Comment: The quality of evidence is downgraded by inconsistency (heterogeneity in interventions and outcomes) and by imprecise results (few patients and wide confidence intervals).
Psychosocial and psychological interventions are recommended for the treatment of postpartum depression.
Comment: The recommendation attaches a relatively high value on mother and baby wellbeing.
A Cochrane review [Abstract] 1 included 10 studies with a total of 956 subjects. Five trials selected participants based on a clinical diagnosis of depression while five trials enrolled women who met inclusion criteria based on self-reported depressive symptomatology. Follow-up times ranged from immediately post-treatment to five years. Any psychosocial or psychological intervention, compared to usual postpartum care (variously defined), was associated with a reduction in the likelihood of depressive symptomatology at the final assessment within the first year postpartum (9 trials; n=956, RR 0.70, 95% CI 0.60 to 0.81). Psychosocial interventions together showed a decrease in the likelihood of depressive symptomatology at the final assessment in the first year postpartum (5 trials, n=506; RR=0.61, 95% CI 0.39 to 0.94). The three types of psychological interventions were cognitive behavioural therapy, interpersonal psychotherapy, and psychodynamic therapy. Cognitive behavioural therapy appeared to have a beneficial effect on depressive symptomatology (5 trials, n = 482; RR=0.72, 95% CI 0.57 to 0.90). One trial demonstrated a beneficial effect with interpersonal psychotherapy (n = 120; RR=0.80, 95% CI 0.66 to 0.98). One trial evaluating psychodynamic therapy did not show a beneficial effect at final assessment (n = 91; RR = 0.67, 95% CI 0.33 to 1.37). Combining the standard psychological interventions of cognitive behavioural therapy and interpersonal psychotherapy, a beneficial effect was found in reducing postpartum depressive symptomatology at final assessment (six trials, n = 602; RR = 0.75, 95% CI 0.63 to 0.88). The results suggested no significant difference in beneficial effect in reducing depressive symptomatology at final assessment between a psychosocial intervention (non-directive counselling) and a psychological intervention (cognitive behavioural therapy) (n= 358; RR = 1.13, 95% CI 0.84 to 1.52).
A systematic review 2 assessed depression screening and treatment for pregnant and postpartum women. In 6 trials among pregnant and postpartum women (n= 11 869) screening programs showed 18% to 59% relative reductions, or 2.1% to 9.1% absolute reductions, in the risk of depression at follow-up (3-5 months) after participation in programs involving depression screening, with or without additional treatment components, compared with usual care. Based on 23 studies (n = 5398), a cutoff of 13 on the English-language Edinburgh Postnatal Depression Scale demonstrated sensitivity ranging from 0.67 (95% CI, 0.18 to 0.96) to 1.00 (95% CI, 0.67 to 1.00) and specificity consistently 0.87 or higher. Data were sparse for Patient Health Questionnaire instruments. Pooled results for the benefit of cognitive behavioral therapy (CBT) for pregnant and postpartum women with screen-detected depression showed an increase in the likelihood of remission (pooled relative risk 1.34, 95% CI 1.19 to 1.50; 10 trials, I² = 7.9%) compared with usual care, with absolute increases ranging from 6.2% to 34.6%.
A meta-analysis 3 assessed effectiveness of mother-infant psychotherapy on postpartum depression. A total of 13 RCTs were included. In the short-term effect analysis, mother-infant psychotherapy reduced standardized mean depressive scores (-0.25, 95% CI -0.40 to -0.09) and risk ratio (0.71, 95% CI 0.55 to 0.91). In the long-term effect analysis, mother-infant psychotherapy did not improve maternal mood, mother-infant interaction and infant attachment.
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