase self-efficacy. The results for fish oil have been mixed. The do create stress resilience to stress and have been helpful as adjunct treatments (they especially boost the effectiveness of antidepressants). It’s also important to differentiate the type of Omega-3: DHA vs. EPA. EPA specifically treats depression. DHA does not (and is marginal at preventing it, at least in clinical trials. Where you see better results is in population studies where they eat a lot of fish. I’d recommend combining EPA with other modalities.
I’ve done a complete review of all these studies in the 3rd Edition of my book, Depression in New Mothers (Routledge UK). I also review the literature on the effectiveness of community-based interventions. You might find that book to be helpful.
Joni Parker
I love this site and applaud all who make this form of study Possible. It helps educators accurately help their patients deal with this awful experience, Thank you Anne Englash