FPIN's Help Desk Answers

Cognitive Behavior Therapy for Postpartum Depression

 

Am Fam Physician. 2019 Aug 15;100(4):244-245.

Clinical Question

Is cognitive behavior therapy (CBT) an effective treatment for postpartum depression?

Evidence-Based Answer

In women with postpartum depression, the addition of CBT reduces depressive symptoms more effectively than usual care alone (medication and other therapies), with a medium effect size at the end of the intervention and a residual small effect size six months later. (Strength of Recommendation: B, based on a meta-analysis of low-quality randomized controlled trials [RCTs] and two additional small RCTs.)

Evidence Summary

A 2016 systematic review and meta-analysis of 10 RCTs (N = 1,324) examined the effectiveness of psychological therapies (including but not limited to CBT) for postpartum depression compared with usual treatment.1 Women with postpartum depression who had infants younger than 12 months were recruited from primary care settings. CBT was delivered in 30-to 120-minute group or individual sessions (frequency not reported) by trained clinicians over one to eight months. Usual treatment included antidepressants, referral to subspecialists, continuation of preexisting counseling, or wait list control. Depression symptoms were measured by the Edinburgh Postnatal Depression Scale (EPDS; score range: 0 to 30) or the Beck Depression Inventory-II (BDI-II; score range: 0 to 63). An EPDS score of 12 or greater or a BDI-II score of 10 or greater was diagnostic for depression. Symptoms were assessed immediately after the intervention in all studies, and some studies included a final assessment up to five years later. Compared with usual treatment, patients receiving CBT had a reduction in depression symptoms immediately after the intervention (six trials; N = 616; standardized mean difference [SMD] = −0.36; 95% CI, −0.52 to −0.21). (An SMD of 0.80 or greater is considered a large effect, 0.50 is a medium effect, and 0.20 is a small effect.) At a median follow-up of six months, any psychological intervention reduced depression symptoms compared with usual treatment (four trials; N = 516; SMD = −0.21; 95% CI, −0.37 to −0.05); of note, 73% of the patients in the intervention group received CBT. Limitations included high attrition rates and potential confounding from concomitant medication use.

A 2014 RCT (N = 213) that was not included in the 2016 meta-analysis compared the effect of CBT in combination with systemic family therapy (which addresses an individual as part of multiple familial relationships) vs. usual care in patients with mild to moderate postpartum depression.2  Investigators enrolled primiparous Chinese women 19 to 40 years of age who were presenting for postpartum care up to 42 days after delivery of a singleton infant. Participants must have had depression lasting at least two weeks at presentation. CBT was delivered by certified counselors in the form of weekly 60-minute sessions over 13 weeks beginning two months after delivery. Additional follow-up assessments occurred six, 12, 18, and 24 months after delivery. Before the intervention, there were no significant differences in EPDS scores between the groups. Compared with usual care, the combination

Address correspondence to Katherine Buck, PhD, LMFT, at kbuck@jpshealth.org. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

1. Stephens S, Ford E, Paudyal P, et al. Effectiveness of psychological interventions for postnatal depression in primary care: a meta-analysis. Ann Fam Med. 2016;14(5):463–472.

2. Hou Y, Hu P, Zhang Y, et al. Cognitive behavioral therapy in combination with systemic family therapy improves mild to moderate postpartum depression. Braz J Psychiatry. 2014;36(1):47–52.

3. Milgrom J, Gemmill AW, Ericksen J, et al. Treatment of postnatal depression with cognitive behavioural therapy, sertraline, and combination therapy: a randomised controlled trial. Aust N Z J Psychiatry. 2015;49(3):236–245.

Help Desk Answers provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (https://www.cebm.net).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to https://www.fpin.org or email: questions@fpin.org.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Associate Medical Editor.

A collection of FPIN's Help Desk Answers published in AFP is available at https://www.aafp.org/afp/hda.

 

 

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