BMJ  2005;331:15 (2 July), doi:10.1136/bmj.331.7507.15

Paper

Psychosocial and psychological interventions for prevention of postnatal depression: systematic review

¹ University of Toronto, Faculty of Nursing, 50 St George Street, Toronto, ON, Canada M5S 3H4

Abstract

Objective To assess the effects of psychosocial and psychological interventions compared with usual antepartum, intrapartum, or postpartum care on the risk of postnatal depression.

Data sources Medline, Embase, CINAHL, Cochrane central register of controlled trials, Cochrane pregnancy and childbirth group trials register, Cochrane depression, anxiety, and neurosis trials register, secondary references and review articles, and experts in the field.

Study selection All published and unpublished randomised controlled trials of preventive psychosocial or psychological interventions in which the primary or secondary aim was a reduction in the risk of postnatal depression. All trials recruited pregnant women or new mothers less than six weeks postpartum. Eligible studies were abstracted, assessed for methodological quality, and pooled with relative risk for categorical data and weighted mean difference for continuous data.

Results Fifteen trials with 7697 women were included. Although there was no overall statistically significant effect on the prevention of postnatal depression in the meta-analysis of all types of interventions (15 trials, n = 7697; relative risk 0.81, 95% confidence interval 0.65 to 1.02), these results suggest a potential reduction in postnatal depression. The only intervention to have a clear preventive effect was intensive postpartum support provided by a health professional (0.68, 0.55 to 0.84). Identifying women "at risk" assisted in the prevention of postnatal depression (0.67, 0.51 to 0.89). Interventions with only a postnatal component were more beneficial (0.76, 0.58 to 0.98) than interventions that incorporated an antenatal component. In addition, individually based interventions were more effective (0.76, 0.59 to 1.00) than group based interventions (1.03, 0.65 to 1.63).

Conclusions Diverse psychosocial or psychological interventions do not significantly reduce the number of women who develop postnatal depression. The most promising intervention is the provision of intensive, professionally based postpartum support.

Introduction

The cause of postnatal depression remains unclear.¹ Epidemiological studies and meta-analyses of predictive studies have consistently identified the importance of psychosocial and psychological risk factors^1-3—such as life stress, marital conflict, maternal self esteem, and lack of social support. A comprehensive review suggested that in women with postnatal depression, psychosocial and psychological treatment may be suitable.⁴ As such, it is theoretically possible that these interventions may also prevent postnatal depression, as many of the known risk factors are present during pregnancy and the immediate postpartum period. There have been two critical reviews of preventive trials^{5 6} and one systematic review that examined diverse interventions to reduce "probable depression" in the postnatal period.⁷ However, no systematic review has examined the overall preventive effect of psychosocial and psychological interventions or determined which characteristics are most beneficial.

I assessed the effects of such interventions compared with usual antepartum, intrapartum, or postpartum care on the risk of postnatal depression. A full review is published in the Cochrane Library.⁸

Methods

Searches—I searched the Cochrane pregnancy and childbirth group trials register database and the Cochrane depression, anxiety, and neurosis trials register, Medline (1966-2004), Embase (1980-2004), and CINAHL (1982-2004). Secondary references and review articles were scanned and experts in the field contacted.

Selection—Published and unpublished studies were eligible if they were randomised controlled trials; were methodologically strong, based on a validity assessment; evaluated a psychosocial or psychological intervention in which the primary or secondary aim was a reduced risk of postnatal depression; and included pregnant women and new mothers less than six weeks postpartum. I excluded studies if they incorporated a quasi-randomised design; recruited women identified with symptoms of depression, or solely evaluated an educational intervention. A psychosocial or psychological intervention incorporated various non-pharmaceutical strategies that were delivered antenatally or within the first month postpartum, or both, by a health professional or layperson.

View larger version (56K): [in this window] [in a new window]   Fig 1 Postnatal depression at final assessment (variously defined) among studies evaluating interventions versus normal care in the prevention of postnatal depression

 
Assessment of validity—The methodological quality of each trial was assessed according to the recommendations of the Cochrane Collaboration. Two reviewers independently assigned a quality rating to each trial; results were compared and differences discussed until agreement was obtained.

Abstraction of data—Two reviewers independently extracted data and included study design; participants; intervention type, mode, onset, duration, and provider; outcomes measured; and results. Wherever necessary, unpublished or missing data were requested from the author.

Quantitative data synthesis—While the primary meta-analysis was based on the occurrence of postnatal depression (however measured), several depression rating scales or cut-off points were incorporated. I made direct comparisons, using a fixed effect model, between trials using the same rating scale and cut off. Meta-analyses were performed using relative risks as the measure of effect size for binary outcomes and weighted mean differences for continuous outcome measures. Heterogeneity was investigated by calculating I² statistics, and if high (I² > 50%) a random effects meta-analysis was used. Sensitivity analyses, where I excluded trials most susceptible to bias, were also completed for high levels of heterogeneity. A priori subgroup analyses estimated the effect of intervention type, intervention mode, intervention onset, and sample selection criteria.

Results

The search identified 155 studies. After exclusions, I included 15 trials, incorporating 7697 women and published between 1995 and 2003, in the analysis (see bmj.com). Most trials were conducted in Australia and the United Kingdom; two trials were conducted in the United States and one in China. Seven trials targeted women believed to be at additional risk of postnatal depression. The eight others enrolled women from the general population.

Types of interventions
Categories of psychosocial interventions included antenatal and postnatal classes, professional and lay home visits, continuity of care, and early postpartum follow-up and psychological interventions included debriefing and interpersonal psychotherapy. The interventions were provided by various professionals, including physicians, nurses, midwives, and, in one trial, lay women recruited from the community. In most studies, the control group received usual antenatal/postnatal care, which varied both between and within countries.

View larger version (34K): [in this window] [in a new window]   Fig 2 Mean depression scores at final assessment among studies evaluating interventions versus normal care in the prevention of postnatal depression

 
Definition of postnatal depression
In all trials but one, postnatal depression was defined as a score above a specified cut-off point on a self reported measure. The Edinburgh postnatal depression scale is the most commonly used instrument to assess postpartum depressive symptoms, and in this systematic review most studies (10 out of 15) used a score > 12 on this measure to indicate postnatal depression; one study used a 10/11 cut off while another selected a 11/12 cut off. Several studies also reported mean scores. Two trials used the self reported hospital anxiety depression scale, and two used a semistructured diagnostic interview. The timing of the outcome assessment varied considerably between studies, ranging from three to 24 weeks postpartum; one trial included a 52 week assessment.

Quantitative data synthesis
Postnatal depression at last assessment
Variously defined—Although there was no statistically significant beneficial effect on the prevention of postnatal depression in the meta-analysis of all types of interventions (15 trials, n = 7697; relative risk 0.81, 95% confidence interval 0.65 to 1.02) (fig 1), these results suggest a potential 19% reduction in postnatal depression. There was significant heterogeneity among these trials (I² = 68.8%). The removal of trials at risk of bias resulted in no substantial change to the conclusion. I found a similar non-significant effect when I calculated a weighted mean difference (WMD) among the trials that provided a mean score on the Edinburgh postnatal depression scale (seven trials, n = 3300; WMD -0.06, -0.37 to 0.26) (fig 2).

Edinburgh postnatal depression scale score >12—I directly compared trials that used the Edinburgh postnatal depression scale with the recommended 12/13 cut-off score⁹ and found no preventive effect (10 trials, n = 6126; 0.91, 0.73 to 1.15).

Postnatal depression at 8, 16, and 24 weeks
Variously defined—I categorised assessments of postnatal depression at 0-8 weeks postpartum (short term effect); 9-16 weeks (intermediate effect); and 17-24 weeks (longer term effect). Results showed a short term reduction in the development of postnatal depression (eight trials, n = 4091; 0.65, 0.43 to 1.00). The effect weakened at the intermediate period (eight trials, n = 3326; 0.80, 0.56 to 1.12) and disappeared after 16 weeks (seven trials, n = 4314; 1.02, 0.87 to 1.19).

Edinburgh postnatal depression scale score >12—When I included only those trials that used an Edinburgh postnatal depression scale score > 12 as the outcome measure, there were no statistically significant short term (six trials, n = 3452; 0.90, 0.65 to 1.25), intermediate (five trials, n = 2369; 0.72, 0.49 to 1.06), or longer term (six trials, n = 3598; 1.00, 0.84 to 1.19) effects.

Subgroup analyses
Type of intervention—I found no preventive effect with antenatal and postnatal classes (two trials, n = 311; 1.02, 0.61 to 1.72), lay home visits (one trial, n = 481; 0.89, 0.62 to 1.27), and early postpartum follow-up (one trial, n = 475; 0.91, 0.56 to 1.48). I did find a positive trend related to continuity of care (one trial, n = 935; 1.34, 0.97 to 1.85) and a clear beneficial effect with home visits provided by a health professional (two trials, n = 1663; 0.68, 0.55 to 0.84). Among psychological interventions, there was no preventive effect in relation to interpersonal psychotherapy (two trials, n = 72; 0.31, 0.04 to 2.52) but a positive trend in relation to debriefing in hospital (five trials, n = 3051; 0.57, 0.31 to 1.04).

Mode of intervention—Analysis of 11 trials evaluating individually based interventions showed a benefit in preventing postnatal depression at the last study assessment (n = 6642; 0.76, 0.59 to 1.00). Of the four trials that evaluated group based interventions, there was no apparent reduction in depressive symptoms at last study assessment (n = 1055; 1.03, 0.65 to 1.63).

Onset of intervention—Studies in which the intervention began antenatally and continued postnatally failed to reduce the likelihood of women developing postnatal depression (four trials, n = 1283; 1.21, 0.93 to 1.59). However, there was a preventive effect in those trials evaluating a postnatal only intervention (10 trials, n = 6379; 0.76, 0.58 to 0.98).

Effect of sample selected—Trials that selected participants considered to be "at risk" had more success in preventing postnatal depression (seven trials, n = 1162; 0.67, 0.51 to 0.89) than those that enrolled women from the general population (eight trials, n = 6535; 0.87, 0.66 to 1.16).

Discussion

This systematic review shows that there is no clear evidence to recommend the implementation of antenatal and postnatal classes, early postpartum follow-up, continuity of care models, psychological debriefing in hospital, and interpersonal psychotherapy. There is emerging evidence to support the importance of additional professional support provided postnatally. Although one trial suggested that intensive home visits by nurses with at risk mothers was protective during the first six weeks postpartum, the benefit was not maintained to 16 weeks when the visits decreased from weekly to monthly. One trial showed that flexible, individualised postpartum care by midwives that incorporated assessment tools also had a preventive effect. Due to the cluster randomisation process, however, this trial may have been overweighted in the meta-analyses.

Subgroup analysis showed that identifying mothers with risk factors assisted in the prevention of postnatal depression. A review of 16 antenatal screening tools, however, suggests that there is no measure with acceptable predictive validity to accurately identify women who will later develop postnatal depression.¹⁰ This may partially explain why interventions with only a postnatal component seem to be more beneficial than interventions that also incorporate an antenatal component.

The included trials were of good methodological quality, but the reporting of the trials was often not comprehensive. There was also a failure to present details of the informational element of the interventions and on the background features of the care received by the control groups. While intention to treat analyses were performed, in trials with group sessions compliance was poor.

Interpretation of results
The diversity of preventive interventions and the widely differing study end points should urge some caution in the interpretation of the pooled data. This review consistently showed that women who received a preventive intervention were statistically overall just as likely to experience postnatal depression as those who received standard care, even among those trials that incorporated the Edinburgh postnatal depression scale. On the basis of the several promising results found in this study and the potential long term consequences of postnatal depression, future research examining the prevention of postpartum depression is warranted. These studies should include ethnically and socioeconomically diverse women and economic analyses.

What is already known on this topic Postnatal depression is a major health issue affecting about 13% of all new mothers Epidemiological studies and meta-analyses of predictive studies have consistently found that several psychosocial and psychological variables contribute to increased risk No systematic review has examined the preventive effect of psychosocial and psychological strategies or specific intervention characteristics What this study adds There is insufficient evidence that diverse psychosocial or psychological interventions reduce the number of women who develop postnatal depression Interventions that target at risk women, are individually based, or initiated postnatally are more likely to be beneficial

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This is the abridged version; the full version is on bmj.com

I thank L Gorman, R Hagan, and C MacArthur for responding to queries.

Contributions: See bmj.com

Funding: None.

Competing interests: None declared.

Ethical approval: Not required.

References

1. Cooper P, Murray L. Prediction, detection, and treatment of postnatal depression. Arch Dis Child 1997;77: 97-9.[Free Full Text]
2. O'Hara M, Swain A. Rates and risk of postpartum depression—a meta-analysis. Int Rev Psychiatry 1996;8: 37-54.
3. Beck CT. Predictors of postpartum depression: an update. Nursing Res 2001;50: 275-85.
4. Dennis CL. Treatment of postpartum depression. 2: a critical review of nonbiological interventions. J Clin Psychiatry 2004;65: 1252-65.[ISI][Medline]
5. Dennis CL. Preventing postpartum depression. I: a review of biological interventions. Can J Psychiatry 2004;49: 467-75.[Medline]
6. Dennis CL. Preventing postpartum depression. II: A critical review of nonbiological interventions. Can J Psychiatry 2004;49: 526-38.[Medline]
7. Lumley J, Austin MP, Mitchell C. Intervening to reduce depression after birth: a systematic review of the randomized trials. Int J Technol Assess Health Care 2004;20: 128-44.[CrossRef][ISI][Medline]
8. Dennis CL, Creedy D. Psychosocial and psychological interventions for preventing postpartum depression. Cochrane Database Syst Rev 2004;(4): CD001134.
9. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh postnatal depression scale. Br J Psychiatry 1987;150: 782-6.[Abstract/Free Full Text]
10. Austin M, Lumley J. Antenatal screening for postnatal depression: a systematic review. Acta Psychiatr Scand 2003;107: 10-7.[CrossRef][ISI][Medline]

(Accepted 1 February 2005)

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