A depression preventive intervention for rural low-income African-American pregnant women at risk for postpartum depression

The Elephant in the Room: A Systematic Review of the Application and Effects of Psychological Treatments for Pregnant Women with Dual Pathology (Mental Health and Substance-Related Disorders)

PURPOSE

Maternal mental health and substance use, referred to as dual pathology, represent significant concerns associated with adverse pregnancy and birth outcomes, a prevalence higher than commonly anticipated. Nonetheless, a notable dearth exists ofevidence-based treatment protocols tailored for pregnant women with dual pathology.

METHODS

A systematic review, adhering to the PRISMA methodology, was conducted.

RESULTS

Out of the 57 identified papers deemed potentially relevant, only 2were ultimately included. Given the limited number of studies assessing the efficacy of psychological interventions utilizing randomized controlled trials (RCTs) for both mental health and substance misuse, and considering the diverse objectives and measures employed, definitive conclusions regarding the effectiveness of psychological interventions in this domain prove challenging.

CONCLUSIONS

Maternal mental health appears to be the proverbial "elephant in the room". The development of specialized and integrated interventions stands as an imperative to effectively address this pressing issue. As elucidated in the present review, these interventions ought to be grounded in empirical evidence. Furthermore, it is essential that such interventions undergo rigorous evaluation through RCTs to ascertain their efficacy levels. Ultimately, the provision of these interventions by psychology/psychiatric professionals, both within clinical practice and the RCTs themselves, is recommended to facilitate the generalizability of the results to specialized settings.

Study protocol for the ROSE Scale-Up Study: Informing a decision about ROSE as universal postpartum depression prevention

PURPOSE

To examine the effectiveness, cost-outcome, equity, scalability, and mechanisms of the Reach Out, Stay strong, Essentials for mothers of newborns (ROSE) postpartum depression prevention (PPD) program as universal versus selective or indicated prevention.

BACKGROUND

The United States Preventive Services Task Force (USPSTF) currently recommends PPD prevention for pregnant people at risk of PPD (i.e., selective/indicated prevention). However, universal prevention may be more scalable, equitable, and cost-beneficial.

DESIGN

Effectiveness of ROSE for preventing PPD among people at risk is known. To assess ROSE as universal prevention, we need to determine the effectiveness of ROSE among all pregnant people, including those screening negative for PPD risk. We will enroll 2320 pregnant people, assess them with commonly available PPD risk prediction tools, randomize everyone to ROSE or enhanced care as usual, and assess ROSE as universal, selective, and indicated prevention in terms of: (1) effectiveness (PPD prevention and functioning), (2) cost-benefit, (3) equity (PPD cases prevented by universal prevention that would not be prevented under selective/indicated for minority vs. non-Hispanic white people), (4) quantitative and qualitative measures of scalability (from 98 agencies previously implementing ROSE), (5) ROSE mechanisms across risk levels. We will integrate results to outline pros and cons of the three prevention approaches (i.e., universal, selective, indicated).

CONCLUSION

This will be the first trial to assess universal vs. selective/indicated PPD prevention. Trial design illustrates a novel, efficient way to make these comparisons. This trial, the largest PPD prevention trial to date, will examine scalability, an understudied area of implementation science.

Prevalence of Perinatal Depression in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis

Importance

Women who experience depression during or within a year of pregnancy are at increased risk of morbidity and mortality. Although those living in low- and middle-income countries are thought to be at increased risk of perinatal depression, the true prevalence remains unclear.

Objective

To determine the prevalence of depression among individuals living in low- and middle-income countries during pregnancy and up 1 year post partum.

Data Sources

MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and the Cochrane Library were searched from database inception until April 15, 2021.

Study Selection

Studies were included that reported the prevalence of depression using a validated method during pregnancy or up to 12 months post partum in countries defined by the World Bank as low, lower-middle, and upper-middle income.

Data Extraction and Synthesis

This study followed Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Two reviewers independently assessed study eligibility, extracted data, and assessed studies for bias. Prevalence estimates were calculated using a random-effects meta-analysis model. Subgroup analyses were performed among women who were considered at increased risk of developing perinatal depression.

Main Outcomes and Measures

Point prevalence of perinatal depression was the main outcome measured as percentage point estimates with corresponding 95% CIs.

Results

The search identified 8106 studies, of which data were extracted from 589 eligible studies reporting outcomes of 616 708 women from 51 countries. The pooled prevalence of perinatal depression across all studies was 24.7% (95% CI, 23.7%-25.6%). The prevalence of perinatal depression varied slightly by country income status. The highest prevalence was found in lower-middle-income countries, with a pooled prevalence of 25.5% (95% CI, 23.8%-27.1%; 197 studies from 23 countries including 212 103 individuals). In upper-middle-income countries, the pooled prevalence was 24.7% (95% CI, 23.6%-25.9%; 344 studies from 21 countries including 364 103 individuals) and in low-income countries, the pooled prevalence was 20.7% (95% CI, 18.4%-23.0%; 50 studies from 7 countries including 40 502 individuals). The East Asia and the Pacific region had the lowest prevalence of perinatal depression at 21.4% (95% CI, 19.8%-23.1%) and was significantly increased in the Middle East and North Africa at 31.5% (95% CI, 26.9%-36.2%; between-group comparison: P < .001). In subgroup analyses, the highest prevalence of perinatal depression was found among women who experienced intimate partner violence, at 38.9% (95% CI, 34.1%-43.6%). revalence of depression was also high among women with HIV (35.1% [95% CI, 29.6%-40.6%]) and those who had experienced a natural disaster (34.8% [95% CI, 29.4%-40.2%]).

Conclusions and Relevance

This meta-analysis found that depression was common in low- and middle-income countries, affecting 1 in 4 perinatal women. Accurate estimates of the prevalence of perinatal depression in low- and middle-income countries are essential in informing policy, allocating scarce resources, and directing further research to improve outcomes for women, infants, and families.

Black with 'Baby Blues': A Systematic Scoping Review of Programs to Address Postpartum Depression in African American Women

OBJECTIVE

 The literature review reports on programs and interventions that address postpartum depression (PPD) in African American women. African American women are at a higher risk of developing PPD compared to white women. The review will highlight and recommend approaches that may render positive outcomes in the future for this population.

METHODS

 A systematic scoping literature review was conducted using Academic Search Complete, CINAHL, APA PsycArticles, APA PsychInfo, PubMed, Social Services Abstracts, and Social Work Abstracts. Keywords used in the search included "postpartum depression," "African American," and "interventions OR programs OR therapy OR treatment." Fourteen studies were selected, analyzed, and included in the review.

RESULTS

Group psychosocial, individual psychosocial, internet-based, and integrated care interventions were included. While many articles noted within group changes in depression symptoms, fewer studies documented between group differences. Studies that investigated subsamples of "high risk" participants or those that used "culturally tailored" approaches showed promise.

CONCLUSION

The literature review yielded some examples of programs/interventions that target postpartum depression in African American women; however, results were mixed. More research is needed to confirm the most effective interventions to address postpartum depression in African American women.

Protocol for the Healing After Loss (HeAL) Study: a randomised controlled trial of interpersonal psychotherapy (IPT) for major depression following perinatal loss

INTRODUCTION

This protocol describes a study testing the efficacy of interpersonal psychotherapy (IPT) for major depressive disorder following perinatal loss (early and late fetal death and early neonatal death). Perinatal loss is associated with elevated risk of major depressive disorder and post-traumatic stress disorder (PTSD). Perinatal loss conveys specific treatment needs. The trial will be the first fully powered randomised trial of treatment for any psychiatric disorder following perinatal loss.

METHODS AND ANALYSIS

A sample of 274 women in Flint and Detroit areas in Michigan who experience a major depressive episode following a perinatal loss will be randomised to group IPT for perinatal loss or to group coping with depression. We anticipate that 50% of the sample will have co-occurring PTSD. Assessments occur at baseline, mid-treatment (8 weeks), post-treatment (16 weeks) and follow-up (28 weeks). Clinical outcomes include time to recovery from major depressive episode (primary), depressive symptoms, PTSD symptoms and time to recovery from PTSD. Additional outcomes include social support, social role functioning (including parental functioning for those with living children), well-being, grief (including complicated grief and fault beliefs) and fear of subsequent pregnancies. Social support and grief are hypothesised mediators of IPT effects on time to recovery from major depressive episode.

ETHICS AND DISSEMINATION

The trial was approved by Michigan State University's Biomedical Institutional Review Board. It has a data and safety monitoring board and has been submitted to the community-based organisation partners community ethics review board. Written operating procedures outline methods for protecting confidentiality, monitoring and recording adverse events, and safeguarding participants. We will share study results with research and clinical communities, community organisations through which we recruited, and will offer results to study participants. Deidentified datasets will be available through the National Institute of Mental Health Data Archive and to qualified investigators on request.

TRIAL REGISTRATION NUMBER

NCT04629599.

Effectiveness of psychological interventions in preventing postpartum depression in non-depressed women: a systematic review and meta-analysis of randomized controlled trials

Postpartum depression (PPD) is one of the most common disorders following childbirth. This systematic review and meta-analysis (SR/MA) aimed to assess the effectiveness of psychological interventions in preventing PPD in non-depressed women. PRISMA guidelines were followed. MEDLINE (Ovid and PubMed), PsycINFO, Web of Science, Scopus, CINAHL, CENTRAL, OpenGrey, Australian New Zealand Clinical Trial Registry and clinicaltrial.gov were searched. Randomized controlled trials (RCTs) conducted with pregnant or postpartum (up to 12 months) women who were non-depressed at baseline were selected. The outcomes were the incidence of PPD and/or the reduction of postpartum depressive symptoms. The standardized mean difference (SMD) using random-effect models was calculated. Sensitivity, sub-group and meta-regression analyses were performed. 17 RCTs were included in the SR and 15 in the MA, representing 4958 participants from four continents. The pooled SMD was -0.175 [95% confidence interval (CI) -0.266 to -0.083; p < 0.001] and sensitivity analyses confirmed the robustness of this result. Heterogeneity was low (I2 = 21.20%) and was fully explained by a meta-regression model including one variable (previous deliveries). The meta-regression model and MA stratified by previous deliveries indicated that interventions focused on primiparous women are more effective. There was no evidence of publication bias. Few RCTs had an overall low risk of bias. According to GRADE, the quality of evidence was moderate. Psychological interventions have very little effectiveness in preventing PPD in non-depressed women, although this effectiveness is greater in interventions focused on primiparous women. Further RCTs with a low risk of bias and more effective interventions are needed.

The Before Baby Relationship Checkup: A Couples-Based Intervention to Reduce Relationship Risk Factors for Perinatal Mood and Anxiety Disorders

Relationship conflict and lack of partner support are risk factors for perinatal mood and anxiety disorders. An intervention to strengthen couples' relationships before birth may reduce relationship risk factors for perinatal mood and anxiety disorders, though no research has explored this to date. The aims of this Stage 1 open-series non-experimental proof of concept study were to adapt the 'Marriage Checkup', an evidence-based intervention for relationship distress, as a preventative intervention for perinatal mood and anxiety disorders and to assess its feasibility and acceptability. Pregnant women receiving care at a university-based obstetric practice, and their partners, were recruited. Ten couples participated in the Before Baby Relationship Checkup, a personalized relationship health service offered in the obstetric clinic. Quantitative and qualitative data gathered suggests the intervention is feasible to implement in an obstetric setting, and acceptable to perinatal couples. Specific adaptations to the Marriage Checkup for perinatal couples are warranted and further testing is needed to evaluate efficacy.

Identifying urban built environment factors in pregnancy care and maternal mental health outcomes

Backgrounds

Risk factors related to the built environment have been associated with women’s mental health and preventive care. This study sought to identify built environment factors that are associated with variations in prenatal care and subsequent pregnancy-related outcomes in an urban setting.

Methods

In a retrospective observational study, we characterized the types and frequency of prenatal care events that are associated with the various built environment factors of the patients’ residing neighborhoods. In comparison to women living in higher-quality built environments, we hypothesize that women who reside in lower-quality built environments experience different patterns of clinical events that may increase the risk for adverse outcomes. Using machine learning, we performed pattern detection to characterize the variability in prenatal care concerning encounter types, clinical problems, and medication prescriptions. Structural equation modeling was used to test the associations among built environment, prenatal care variation, and pregnancy outcome. The main outcome is postpartum depression (PPD) diagnosis within 1 year following childbirth. The exposures were the quality of the built environment in the patients’ residing neighborhoods. Electronic health records (EHR) data of pregnant women (n = 8,949) who had live delivery at an urban academic medical center from 2015 to 2017 were included in the study.

Results

We discovered prenatal care patterns that were summarized into three common types. Women who experienced the prenatal care pattern with the highest rates of PPD were more likely to reside in neighborhoods with homogeneous land use, lower walkability, lower air pollutant concentration, and lower retail floor ratios after adjusting for age, neighborhood average education level, marital status, and income inequality.

Conclusions

In an urban setting, multi-purpose and walkable communities were found to be associated with a lower risk of PPD. Findings may inform urban design policies and provide awareness for care providers on the association of patients’ residing neighborhoods and healthy pregnancy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04056-1.

Psychological interventions for maternal depression among women of African and Caribbean origin: a systematic review

BACKGROUND

Maternal depression is a leading cause of disease burden for women worldwide; however, there are ethnic inequalities in access to psychological interventions in high-income countries (HICs). Culturally appropriate interventions might prove beneficial for African and Caribbean women living in HICs as ethnic minorities.

METHODS

The review strategy was formulated using the PICo (Population, phenomenon of Interest, and Context) framework with Boolean operators (AND/OR/NOT) to ensure rigour in the use of search terms ("postpartum depression", "maternal depression", "postnatal depression", "perinatal depression" "mental health", "psychotherapy" "intervention", "treatment", "black Caribbean", "black African", "mothers" and "women"). Five databases, including Scopus, PsycINFO, Applied Social Science Index and Abstracts (ASSIA), ProQuest Central and Web of Science, were searched for published articles between 2000 and July 2020. 13 studies met the inclusion criteria, and the relevant data extracted were synthesised and thematically analysed.

RESULTS

Data syntheses and analyses of included studies produced four themes, including (1) enhance parenting confidence and self-care; (2) effective mother-child interpersonal relationship; (3) culturally appropriate maternal care; and (4) internet-mediated care for maternal depression.

CONCLUSION

In the quest to address maternal mental health disparities among mothers of African and Caribbean origin in HICs, the authors recommend culturally adapted psychological interventions to be tested in randomised control trials.

Interpersonal Psychotherapy to Reduce Psychological Distress in Perinatal Women: A Systematic Review

BACKGROUND

Interpersonal psychotherapy (IPT) is a psychological intervention with established efficacy in the prevention and treatment of depressive disorders. Previous systematic reviews have not evaluated the effectiveness of IPT on symptoms of stress, anxiety, depression, quality of life, relationship satisfaction/quality, social supports, and an improved psychological sense of wellbeing. There is limited information regarding moderating and mediating factors that impact the effectiveness of IPT such as the timing of the intervention or the mode of delivery of IPT intervention. The overall objective of this systematic review was to evaluate the effectiveness of IPT interventions to treat perinatal (from pregnancy up to 12 months postpartum) psychological distress.

METHODS

MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily (Ovid), EMBASE (Ovid), PsycINFO (Ovid), Cochrane Central Register of Controlled Trials (OVID), CINAHL with Full Text (Ebsco), Social Work Abstracts (Ebsco), SocINDEX with Full Text (Ebsco), Academic Search Complete (Ebsco), Family & Society Studies Worldwide (Ebsco), Family Studies Abstracts (Ebsco), and Scopus databases were searched from inception until 31 January 2019. Two researchers independently screened articles for eligibility. Of the 685 screened articles, 43 met the inclusion criteria. The search was re-run on 11 May 2020. An additional 204 articles were screened and two met the inclusion criteria, resulting in a total of 45 studies included in this review. There were 25 Randomized Controlled Trials, 10 Quasi-experimental studies, eight Open Trials, and two Single Case Studies. All included studies were critically appraised for quality.

RESULTS

In most studies (n = 24, 53%), the IPT intervention was delivered individually; in 17 (38%) studies IPT was delivered in a group setting and two (4%) studies delivered the intervention as a combination of group and individual IPT. Most interventions were initiated during pregnancy (n = 27, 60%), with the remaining 18 (40%) studies initiating interventions during the postpartum period.

LIMITATIONS

This review included only English-language articles and peer-reviewed literature. It excluded government reports, dissertations, conference papers, and reviews. This limited the access to grassroots or community-based recruitment and retention strategies that may have been used to target smaller or marginalized groups of perinatal women.

CONCLUSIONS

IPT is an effective intervention for the prevention and treatment of psychological distress in women during their pregnancy and postpartum period. As a treatment intervention, IPT is effective in significantly reducing symptoms of depression and anxiety as well as improving social support, relationship quality/satisfaction, and adjustment. Systematic Review Registration: PROSPERO CRD42019114292.

Preventing Perinatal Depression Now: A Call to Action

In the United States, perinatal depression (PD) affects an estimated 11.5% of pregnant and postpartum individuals annually and is one of the most common complications of pregnancy and the postpartum period. Alarmingly, up to 51% of people with PD are undiagnosed. Despite the availability of tools to screen for PD, there is no consensus on which tool is most accurate, nor is there a universal policy on when and how to best screen patients with PD. Screening to identify PD is essential, but prevention of depression is even more critical, yet traditionally not well addressed until recently with the US Preventive Services Task Force (USPSTF) recommendation in 2019. When the USPSTF recommended implementing programs to prevent PD in at-risk individuals, the recommendation cited two evidence-based PD prevention programs by name. One of these, ROSE (Reach Out, Stay Strong, Essentials for mothers of newborns), is a four-session class taught in prenatal settings. The second program mentioned is the Mothers and Babies program, which has been shown to be effective in using a cognitive behavioral therapy approach to prevent PD. Although scientists develop effective mental health interventions to prevent PD, community-based advocacy groups are engaged in grassroots efforts to provide support and encouragement to racially and ethnically diverse pregnant and postpartum women. To increase the number of pregnant and postpartum women who are screened and supported so that they do not develop PD, research supports three key strategies: (1) Establish a standard combination of multicultural PD screening tools with evidence-based timepoints for screening administration. (2) Introduce an evidence-based definition of PD that accurately captures the prevalence and incidence of this mental health condition. (3) Improve our understanding of PD by incorporating the psychosocial context in which mental health complications occur into routine clinical practice for pregnant and postpartum women.

Psychological interventions for depression and anxiety in pregnant Latina and Black women in the United States: A systematic review

Black women and Latinas have more symptoms of depression and anxiety during pregnancy than do their non-Latina White counterparts. Although effective interventions targeting internalizing disorders in pregnancy are available, they are primarily tested with White women. This article reviews randomized controlled trials and non-randomized studies to better understand the effectiveness of psychological interventions for anxiety and depression during pregnancy in Latinas and Black women. Additionally, this review summarizes important characteristics of interventions such as intervention format, treatment modality, and the use of cultural adaptations. Literature searches of relevant research citation databases produced 68 studies; 13 of which were included in the final review. Most studies were excluded because their samples were not majority Latina or Black women or because they did not test an intervention. Of the included studies, three interventions outperformed a control group condition and showed statistically significant reductions in depressive symptoms. An additional two studies showed reductions in depressive symptoms from pretreatment to post-treatment using non-controlled designs. The remaining eight studies (seven randomized and one non-randomized) did not show significant intervention effects. Cognitive behavioral therapy was the modality with most evidence for reducing depressive symptoms in pregnant Black and Latina women. No intervention was found to reduce anxiety symptoms, although only two of the 13 measured anxiety as an outcome. Five studies made cultural adaptations to their treatment protocols. Future studies should strive to better understand the importance of cultural modifications to improve engagement and clinical outcomes with pregnant women receiving treatment for anxiety and depression.

Culturally-adapted cognitive behavioural therapy based intervention for maternal depression: a mixed-methods feasibility study

BACKGROUND

British Pakistanis are one of the largest ethnic minority groups living in the UK, with high rates of maternal depression being reported in this population. Evidence suggests that culturally-adapted Cognitive Behavioural Therapy (CBT)-based interventions for depression, may improve clinical outcomes and patient satisfaction. This study was conducted to develop and test the feasibility and acceptability of a culturally-adapted, CBT-based, manual-assisted intervention in British Pakistani mothers experiencing maternal depression.

METHODS

A mixed-method feasibility study that included qualitative interviews followed by the development of a CBT-based intervention for mothers with mild to moderate depression. Following the qualitative interviews, a CBT-based intervention called the Positive Health Program (PHP) was developed and delivered consisting of 12-weekly sessions. A before and after design was used to explore the feasibility and acceptability of the Positive Health Programme.

RESULTS

A culturally-adapted CBT-based group intervention (PHP) was acceptable to this group and improvements were reported in depression and health-related quality of life. The women's understanding of 'depression' as a general consensus was in physical terms, but with an onset triggered by psychosocial causes. The most commonly reported factors contributing to depression were marital disharmony, lack of social support, and financial difficulties. Past help offered was primarily antidepressants, which were not welcomed by most of the women. A lack of availability of culturally sensitive interventions and the limited cultural sensitivity of NHS staff was also reported.

CONCLUSION

This study provides preliminary evidence for the feasibility and acceptability of a CBT-based culturally-adapted group psychological intervention for British Pakistani mothers.

TRIAL REGISTRATION

Study ethics registration number: 10/H1005/62 (University of Manchester).

Protocol for the ROSE sustainment (ROSES) study, a sequential multiple assignment randomized trial to determine the minimum necessary intervention to maintain a postpartum depression prevention program in prenatal clinics serving low-income women

BACKGROUND

More research on sustainment of interventions is needed, especially return on investment (ROI) studies to determine cost-benefit trade-offs for effort required to sustain and how much is gained when effective programs are sustained. The ROSE sustainment (ROSES) study uses a sequential multiple assignment randomized (SMART) design to evaluate the effectiveness and cost-effectiveness of a stepwise approach to sustainment of the ROSE postpartum depression prevention program in 90 outpatient clinics providing prenatal care to pregnant women on public assistance. Postpartum depression (PPD) is common and can have lasting consequences. Outpatient clinics offering prenatal care are an opportune place to provide PPD prevention because most women visit while pregnant. The ROSE (Reach Out, Stay Strong, Essentials for mothers of newborns) program is a group educational intervention to prevent PPD, delivered during pregnancy. ROSE has been found to reduce cases of PPD in community prenatal settings serving low-income pregnant women.

METHODS

All 90 prenatal clinics will receive enhanced implementation as usual (EIAU; initial training + tools for sustainment). At the first time at which a clinic is determined to be at risk for failure to sustain (i.e., at 3, 6, 9, 12, and 15 months), that clinic will be randomized to receive either (1) no additional implementation support (i.e., EIAU only), or (2) low-intensity coaching and feedback (LICF). If clinics receiving LICF are still at risk at subsequent assessments, they will be randomized to either (1) EIAU + LICF only, or (2) high-intensity coaching and feedback (HICF). Additional follow-up interviews will occur at 18, 24, and 30 months, but no implementation intervention will occur after 18 months. Outcomes include (1) percent sustainment of core program elements at each time point, (2) health impact (PPD rates over time at each clinic) and reach, and (3) ROI (costs and cost-effectiveness) of each sustainment step. Hypothesized mechanisms include sustainment of capacity to deliver core elements and engagement/ownership.

DISCUSSION

This study is the first randomized trial evaluating the ROI of a stepped approach to sustainment, a critical unanswered question in implementation science. It will also advance knowledge of implementation mechanisms and clinical care for an at-risk population.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03267563 . Registered June 14, 2018.

A systematic review, evidence synthesis and meta-analysis of quantitative and qualitative studies evaluating the clinical effectiveness, the cost-effectiveness, safety and acceptability of interventions to prevent postnatal depression

BACKGROUND

Postnatal depression (PND) is a major depressive disorder in the year following childbirth, which impacts on women, their infants and their families. A range of interventions has been developed to prevent PND.

OBJECTIVES

To (1) evaluate the clinical effectiveness, cost-effectiveness, acceptability and safety of antenatal and postnatal interventions for pregnant and postnatal women to prevent PND; (2) apply rigorous methods of systematic reviewing of quantitative and qualitative studies, evidence synthesis and decision-analytic modelling to evaluate the preventive impact on women, their infants and their families; and (3) estimate cost-effectiveness.

DATA SOURCES

We searched MEDLINE, EMBASE, Science Citation Index and other databases (from inception to July 2013) in December 2012, and we were updated by electronic alerts until July 2013.

REVIEW METHODS

Two reviewers independently screened titles and abstracts with consensus agreement. We undertook quality assessment. All universal, selective and indicated preventive interventions for pregnant women and women in the first 6 postnatal weeks were included. All outcomes were included, focusing on the Edinburgh Postnatal Depression Scale (EPDS), diagnostic instruments and infant outcomes. The quantitative evidence was synthesised using network meta-analyses (NMAs). A mathematical model was constructed to explore the cost-effectiveness of interventions contained within the NMA for EPDS values.

RESULTS

From 3072 records identified, 122 papers (86 trials) were included in the quantitative review. From 2152 records, 56 papers (44 studies) were included in the qualitative review. The results were inconclusive. The most beneficial interventions appeared to be midwifery redesigned postnatal care [as shown by the mean 12-month EPDS score difference of -1.43 (95% credible interval -4.00 to 1.36)], person-centred approach (PCA)-based and cognitive-behavioural therapy (CBT)-based intervention (universal), interpersonal psychotherapy (IPT)-based intervention and education on preparing for parenting (selective), promoting parent-infant interaction, peer support, IPT-based intervention and PCA-based and CBT-based intervention (indicated). Women valued seeing the same health worker, the involvement of partners and access to several visits from a midwife or health visitor trained in person-centred or cognitive-behavioural approaches. The most cost-effective interventions were estimated to be midwifery redesigned postnatal care (universal), PCA-based intervention (indicated) and IPT-based intervention in the sensitivity analysis (indicated), although there was considerable uncertainty. Expected value of partial perfect information (EVPPI) for efficacy data was in excess of £150M for each population. Given the EVPPI values, future trials assessing the relative efficacies of promising interventions appears to represent value for money.

LIMITATIONS

In the NMAs, some trials were omitted because they could not be connected to the main network of evidence or did not provide EPDS scores. This may have introduced reporting or selection bias. No adjustment was made for the lack of quality of some trials. Although we appraised a very large number of studies, much of the evidence was inconclusive.

CONCLUSIONS

Interventions warrant replication within randomised controlled trials (RCTs). Several interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty.

FUTURE WORK RECOMMENDATIONS

Several interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty. Future research conducting RCTs to establish which interventions are most clinically effective and cost-effective should be considered.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012003273.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Positive postpartum depression screening practices and subsequent mental health treatment for low-income women in Western countries: a systematic literature review

Problem statement and significance

Left undiagnosed and/or untreated, the short-and long-term sequelae of postpartum depression may negatively impact both mother and child. In Western countries, access to mental health care is influenced by socioeconomic factors. The objective of this systematic literature review is to compile factors that hinder and improve access to postpartum depression treatment in low-income women after a positive screen for postpartum depression. The key question of focus is: what are the characteristics associated with access to mental health treatment for low-income women with a positive postpartum depression screen in Western countries?

Methods

A PRISMA-based systematic literature review was conducted of studies published in English before February 2016 that looked at treatment for postpartum depression in low-income women who had been identified with the condition. PubMed and EBSCO databases were searched using MESH and key terms and found 100 articles that met the selection criteria. After review by two independent researchers, 18 studies with 17 unique populations were included in the literature review.

Results

Two independent abstractors searched the included articles for themes surrounding impediments and advantages for low-income women identified with postpartum depression in obtaining mental health treatment. Characteristics of successful mental health treatment included studies that employed the use of a home visitor and those that separated outcomes for women with previous mental health treatment. Themes that emerged as treatment obstacles included cultural barriers, physical barriers, systemic health care barriers, and social barriers.

Implications for practice

This review will help to better inform screening and treatment priorities for those in the medical field who may encounter women experiencing postpartum depression and are not aware of the various barriers to care specific to low-income women. This review will also help policymakers identify specific obstacles that are not addressed in postpartum screening mandate policies which can affect the implementation of these policies.

The Impact of Antenatal Psychological Group Interventions on Psychological Well-Being: A Systematic Review of the Qualitative and Quantitative Evidence

Depression, anxiety and stress in the perinatal period can have serious, long-term consequences for women, their babies and their families. Over the last two decades, an increasing number of group interventions with a psychological approach have been developed to improve the psychological well-being of pregnant women. This systematic review examines interventions targeting women with elevated symptoms of, or at risk of developing, perinatal mental health problems, with the aim of understanding the successful and unsuccessful features of these interventions. We systematically searched online databases to retrieve qualitative and quantitative studies on psychological antenatal group interventions. A total number of 19 papers describing 15 studies were identified; these included interventions based on cognitive behavioural therapy, interpersonal therapy and mindfulness. Quantitative findings suggested beneficial effects in some studies, particularly for women with high baseline symptoms. However, overall there is insufficient quantitative evidence to make a general recommendation for antenatal group interventions. Qualitative findings suggest that women and their partners experience these interventions positively in terms of psychological wellbeing and providing reassurance of their 'normality'. This review suggests that there are some benefits to attending group interventions, but further research is required to fully understand their successful and unsuccessful features.

An Integrative Review of Postpartum Depression in Rural U.S. Communities

AIM

This study's aim is to synthesize and summarize the literature on postpartum depression (PPD) in U.S. rural populations.

BACKGROUND

Internationally, PPD has a high prevalence in rural communities. Although women in rural U.S. communities have higher rates of depression outside of the postpartum time period, little study has been conducted on PPD in U.S. rural populations. It is unknown whether rural women in the United States have high rates of PPD as is common in rural populations internationally.

DESIGN

We used integrative literature review using Whittemore and Knafl's (2005) methodology.

DATA SOURCES AND METHODS

We searched the databases MEDLINE, CINAHL, PsycINFO, and Academic Search Premier with the words "postpartum depression" or "postnatal depression" and the word "rural."

RESULTS

We found 11 articles with empirical data that met the criteria and thus were included in the review. Seven articles were quantitative, two were qualitative, one was mixed methods, and one was a nonexperimental design. Five foci emerged in the literature including (a) screening and prevalence, (b) demographic factors, (c) program creation and implementation, (d) mental health care seeking, and (e) social support. The results suggest that prevalence of PPD may be higher in rural U.S. areas, that implementing PPD prevention and screening programs for rural women is feasible, and that women in rural areas rely on informal networks and may face a stigma for seeking mental health care.

CONCLUSIONS

Further research is needed on PPD in rural U.S.

POPULATIONS

Specifically, this research should focus on the mix of variables found throughout this review such as race and income level. Nurses should lead for changes in clinical practice and policy that increase screening and interventions for PPD in rural communities.

Psychometric properties of the newly translated creole multidimensional scale of perceived social support (MSPSS) and perceived adequacy of resource scale (PARS) and the relationship between perceived social support and resources in Haitian mothers in the US

BACKGROUND

Low income postpartum mothers with little to no social support have increased maternal and infant morbidity and mortality, especially those with limited English proficiency and limited accesses to resources. Haitians, a growing minority in the US are an understudied population excluded from most studies due to the lack of instruments in Creole. The most widely used instruments for measuring social support, the Multidimensional Scale of Perceived Social Support (MSPSS) and Perceived Adequacy of Resource Scale (PARS), are not available in Creole. Currently, there are no published studies on the psychometric properties of the MSPSS or the PARS in Creole. Data from Haitian mothers are needed to identify potential postpartum mothers and infants most at risk of developing adverse maternal and infant outcomes from a lack of social support and perceived resources. The purpose of this study is to test the psychometrics of the newly-translated Creole instruments of the MSPSS and PARS with a sample of bilingual (Creole/English) mothers.

METHODS

The MSPSS and PARS were translated and back translated from English to Creole. The adapted Creole versions of the instruments were tested using a convenience sample. A total of 85 Haitian mothers' completed both instruments in Creole and English 2 weeks apart.

RESULT

Internal consistency reliability and stability were strong for both the MSPSS and PARS (.91-.99). The two instruments had strong reliability and validity for the translated Creole versions and similar to the English versions.

CONCLUSION

The MSPSS and PARS are a valid measure of perceived social support and resources. Psychometric findings suggest that the newly translated Creole versions are good representations of the English versions indicating the translation process was successful. The newly translated instruments available in Creole provide non-English speaking Haitian mothers the opportunity to participate in studies.

Group psychological intervention for postnatal depression: a nested qualitative study with British South Asian women

BACKGROUND

Postnatal depression affects 10-15 % of all mothers in Western societies and remains a major public health concern for women from diverse cultures. British Pakistani and Indian women have a higher prevalence of depression in comparison to their white counterparts. Research has shown that culturally adapted interventions using Cognitive Behavioural Therapy (CBT) may be acceptable and may help to address the needs of this population. The aim of this study was to assess the acceptability and overall experience of the Positive Health Programme by British South Asian mothers.

METHODS

This was a nested qualitative study, part of an exploratory randomized controlled trial (RCT) conducted to test the feasibility and acceptability of a culturally-adapted intervention (Positive Health Programme or PHP) for postnatal depression in British South Asian women. In-depth interviews (N = 17) were conducted to determine the views of the participants on the feasibility and acceptability of the intervention.

RESULTS

The participants found the intervention acceptable and experienced an overall positive change in their attitudes, behaviour, and increased self-confidence.

CONCLUSIONS

The findings suggest that the culturally adapted Positive Health Programme is acceptable to British South Asian women. These results support that culturally sensitive interventions may lead to better health outcomes and overall satisfaction.

TRIAL REGISTRATION

Protocol registered on Clinicaltrials.gov NCT01838889.

Maternal mental health: The missing "m" in the global maternal and child health agenda

While the physical health of women and children is emphasized, the mental aspects of their health are often ignored by maternal and child health programs, especially in low- and middle-income countries. We review the evidence of the magnitude, impact, and interventions for common maternal mental health problems with a focus on depression, the condition with the greatest public health impact. The mean prevalence of maternal depression ranges between 15.6% in the prenatal and 19.8% in the postnatal period. It is associated with preterm birth, low birth weight, and poor infant growth and cognitive development. There is emerging evidence for the effectiveness of interventions, especially those that can be delivered by non-specialists, including community health workers, in low-income settings. Strategies for integrating maternal mental health in the maternal and child health agenda are suggested.

Preventing postpartum depression: review and recommendations

Nearly 20 % of mothers will experience an episode of major or minor depression within the first 3 months postpartum, making it the most common complication of childbearing. Postpartum depression (PPD) is significantly undertreated, and because prospective mothers are especially motivated for self-care, a focus on the prevention of PPD holds promise of clinical efficacy. This study is a qualitative review of existing approaches to prevent PPD. A PubMed search identified studies of methods of PPD prevention. The search was limited to peer-reviewed, published, English-language, randomized controlled trials (RCTs) of biological, psychological, and psychosocial interventions. Eighty articles were initially identified, and 45 were found to meet inclusion criteria. Eight RCTs of biological interventions were identified and 37 RCTs of psychological or psychosocial interventions. Results were mixed, with 20 studies showing clear positive effects of an intervention and 25 showing no effect. Studies differed widely in screening, population, measurement, and intervention. Among biological studies, anti-depressants and nutrients provided the most evidence of successful intervention. Among psychological and psychosocial studies, 13/17 successful trials targeted an at-risk population, and 4/7 trials using interpersonal therapy demonstrated success of the intervention versus control, with a further two small studies showing trends toward statistical significance. Existing approaches to the prevention of PPD vary widely, and given the current literature, it is not possible to identify one approach that is superior to others. Interpersonal therapy trials and trials that targeted an at-risk population appear to hold the most promise for further study.

Six-month outcomes from a randomized controlled trial to prevent perinatal depression in low-income home visiting clients

Perinatal depression (PD) has negative consequences for mothers and children and is more prevalent among women of low socioeconomic status. Home visitation programs serve low-income pregnant women at risk for PD. This study tested the efficacy of a group-based cognitive behavioral intervention (Mothers and Babies Course; MB) in reducing depressive symptoms and preventing the onset of perinatal depression among low-income women enrolled in home visitation. A randomized controlled trial was conducted. Seventy-eight women who were pregnant or had a child less than 6 months of age and who were assessed as at risk for PD were randomized to the MB intervention or usual home visiting services. Depressive symptoms were assessed at baseline and 1-week, 3- and 6-months post-intervention; depressive episodes were assessed with a clinical interview at the 6-month follow-up. Depressive symptoms declined at a significantly greater rate for intervention participants than usual care participants between baseline and 1-week, 3 and 6 months post-intervention. At the 6-month follow-up, 15 % of women who received the MB intervention had experienced a major depressive episode as compared with 32 % of women receiving usual care. Integrating mental health interventions into home visitation appears to be a promising approach for preventing PD. Cognitive behavioral techniques can be effective in preventing depression in perinatal populations and treating it.

Pilot early intervention antenatal group program for pregnant women with anxiety and depression

This study aims to examine the acceptability and effectiveness of an antenatal group intervention designed to reduce the severity of depression and anxiety symptoms and improve maternal attachment in pregnant women with current or emerging depression and anxiety. Women who participated in the program completed pre- and posttreatment measures of depression (Centre of Epidemiological Studies Depression Scale) and Edinburgh Postnatal Depression Scale), anxiety (State-Trait Anxiety Inventory) and maternal attachment (Condon Maternal Antenatal Attachment Scale). Participants also completed a satisfaction questionnaire and provided general feedback about the group intervention and experience. A total of 48 women (M = 26 weeks of gestation) commenced and 37 (77 %) completed at least 80 % of the six session group intervention. Significant improvements with moderate to large effect sizes were observed for depression as measured on the Centre of Epidemiological Studies Depression Scale (CES-D) (p < 0.001), Edinburgh Postnatal Depression Scale (EPDS) (p < 0.001), state anxiety (p < 0.001) and maternal attachment (p = 0.006). Improvements in posttreatment depression scores on the EPDS were maintained at 2 months postpartum. Participants reported that the program had met their expectations. Partners (n = 21) who completed evaluation forms indicated that their attendance had improved their awareness of their partner's mental health issues and resources available to their family and would recommend the program to other fathers. These preliminary findings suggest that our antenatal group program is an effective and acceptable intervention for a clinical sample of women and partners. It is a feasible addition or alternative treatment option to perinatal mental health care. Future directions could involve more comprehensive randomised controlled trials (RCT) to examine the effectiveness of the group intervention.

Relationships of race and socioeconomic status to postpartum depressive symptoms in rural African American and non-Hispanic white women

This study examines the potential racial disparity in postpartum depression (PPD) symptoms among a cohort of non-Hispanic white and African American women after taking into consideration the influence of socioeconomic status (SES). Participants (N = 299) were recruited from maternity clinics serving rural counties, with oversampling of low SES and African Americans. The Edinburgh Postnatal Depression Scale (EPDS) was administered 1 and 6 months postpartum, and subjective SES scale at 6 months postpartum. Demographic information was collected during enrollment and 1 month postpartum, with updates at 6 months postpartum. Separate logistic regressions were conducted for 1 and 6 month time points for minor-major PPD (EPDS ≥ 10) and major PPD (EPDS > 12); with marital status, poverty, education, subjective SES, and race predictors entered in block sequence. After including all other predictors, race was not a significant predictor of minor-major or major PPD at 1 or 6 months postpartum. Subjective SES was the most consistent predictor of PPD, being significantly associated with minor-major PPD and major PPD at 6 months postpartum, with higher subjective SES indicating lower odds of PPD, even after accounting for all other predictors. This study shows that significant racial disparities were not observed for minor-major or major PPD criteria at 1 or 6 months postpartum. The most consistent and significant predictor of PPD was subjective SES. Implications of these findings for future research, as well as PPD screening and intervention are discussed.

Preventing postpartum depression: a meta-analytic review

This meta-analysis assessed the efficacy of a wide range of preventive interventions designed to reduce the severity of postpartum depressive symptoms or decrease the prevalence of postpartum depressive episodes. A systematic review identified 37 randomized or quasi-randomized controlled trials in which an intervention was compared to a control condition. Differences between treatment and control conditions in the level of depressive symptoms and prevalence of depressive episodes by 6 months postpartum were assessed in separate analyses. Depressive symptoms were significantly lower at post-treatment in intervention conditions, with an overall effect size in the small range after exclusion of outliers (Hedges' g=0.18). There was a 27% reduction in the prevalence of depressive episodes in intervention conditions by 6 months postpartum after removal of outliers and correction for publication bias. Later timing of the postpartum assessment was associated with smaller differences between intervention and control conditions in both analyses. Among studies that assessed depressive symptoms using the EPDS, higher levels of depressive symptoms at pre-treatment were associated with smaller differences in depressive symptoms by 6 months postpartum. These findings suggest that interventions designed to prevent postpartum depression effectively reduce levels of postpartum depressive symptoms and decrease risk for postpartum depressive episodes.

Impact of a preventive intervention for perinatal depression on mood regulation, social support, and coping

Perinatal depression prevention trials have rarely examined proximal outcomes that may be relevant for understanding long-term risk for depression. The Mothers and Babies (MB) Course is a cognitive-behavioral depression prevention intervention, which has been shown to prevent depressive symptoms among at-risk perinatal women of color. This study examined intervention impact on three proximal outcomes that are theoretically linked with the intervention's model of change and have been empirically linked with risk for depression: mood regulation expectancies, perceived social support, and coping. The study used data from a randomized intervention trial of the MB Course with 78 low-income, predominantly African-American perinatal women enrolled at one of four home visitation programs in Baltimore City. Mood regulation expectancies, perceived social support, and coping were assessed with self-report instruments at baseline, post-intervention, and 3- and 6-month follow-ups. The intervention group experienced 16 % greater growth in mood regulation from baseline to 6-month follow-up compared to the usual care group, suggesting a prevention effect. The pattern of findings was similar, although not statistically significant, for social support. Contrary to prediction, the control group experienced less growth in avoidant coping than the intervention group. Findings indicate the MB Course enhances mood regulation, which may facilitate prevention of depression over time. Assessment of intervention effects on proximal outcomes is beneficial for understanding how interventions may enhance protective factors relevant to successful long-term outcomes.

Psychosocial and psychological interventions for preventing postpartum depression

BACKGROUND

Epidemiological studies and meta-analyses of predictive studies have consistently demonstrated the importance of psychosocial and psychological variables as postpartum depression risk factors. While interventions based on these variables may be effective treatment strategies, theoretically they may also be used in pregnancy and the early postpartum period to prevent postpartum depression.

OBJECTIVES

Primary: to assess the effect of diverse psychosocial and psychological interventions compared with usual antepartum, intrapartum, or postpartum care to reduce the risk of developing postpartum depression. Secondary: to examine (1) the effectiveness of specific types of psychosocial and psychological interventions, (2) the effectiveness of professionally-based versus lay-based interventions, (3) the effectiveness of individually-based versus group-based interventions, (4) the effects of intervention onset and duration, and (5) whether interventions are more effective in women selected with specific risk factors.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2011), scanned secondary references and contacted experts in the field. We updated the search on 31 December 2012 and added the results to the awaiting classification section of the review for assessment at the next update.

SELECTION CRITERIA

All published and unpublished randomised controlled trials of acceptable quality comparing a psychosocial or psychological intervention with usual antenatal, intrapartum, or postpartum care.

DATA COLLECTION AND ANALYSIS

Review authors and a research co-ordinator with Cochrane review experience participated in the evaluation of methodological quality and data extraction. Additional information was sought from several trial researchers. Results are presented using risk ratio (RR) for categorical data and mean difference (MD) for continuous data.

MAIN RESULTS

Twenty-eight trials, involving almost 17,000 women, contributed data to the review. Overall, women who received a psychosocial or psychological intervention were significantly less likely to develop postpartum depression compared with those receiving standard care (average RR 0.78, 95% confidence interval (CI) 0.66 to 0.93; 20 trials, 14,727 women). Several promising interventions include: (1) the provision of intensive, individualised postpartum home visits provided by public health nurses or midwives (RR 0.56, 95% CI 0.43 to 0.73; two trials, 1262 women); (2) lay (peer)-based telephone support (RR 0.54, 95% CI 0.38 to 0.77; one trial, 612 women); and (3) interpersonal psychotherapy (standardised mean difference -0.27, 95% CI -0.52 to -0.01; five trials, 366 women). Professional- and lay-based interventions were both effective in reducing the risk to develop depressive symptomatology. Individually-based interventions reduced depressive symptomatology at final assessment (RR 0.75, 95% CI 0.61 to 0.92; 14 trials, 12,914 women) as did multiple-contact interventions (RR 0.78, 95% CI 0.66 to 0.93; 16 trials, 11,850 women). Interventions that were initiated in the postpartum period also significantly reduced the risk to develop depressive symptomatology (RR 0.73, 95% CI 0.59 to 0.90; 12 trials, 12,786 women). Identifying mothers 'at-risk' assisted the prevention of postpartum depression (RR 0.66, 95% CI 0.50 to 0.88; eight trials, 1853 women).

AUTHORS' CONCLUSIONS

Overall, psychosocial and psychological interventions significantly reduce the number of women who develop postpartum depression. Promising interventions include the provision of intensive, professionally-based postpartum home visits, telephone-based peer support, and interpersonal psychotherapy.

Grand challenges: integrating maternal mental health into maternal and child health programmes

In the second article of a five-part series providing a global perspective on integrating mental health, Atif Rahman and colleagues argue that integrating maternal mental health care will help advance maternal and child health. Please see later in the article for the Editors' Summary

A Person-Centered Approach to Multicultural Counseling Competence

This article examines current and historical trends in psychotherapy research and practice with racial/ethnic minority populations. Initially, research on Derald Sue’s multicultural counseling competencies is provided as a foundation to further examine the evidence regarding effective cultural adaptations to mainstream treatment approaches, such as cognitive-behavior therapy and interpersonal psychotherapy. Next, a brief outline of Carl Rogers’s psychotherapy research tradition is presented, with a focus on both past and present evidence suggesting that person-centered therapy may be effective across diagnoses, as well as cultures. Using psychotherapy evidence from both the latter half of the 20th century and the initial decades of the 21st century, cultural adaptations to previously hypothesized person-centered therapy mechanisms of change are proposed. In particular, this culturally adapted person-centered approach is suggested to provide a competent and effective treatment system for racial/ethnic minority clients and families.

Postpartum Depression Prevention for Reservation-Based American Indians: Results from a Pilot Randomized Controlled Trial

BACKGROUND: Postpartum depression is a devastating condition that affects a significant number of women and their offspring. Few preventive interventions have targeted high risk youth, such as American Indians (AIs). OBJECTIVE: To evaluate the feasibility of a depression prevention program for AI adolescents and young adults. METHODS: Expectant AI women (mean age = 18.15; N = 47) were randomized (1:1) to either the Living in Harmony program (LIH, an 8 lesson cognitive-behaviorally based program) or an Educational-Support program (ES, an 8 lesson education program). Both interventions were delivered by AI paraprofessionals. Adolescents were evaluated during their pregnancy at baseline, at post-intervention, and at 4, 12, and 24 weeks postpartum. The primary outcome measure was the Center for Epidemiological Studies-Depression scale (CES-D). Additional measures of depression included the onset of major depressive disorder (MDD; assessed via computerized diagnostic interview) and the Edinburgh Postpartum Depression Scale (EPDS). Secondary outcomes included changes in mothers' global functioning and social support. RESULTS: At all post intervention assessments, mothers in both groups showed similar reductions in depressive symptoms and similar rates of MDD (0 and 6% in LIH and ES respectively). Both groups of participants also showed similar improvements in global functioning. No changes in either group were found on the measure of social support. CONCLUSIONS: Findings suggest that both paraprofessional-delivered interventions may reduce symptoms of depression among AIs. Replication with a larger sample, a usual care control condition, blinded evaluators, and a longer follow-up is needed.

The effectiveness of antenatal interventions to prevent postnatal depression in high-risk women

BACKGROUND

Postnatal depression can have a major impact on the lives of women affected and on those around them. While effective treatments are available, it would be preferable to prevent the condition. The aim of this review was to examine the effectiveness of antenatal interventions designed to prevent postnatal depression in high-risk women.

METHODS

Randomised controlled trials of interventions to prevent postnatal depression delivered to high-risk women in pregnancy were identified through an electronic database search and a reference list search. Information regarding the selection criteria, content and delivery of the interventions was extracted and synthesised.

RESULTS

Eleven studies met the review inclusion criteria. Six described interventions that were significantly more effective in reducing the incidence and/or symptoms of postnatal depression than a control condition. Interventions were most likely to be effective when delivered to women who were depressed during pregnancy and when incorporating evidence-based psychological treatments for depression and addressing interpersonal difficulties.

LIMITATIONS

It is possible that unpublished trials of antenatal interventions to prevent postnatal depression exist that were not detected. Due to the recognised publication bias, these studies may have been less likely to find a significant effect of antenatal interventions on postnatal depression.

CONCLUSIONS

There is evidence to suggest that interventions delivered in pregnancy can be effective in preventing postnatal depression. However, these interventions may be better conceptualised as treatment than prevention as they were delivered to women experiencing antenatal depression. There is a need to identify pregnant women experiencing depression and deliver evidence-based psychological interventions.

Preventing postpartum depression

Major depression is a frequent complication of the postpartum period. Untreated postpartum depression increases the risk of maternal suicide and can impair parenting capability with resultant adverse effects on offspring development. A number of factors influence a woman's vulnerability to postpartum depressive episodes. This article summarizes processes for assessing these risk factors and implementing primary preventive interventions, and summarizes methods of early detection to promote secondary and tertiary prevention.

Psychotherapeutic interventions for depressed, low-income women: a review of the literature

Low-income women have very high rates of depression and also face a number of unique barriers that can prevent them from seeking, accepting, engaging in, or benefiting from psychotherapy treatment. Untreated depression often leads to deleterious psychological consequences for these women and their children, and may also diminish a woman's ability to improve her economic circumstances. We reviewed the literature on psychotherapeutic interventions for depressed, low-income women, identifying a number of practical, psychological, and cultural barriers that often prevent them from engaging in psychotherapy. Next, we assessed the degree to which established intervention programs help women overcome these barriers. The data suggest that it is quite difficult to engage depressed, low-income women in psychotherapy, but that a number of standard psychotherapy approaches do show promise. However, we found that many of the currently available interventions fail to fully address the barriers that prevent this population from engaging in treatment. Moreover, the impact these interventions have on engagement and attrition rates or clinical improvements is often inadequately reported. We provide preliminary recommendations for clinicians who work with low-income women as well as suggestions for bolstering the literature base.

Alleviating perinatal depressive symptoms and stress: a nurse-community health worker randomized trial

To determine whether a Nurse-Community Health Worker (CHW) home visiting team, in the context of a Medicaid enhanced prenatal/postnatal services (EPS), would demonstrate greater reduction of depressive symptoms and stress and improvement of psychosocial resources (mastery, self-esteem, social support) when compared with usual Community Care (CC) that includes Medicaid EPS delivered by professionals. Greatest program benefits were expected for women who reported low psychosocial resources, high stress, or both at the time of enrollment. Medicaid eligible pregnant women (N = 613) were randomly assigned to either usual CC or the Nurse-CHW team. Mixed effects regression was used to analyze up to five prenatal and postnatal psychosocial assessments. Compared to usual CC, assignment to the Nurse-CHW team resulted in significantly fewer depressive symptoms, and as hypothesized, reductions in depressive symptoms were most pronounced for women with low psychosocial resources, high stress, or both high stress and low resources. Outcomes for mastery and stress approached statistical significance, with the women in the Nurse-CHW group reporting less stress and greater mastery. Women in the Nurse-CHW group with low psychosocial resources reported significantly less perceived stress than women in usual CC. No differences between the groups were found for self-esteem and social support. A Nurse-CHW team approach to EPS demonstrated advantage for alleviating depressive symptoms in Medicaid eligible women compared to CC, especially for women at higher risk.