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Am Fam Physician. 2019;100(6):online

Related editorial: Can We Prevent Perinatal Depression in the Primary Care Office?

As published by the USPSTF.

Summary of Recommendation and Evidence

The USPSTF recommends that clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions (Table 1). B recommendation.

PopulationPregnant and postpartum persons
RecommendationProvide or refer persons at increased risk of perinatal depression to counseling interventions.
Grade: B
Risk assessmentThere is no accurate screening tool for identifying who is 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 risk factors: 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.
InterventionsStudies on counseling interventions to prevent perinatal depression mainly included cognitive behavior therapy and interpersonal therapy. 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.
Other relevant USPSTF recommendationsThe USPSTF recommends screening for depression in adults, including pregnant and postpartum women. The USPSTF also recommends screening for depression in adolescents aged 12 to 18 years and found insufficient evidence to recommend for or against screening in children 11 years or younger.

See the Clinical Considerations section for information on risk assessment.

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 behavior 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.

Clinical Considerations

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 (e.g., preterm delivery, 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 behavior therapy and interpersonal therapy.

Cognitive behavior 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 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. 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 comprised mainly 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.710 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 behavior 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 program is an example of an interpersonal therapy approach reviewed by the USPSTF.4,5,1113 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 Services 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 Services Administration provides resources for locating mental health services.15 The Mothers and Babies program, based on cognitive behavior 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

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