Perinatal depression prevention through home visitation: a cluster randomized trial of mothers and babies 1-on-1

Acceptability and Utility of a Digital Group Intervention to Prevent Perinatal Depression in Youths via Interactive Maternal Group for Information and Emotional Support (IMAGINE): Pilot Cohort Study

BACKGROUND

Perinatal depression (depression during pregnancy or the first year postpartum) affects 10%-25% of perinatal individuals, with a higher risk among youths aged <25 years. The Mothers and Babies Course (MB) is an evidence-based intervention for the prevention of perinatal depression, grounded in cognitive behavioral therapy, attachment theory, and psychoeducation.

OBJECTIVE

We developed a digital adaptation of MB (Interactive Maternal Group for Information and Emotional Support [IMAGINE]) and evaluated it in a pre-post mixed methods pilot among young perinatal people in the United States.

METHODS

IMAGINE was a structured digital group of up to 7 participants, with scheduled MB content and open discussion for 12 weeks, facilitated by a social worker. Scheduled content included asynchronous SMS text messages, graphics, prerecorded videos, mood polls, and optional weekly synchronous video calls. Eligible participants were pregnant or ≤80 days postpartum, aged 16 to 24 years, had access to a smartphone, spoke English, and had a Patient Health Questionnaire score <10. Participants were recruited throughout the United States from August 2020 to January 2021 through paid social media ads, in-person outreach at clinics, and respondent-driven sampling. Participants completed quantitative questionnaires at enrollment and 3 months, and qualitative interviews at 3 months. We determined uptake, acceptability (by Acceptability of Intervention Measure score), and utility (by use of cognitive behavioral therapy skills). We compared depression symptoms (by Patient Health Questionnaire score), social support (by abbreviated Social Support Behavior score), and perceived stress (by Perceived Stress Score) between enrollment and follow-up by paired 2-tailed t test.

RESULTS

Among 68 individuals who contacted this study, 22 were screened, 13 were eligible, and 10 enrolled, for an uptake of 76.9%. Furthermore, 4 (40%) participants were pregnant at enrollment. Participants had a median age of 17.9 (IQR 17.4-21.7) years, 6 (67%) identified as Black, 5 (56%) Latinx, and 6 (67%) using Medicaid health insurance. Further, 9 (90%) participants completed follow-up. Among these, the mean acceptability score was 4.3 out of 5 (SD 0.6) and all participants said they would recommend IMAGINE to a friend. Participants reported using a median of 7 of 11 skills (IQR 5-7 skills) at least half the days. We found no significant changes in depression symptoms, perceived stress, or social support. Qualitatively, participants reported one-to-one support from the facilitator, connection with other parents, and regular mood reflection were especially helpful aspects of the intervention. Additionally, participants reported that the intervention normalized their mental health challenges, improved their ability to manage their mood, and increased their openness to mental health care.

CONCLUSIONS

This pilot study provides promising evidence of the acceptability and utility of IMAGINE among perinatal youths. Our study's small sample size did not detect changes in clinical outcomes; our findings suggest IMAGINE warrants larger-scale evaluation.

Can psychological interventions prevent or reduce risk for perinatal anxiety disorders? A systematic review and meta-analysis

OBJECTIVE

Little is known about the extent to which interventions can prevent perinatal anxiety disorders. We conducted a systematic review and meta-analysis to examine whether interventions can decrease the onset and symptoms of perinatal anxiety among individuals without an anxiety disorder diagnosis.

METHOD

We conducted a comprehensive literature search across five databases related to key concepts: (1) anxiety disorders/anxiety symptom severity (2) perinatal (3) interventions (4) prevention. We included studies that examined a perinatal population without an anxiety disorder diagnosis, included a comparator group, and assessed perinatal anxiety. We included interventions focused on perinatal anxiety as well as interventions to prevent perinatal depression or influence related outcomes (e.g., physical activity).

RESULTS

Thirty-six studies were included. No study assessing the incidence of perinatal anxiety disorder (n = 4) found a significant effect of an intervention. Among studies assessing anxiety symptom severity and included in the quantitative analysis (n = 30), a meta-analysis suggested a small standardized mean difference of -0.31 (95% CI [-0.46, -0.16], p < .001) for anxiety at post intervention, favoring the intervention group. Both mindfulness (n = 6), and cognitive behavioral therapy approaches (n = 10) were effective.

CONCLUSIONS

Interventions developed for perinatal anxiety were more effective than interventions to prevent perinatal depression. Psychological interventions show promise for reducing perinatal anxiety symptom severity, though interventions specifically targeting anxiety are needed.

Optimizing cognitive and behavioral approaches for perinatal depression: A systematic review and meta-regression analysis

Cognitive behavioral therapies (CBT) have been demonstrated efficacious in treating perinatal depression (PND). This has been demonstrated in several meta-analyses of randomized controlled trials and quasi-experimental studies. However, there is a need for up-to-date meta-analytical evidence providing reliable estimates for CBT's effectiveness in treating and preventing PND. Furthermore, with the world moving toward precision medicine, approaches require a critical synthesis of psychotherapies, especially to unpack their mechanisms of action and to understand what approaches work best for whom. Therefore, the present systematic review and meta-regression analyses aim to answer these research questions. We searched six academic databases through February 2022 and identified 56 studies for an in-depth review. Using pretested data extraction sheets, we extracted patient-level and intervention-level characteristics and effect size data from each study. Random-effects meta-analyses and mixed-effect subgroup analyses were run to delineate the effectiveness and moderators of CBT interventions for PND, respectively. CBT-based interventions yielded a strong effect size (SMD = -0.74, 95% confidence interval [CI]: -0.91 to -0.56, n = 9,722) in alleviating depressive symptoms. These interventions were effective across different delivery formats (individual, group, and electronic) and could be delivered effectively by specialists and nonspecialists. Longer duration CBT interventions may not necessarily be more effective than shorter ones. Moreover, CBT-based interventions should consider including various behavioral ingredients to maximize intervention benefits.

Effectiveness of social support-based interventions in preventing depression in people without clinical depression: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The evidence available on the association between social support and prevention of depression has been basically obtained from observational studies.

AIM

We evaluated the effectiveness of social support-based interventions for the prevention of depression in people without clinical depression.

METHODS

Systematic review and meta-analysis (SR/MA) of randomized controlled trials (RCT), which were searched for in MEDLINE, EMBASE, CENTRAL, WOS, PsycINFO, OpenGrey and other sources from the inception dates to June 8, 2022. We selected RCTs that assessed the effectiveness of social support-based interventions as compared to controls, included subjects without baseline clinical depression, and measured as results a reduction in depressive symptoms and/or the incidence of new cases of depression. Pooled standardized mean differences (SMDs) were calculated from random effects models.

RESULTS

Nine RCTs involving 927 patients from North America, Asia and Europe were included. The pooled SMD was -0.43 [95% confidence interval (CI) -0.82 to -0.04; p = .031]. Sensitivity analyses confirmed the robustness of results. Heterogeneity was substantial [I² = 80% (95% CI: 64% to 89%)]. A meta-regression model that included usual care as comparator and the continent (Europe), explained 53% of heterogeneity. Eight RCTs had a moderate overall risk of bias and one had a high risk of bias. Follow-up was ⩾1 year in only three RCTs. There was no statistical evidence of publication bias. The quality of evidence, as measured on GRADE guidelines, was low.

CONCLUSION

Social support-based interventions had a small preventive effect on depression. Longer RCTs with a low risk of bias are necessary.

Results from an effectiveness-implementation evaluation of a postpartum depression prevention intervention delivered in home visiting programs

BACKGROUND

Building on growing research examining lay health professionals delivering postpartum depression preventive interventions, we conducted a hybrid effectiveness-implementation Type 2 trial to examine implementation metrics and determine whether pregnant women receiving Mothers and Babies 1-on-1 delivered by lay home visitors exhibit greater reductions in depressive symptoms and perceived stress than women receiving usual home visiting.

METHODS

1229 (672 control, 557 intervention) pregnant women were enrolled, with intervention participants receiving Mothers and Babies 1-on-1 delivered by a lay home visitor and control participants receiving usual home visiting services. Baseline and six-month follow-up assessments measured client mental health outcomes, with management information system data collected to assess intervention dosage. Surveys were administered nine months post-training to agency managers as well as home visitors who delivered any intervention content.

RESULTS

Intent-to-treat analyses indicated a significant reduction in perceived stress among intervention participants compared to controls, while as-treated analyses showed significant reductions in perceived stress and depressive symptoms. Although all study sites adopted the intervention, <50 % of eligible women received the intervention. Over two-thirds of home visitors made at least one fidelity-consistent adaptation, with client recruitment and retention in home visiting highlighted as challenges to delivery.

LIMITATIONS

Unmeasured historical events may have affected study outcomes and caution should be used generalizing to perinatal women from different racial/ethnic groups and home visiting models.

CONCLUSION

Mothers and Babies 1-on-1 delivered by lay home visitors leads to reductions in perceived stress and depressive symptoms, suggesting task shifting to non-mental health professionals is viable when appropriate training and supervision is provided.

Addressing Maternal Depression Through Home Visiting: One State's Experience With a Breakthrough Series Collaborative

BACKGROUND AND OBJECTIVES

From 2013 to 2017, a national Breakthrough Series (BTS) collaborative in Maternal, Infant, and Early Childhood Home Visiting programs developed a toolkit that led to improvements in maternal depression outcomes. In 2018, Alabama's home visiting program (First Teacher) aimed to reproduce these impacts with a state-led BTS that enrolled 8 local implementing agencies (LIAs) serving more than 500 families.

METHODS

LIAs tested changes in practices using Plan-Do-Study-Act cycles and tracked data regarding depression screening, referrals, service access, and symptom improvement via run charts. First Teacher administered a post-collaborative survey to assess LIA team members' satisfaction with their BTS experience.

RESULTS

Alabama's BTS resulted in positive shifts in maternal depression referrals, service access, and symptom improvement. Change ideas that supported these shifts included the use of a screening script, motivational interviewing, "Mothers and Babies," and a registry. LIAs noted that BTS tools and resources helped build capacity to address the difficult and frequently stigmatized topic of maternal depression.

CONCLUSION

Findings from this study indicate that evidence- and experience-based practices regarding maternal depression screening, referrals, and service access can lead to symptom improvement among mothers enrolled in a state-based home visiting program. Results of this investigation corroborate findings from previous studies while also incorporating feedback from LIAs about the BTS experience.

Predicting the Next-Day Perceived and Physiological Stress of Pregnant Women by Using Machine Learning and Explainability: Algorithm Development and Validation

Background

Cognitive behavioral therapy–based interventions are effective in reducing prenatal stress, which can have severe adverse health effects on mothers and newborns if unaddressed. Predicting next-day physiological or perceived stress can help to inform and enable pre-emptive interventions for a likely physiologically and perceptibly stressful day. Machine learning models are useful tools that can be developed to predict next-day physiological and perceived stress by using data collected from the previous day. Such models can improve our understanding of the specific factors that predict physiological and perceived stress and allow researchers to develop systems that collect selected features for assessment in clinical trials to minimize the burden of data collection.

Objective

The aim of this study was to build and evaluate a machine-learned model that predicts next-day physiological and perceived stress by using sensor-based, ecological momentary assessment (EMA)–based, and intervention-based features and to explain the prediction results.

Methods

We enrolled pregnant women into a prospective proof-of-concept study and collected electrocardiography, EMA, and cognitive behavioral therapy intervention data over 12 weeks. We used the data to train and evaluate 6 machine learning models to predict next-day physiological and perceived stress. After selecting the best performing model, Shapley Additive Explanations were used to identify the feature importance and explainability of each feature.

Results

A total of 16 pregnant women enrolled in the study. Overall, 4157.18 hours of data were collected, and participants answered 2838 EMAs. After applying feature selection, 8 and 10 features were found to positively predict next-day physiological and perceived stress, respectively. A random forest classifier performed the best in predicting next-day physiological stress (F1 score of 0.84) and next-day perceived stress (F1 score of 0.74) by using all features. Although any subset of sensor-based, EMA-based, or intervention-based features could reliably predict next-day physiological stress, EMA-based features were necessary to predict next-day perceived stress. The analysis of explainability metrics showed that the prolonged duration of physiological stress was highly predictive of next-day physiological stress and that physiological stress and perceived stress were temporally divergent.

Conclusions

In this study, we were able to build interpretable machine learning models to predict next-day physiological and perceived stress, and we identified unique features that were highly predictive of next-day stress that can help to reduce the burden of data collection.

Longer wait time after identification of peripartum depression symptoms is associated with increased symptom burden at psychiatric assessment

Untreated peripartum depression (PD) affects one in seven women and is associated with negative maternal outcomes. This retrospective observational study used health record data from an integrated health system in Texas to assess the extent to which time to access reproductive psychiatry influences the mental health of peripartum women. Women with at least one screening for depression symptoms conducted in obstetric or pediatric settings between May 2014 and October 2019 and subsequently seen by the reproductive psychiatry clinic (n=490) were included. Descriptive and inferential statistics were used to assess timing and factors related to psychiatry follow-up. Findings from this study demonstrated that the average time between a positive screen and a psychiatry assessment was 5 weeks. At psychiatry referral appointments, 85% of women continued to screen positive for PD symptoms. Depression symptom scores at the psychiatry appointment were significantly higher than scores precipitating the referral (p = 0.002). Wait time between initial positive screen and referral appointment was positively correlated with clinically meaningful increases in depression symptom scores (p < 0.001). Each week spent waiting for an appointment produced a 13% increase in odds of clinically meaningful worsening of PD scores and 9% increase in odds of developing new self-harm ideation. Given the findings that a longer period between primary care referral and subspecialty appointment has a negative impact on the mental health of women, this study supports the need for earlier psychiatric assessment to minimize decompensation. Expansion of reproductive psychiatry services are needed to support peripartum women and improve maternal outcomes.

Suicide Among Women and the Role of Women's Health Care Providers

Importance

Suicide is a leading cause of death in the United States, with increasing rates among women. Women are more likely to experience suicidal ideation and engage in suicide behavior than men, and risk is elevated at key points where they may engage in care with a women's health care provider.

Objective

This review describes the prevalence of and risk factors for suicide among women and highlights the role of obstetrician-gynecologists in suicide prevention.

Evidence Acquisition

A PubMed, MEDLINE, and PsycINFO search was completed for English-language publications about suicide among women, including subtopics (eg, perinatal suicide, suicide during perimenopause).

Results

There are overlapping risk factors that contribute to suicide among women, including intimate partner violence and substance use. Specific groups of women may present with unique risk factors, such as women veterans, women in rural areas, and women with preexisting mental health diagnoses, particularly serious mental illnesses. Some women at risk for suicide are not seen in clinical settings, and thus community interventions may be beneficial. There are roles for obstetrician-gynecologists within and outside of the clinic to prevent suicide.

Conclusions and Relevance

Obstetrician-gynecologists can save lives by being aware of the prevalence of suicide ideation and behavior among women, understanding risk factors for suicide over the lifespan, regularly screening for these factors, asking directly about suicide ideation and intent, and being aware of clinical and community resources. Outside of the clinic, they can advocate for increased health care access and community-based interventions. These efforts can contribute to the reduction of preventable death and maternal mortality.

Cultural Adaptation of the Mothers and Babies Intervention for Use in Tribal Communities

OBJECTIVE

While one in five women may experience mood and anxiety disorders during pregnancy and postpartum, Indigenous identity increases that risk by 62%, especially among younger Indigenous women. The need for evidence-based perinatal mental health interventions that provide culturally relevant well-being perspectives and practices is critical to improving maternal, child, and community outcomes for Indigenous peoples, and reducing health inequities.

METHODS

Through a collaboration between community maternal and child health professionals, intervention researchers, and a cultural consultant, our workgroup developed cultural adaptations to Mothers and Babies, an evidence-based perinatal depression prevention intervention. Applying a cultural interface model, the workgroup identified existing intervention content for surface adaptations, as well as deep, conceptual adaptations to incorporate traditional teachings into this evidence-based intervention.

RESULTS

This collaboration developed a culturally adapted facilitator manual for intervention providers, including guidance for implementation and further adaptation to represent local tribal culture, and a culturally adapted participant workbook for Indigenous perinatal women that reflects cultural teachings and traditional practices to promote well-being for mother and baby.

IMPLICATIONS

Committing to a culturally respectful process to adapt Mothers and Babies is likely to increase the reach of the intervention into Indigenous communities, reengage communities with cultural practice, improve health outcomes among parents, children, and the next generation's elders, and reduce disparities among Indigenous groups. Replication of this community-engaged process can further the science and understanding of cultural adaptations to evidence-based interventions, while also further reducing health inequities. Future steps include evaluating implementation of the culturally adapted intervention among tribal home visiting organizations.

Transitions to virtual early childhood home visitation during COVID-19

COVID-19 has disrupted many of the preventive service sectors designed to promote infant mental health. The purpose of this study is to examine provider and supervisor transition strategies as well as maternal-child outcomes during the transition from in-person to virtual early childhood home visitation services in Los Angeles County. Los Angeles County is one of the largest home visitation sectors in the U.S. and disproportionately impacted by the COVID-19 pandemic. Transitioning from in-person to virtual home visitation was an important step in ensuring the continuity of infant mental health services. Home visitors reported relative ease in transitioning to virtual services themselves but noted that families encountered greater difficulty. The most helpful strategies to support this transition included training, ongoing reflective supervision, and provision of technology. Family level analysis revealed that positive screening rates for anxiety and depression decreased during the pandemic as did referrals for most support services. These findings likely highlight challenges in delivering virtual home visitation. Understanding how transitions in a key infant serving sector were managed serves an important role in forecasting for the future and preparing for future public heath emergencies.

Integrating SMS Text Messages Into a Preventive Intervention for Postpartum Depression Delivered via In-Home Visitation Programs: Feasibility and Acceptability Study

BACKGROUND

The Mothers and Babies (MB) Course is recognized by the US Preventive Services Task Force as an evidence-based preventive intervention for postpartum depression (PPD) that should be recommended to pregnant women at risk for PPD.

OBJECTIVE

This report examines the feasibility and acceptability of enhancing the MB 1-on-1 intervention by adding 36 SMS text messages that target 3 areas: reinforcement of skills, between-session homework reminders, and responding to self-monitoring texts (ie, MB Plus Text Messaging [MB-TXT]).

METHODS

In partnership with 9 home visiting programs, 28 ethnically and racially diverse pregnant women (mean 25.6, SD 9.0 weeks) received MB-TXT. Feasibility was defined by home visitors' adherence to logging into the HealthySMS platform to enter session data and trigger SMS text messages within 7 days of the in-person session. The acceptability of MB-TXT was measured by participants' usefulness and understanding ratings of the SMS text messages and responses to the self-monitoring SMS text messages.

RESULTS

On average, home visitors followed the study protocol and entered session-specific data between 5.50 and 61.17 days following the MB 1-on-1 sessions. A high proportion of participants responded to self-monitoring texts (25/28, 89%) and rated the text message content as very useful and understandable.

CONCLUSIONS

This report contributes to a growing body of research focusing on digital adaptations of the MB course. SMS is a low-cost, accessible digital tool that can be integrated into existing interventions. With appropriate resources to support staff, it can be implemented in community-based organizations and health care systems that serve women at risk for PPD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03420755; https://clinicaltrials.gov/ct2/show/NCT03420755.

The Development and Pilot of a Technology-Based Intervention in the United States for Father's Mental Health in the Perinatal Period

Paternal mental health is increasingly recognized as an important public health issue, with about 10% of men experiencing depression perinatally. Paternal depression is associated with less responsive parenting, greater parenting stress, and suboptimal child development. In response to a lack of existing interventions that directly focus on fathers’ mental health in the United States, we developed and pilot tested the Fathers and Babies (FAB) intervention for use with partners of women enrolled in home visiting (HV) programs.

After a review of the extant literature, FAB was developed with input from HV stakeholders and infant mental health consultants. FAB was subsequently pilot tested with 30 father-mother dyads, with mixed-method data collected from a subset of intervention participants to assess intervention feasibility and acceptability and guide intervention refinement.

Five themes related to FAB content and delivery considerations emerged from the initial focus groups that were used to guide FAB development. Mixed-method data collected during the pilot study established that fathers receiving FAB reported its content appropriate and thought it was feasible to receive the intervention. Several recommendations for FAB revisions were also provided.

FAB is an innovative intervention developed for fathers from contemporary family structures that was well-received during its pilot testing. Feasibility and acceptability data suggest that fathers have favorable opinions about intervention content and delivery, while also highlighting areas for future revisions of FAB.

Leading the charge toward a world without depression: perinatal depression can be prevented

This manuscript is based on a keynote address presented at the 2020 Marcé Society's Conference celebrating the Society's 40th anniversary. The address described a 50-year perspective on prevention research, current evidence that perinatal depression can be prevented, and how digital tools could be used to disseminate perinatal depression prevention interventions throughout the world. We utilized the Mothers and Babies Course as a case study to illustrate these goals. The article reviews the gradual progress of depression prevention research, from the time when the state of the science was such that it was believed that the onset of major depressive episodes could not be prevented until the present day. In addition, the article recounts the three consensus reports on prevention of mental disorders published by the National Academies of Science, Engineering, and Medicine, culminating in the 2019 report, which calls on the field to implement known interventions for the prevention of depression and other mental disorders, and to scale up their administration to reduce the prevalence of these disorders in the general population. The paper presents the 2019 recommendations of the US Preventive Services Task Force, which instructs the health system to provide routine referrals to perinatal depression prevention interventions (e.g., the Mothers and Babies Course) to perinatal persons at risk for depression. We now have the knowledge to prevent approximately half of episodes of perinatal depression. It is time to implement this knowledge and begin to do research on how to prevent the remaining half.

Prevention of Mental Health Difficulties for Children Aged 0-3 Years: A Review

The period of infancy and early childhood is a critical time for interventions to prevent future mental health problems. The first signs of mental health difficulties can be manifest in infancy, emphasizing the importance of understanding and identifying both protective and risk factors in pregnancy and the early postnatal period. Parents are at a higher risk of developing mental health problems during the perinatal period. An understanding of the evidence around prevention and intervention for parental anxiety and depression is vital to the process of prevention of early mental health disorders in infants and young children. Here we review the existing prevention and treatment interventions in the early years focusing on the period from conception to 3 years - the majority targeting parents in order to improve their mental health, and that of their infants. Elements of successful programs for parents include psychoeducation and practical skills training, as well as work on the co-parenting relationship, developing secure attachment, and enhancing parental reflective functioning. While both targeted and universal programs have produced strong effect sizes, universal programs have the added benefit of reaching people who may otherwise not have sought treatment. In synthesizing this information, our goal is to inform the development of integrated models for prevention and novel early intervention programs as early in life as possible.

Schedules for home visits in the early postpartum period

BACKGROUND

Maternal complications, including psychological/mental health problems and neonatal morbidity, have commonly been observed in the postpartum period. Home visits by health professionals or lay supporters in the weeks following birth may prevent health problems from becoming chronic, with long-term effects. This is an update of a review last published in 2017.

OBJECTIVES

The primary objective of this review is to assess the effects of different home-visiting schedules on maternal and newborn mortality during the early postpartum period. The review focuses on the frequency of home visits (how many home visits in total), the timing (when visits started, e.g. within 48 hours of the birth), duration (when visits ended), intensity (how many visits per week), and different types of home-visiting interventions.

SEARCH METHODS

For this update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (19 May 2021), and checked reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) (including cluster-, quasi-RCTs and studies available only as abstracts) comparing different home-visiting interventions that enrolled participants in the early postpartum period (up to 42 days after birth) were eligible for inclusion. We excluded studies in which women were enrolled and received an intervention during the antenatal period (even if the intervention continued into the postnatal period), and studies recruiting only women from specific high-risk groups (e.g. women with alcohol or drug problems).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 16 randomised trials with data for 12,080 women. The trials were carried out in countries across the world, in both high- and low-resource settings. In low-resource settings, women receiving usual care may have received no additional postnatal care after early hospital discharge. The interventions and controls varied considerably across studies. Trials focused on three broad types of comparisons, as detailed below. In all but four of the included studies, postnatal care at home was delivered by healthcare professionals. The aim of all interventions was broadly to assess the well-being of mothers and babies, and to provide education and support. However, some interventions had more specific aims, such as to encourage breastfeeding, or to provide practical support. For most of our outcomes, only one or two studies provided data, and results were inconsistent overall. All studies had several domains with high or unclear risk of bias. More versus fewer home visits (five studies, 2102 women) The evidence is very uncertain about whether home visits have any effect on maternal and neonatal mortality (very low-certainty evidence). Mean postnatal depression scores as measured with the Edinburgh Postnatal Depression Scale (EPDS) may be slightly higher (worse) with more home visits, though the difference in scores was not clinically meaningful (mean difference (MD) 1.02, 95% confidence interval (CI) 0.25 to 1.79; two studies, 767 women; low-certainty evidence). Two separate analyses indicated conflicting results for maternal satisfaction (both low-certainty evidence); one indicated that there may be benefit with fewer visits, though the 95% CI just crossed the line of no effect (risk ratio (RR) 0.96, 95% CI 0.90 to 1.02; two studies, 862 women). However, in another study, the additional support provided by health visitors was associated with increased mean satisfaction scores (MD 14.70, 95% CI 8.43 to 20.97; one study, 280 women; low-certainty evidence). Infant healthcare utilisation may be decreased with more home visits (RR 0.48, 95% CI 0.36 to 0.64; four studies, 1365 infants) and exclusive breastfeeding at six weeks may be increased (RR 1.17, 95% CI 1.01 to 1.36; three studies, 960 women; low-certainty evidence). Serious neonatal morbidity up to six months was not reported in any trial. Different models of postnatal care (three studies, 4394 women) In a cluster-RCT comparing usual care with individualised care by midwives, extended up to three months after the birth, there may be little or no difference in neonatal mortality (RR 0.97, 95% CI 0.85 to 1.12; one study, 696 infants). The proportion of women with EPDS scores ≥ 13 at four months is probably reduced with individualised care (RR 0.68, 95% CI 0.53 to 0.86; one study, 1295 women). One study suggests there may be little to no difference between home visits and telephone screening in neonatal morbidity up to 28 days (RR 0.97, 95% CI 0.85 to 1.12; one study, 696 women). In a different study, there was no difference between breastfeeding promotion and routine visits in exclusive breastfeeding rates at six months (RR 1.47, 95% CI 0.81 to 2.69; one study, 656 women). Home versus facility-based postnatal care (eight studies, 5179 women) The evidence suggests there may be little to no difference in postnatal depression rates at 42 days postpartum and also as measured on an EPDS scale at 60 days. Maternal satisfaction with postnatal care may be better with home visits (RR 1.36, 95% CI 1.14 to 1.62; three studies, 2368 women). There may be little to no difference in infant emergency health care visits or infant hospital readmissions (RR 1.15, 95% CI 0.95 to 1.38; three studies, 3257 women) or in exclusive breastfeeding at two weeks (RR 1.05, 95% CI 0.93 to 1.18; 1 study, 513 women).

AUTHORS' CONCLUSIONS

The evidence is very uncertain about the effect of home visits on maternal and neonatal mortality. Individualised care as part of a package of home visits probably improves depression scores at four months and increasing the frequency of home visits may improve exclusive breastfeeding rates and infant healthcare utilisation. Maternal satisfaction may also be better with home visits compared to hospital check-ups. Overall, the certainty of evidence was found to be low and findings were not consistent among studies and comparisons. Further well designed RCTs evaluating this complex intervention will be required to formulate the optimal package.

Examining the Effectiveness of the Fathers and Babies Intervention: A Pilot Study

There is increasing recognition of the importance of addressing the mental health of fathers, including during the perinatal period. Fathers exhibiting mental health concerns during the perinatal period are at heightened risk for future negative mental health outcomes and are less likely to engage in nurturing relationships with their children, leading to a sequalae of negative child outcomes during infancy and into adolescence. Although interventions have been developed for perinatal fathers, they typically do not focus directly on addressing paternal mental health. To fill this gap, we developed the Fathers and Babies intervention to be delivered to perinatal fathers whose partners (mothers) were enrolled in home visiting programs. A pre-post longitudinal study was conducted in which 30 father-mother dyads were recruited from home visiting programs. Fathers received the 12-session Fathers and Babies intervention while the mother concurrently received the Mothers and Babies intervention delivered to her by a home visitor. Baseline, 3- and 6-month self-report surveys were conducted with both fathers and mothers. Fathers and mothers had statistically significant decreases in perceived stress between baseline and both follow-up time points, with moderate effect sizes generated for both sexes. No statistically significant differences were found for depressive symptoms, anxiety symptoms, or perceived partner support, although we found small effects for reductions in depressive symptoms among fathers, as well as increases in the percentage of fathers and mothers who reported high levels of emotional and instrumental support post-intervention. While preliminary, these findings suggest the potential for Fathers and Babies to positively impact the mental health of fathers in the perinatal period, and also signal the viability of home visiting as a setting for delivering this intervention. Future research should employ a comparison group to generate stronger evidence of intervention effectiveness and include measurement of dyadic relationships and paternal parenting practices.

Universal and Selective Interventions to Prevent Poor Mental Health Outcomes in Young People: Systematic Review and Meta-analysis

BACKGROUND

Much is not known about the efficacy of interventions to prevent poor mental health outcomes in young people by targeting either the general population (universal prevention) or asymptomatic individuals with high risk of developing a mental disorder (selective prevention).

METHODS

We conducted a PRISMA/MOOSE-compliant systematic review and meta-analysis of Web of Science to identify studies comparing post-test efficacy (effect size [ES]; Hedges' g) of universal or selective interventions for poor mental health outcomes versus control groups, in samples with mean age <35 years (PROSPERO: CRD42018102143). Measurements included random-effects models, I2 statistics, publication bias, meta-regression, sensitivity analyses, quality assessments, number needed to treat, and population impact number.

RESULTS

295 articles (447,206 individuals; mean age = 15.4) appraising 17 poor mental health outcomes were included. Compared to control conditions, universal and selective interventions improved (in descending magnitude order) interpersonal violence, general psychological distress, alcohol use, anxiety features, affective symptoms, other emotional and behavioral problems, consequences of alcohol use, posttraumatic stress disorder features, conduct problems, tobacco use, externalizing behaviors, attention-deficit/hyperactivity disorder features, and cannabis use, but not eating-related problems, impaired functioning, internalizing behavior, or sleep-related problems. Psychoeducation had the highest effect size for ADHD features, affective symptoms, and interpersonal violence. Psychotherapy had the highest effect size for anxiety features.

CONCLUSION

Universal and selective preventive interventions for young individuals are feasible and can improve poor mental health outcomes.

Stress management interventions among socioeconomically disadvantaged parents: A meta-analysis and moderation analysis

BACKGROUND

Socioeconomically disadvantaged parents experience high levels of stress, anxiety, and depression. Many interventions have been tested to reduce parental stress, but no meta-analysis has been conducted to quantitatively summarize the effects and explore the moderators of intervention effects among socioeconomically disadvantaged parents.

OBJECTIVE

This meta-analysis aimed to (1) quantitatively examine the intervention effects of prior stress management interventions among socioeconomically disadvantaged parents on reducing stress, depression, and anxiety; and (2) explore the potential moderators of intervention effects.

METHODS

Six databases, including CINAHL, PubMed, PsycINFO, Sociological Abstracts, Web of Science, and Cochrane, were searched in February 2021. After a two-step literature screening by two independent reviewers, 45 eligible articles were retained. Two evaluators independently assessed each eligible study's quality using the Evidence Project risk of bias tool. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guided the report. Meta-analyses (random-effects model) and moderation analyses (mixed-effects model) were performed.

RESULTS

Previous stress management interventions had a small effect of -0.24 in reducing parental stress (95% confidence interval [CI]: -0.33, -0.15) with a 7.6-month follow-up effect of -0.12 (95% CI: -0.27, 0.04). The pooled effects on reducing depression were -0.15 (95% CI: -0.26, -0.04) with a 9-month follow-up effect of 0.02 (95% CI: -0.21, 0.26). Two studies measured anxiety, and the average effects were -0.03 (95% CI: -0.16, 0.11). Intervention effects on stress were significantly moderated by country (p = .005), study design (p < .001), and intervention duration (p = .030). Interventions conducted in developing countries (g = -0.52) had a significantly larger effect in reducing stress than those conducted in developed countries (g = -0.19). Studies using a quasi-experimental design (g = -0.47) resulted in a significantly greater effect in reducing stress than RCTs (g = -0.12). Interventions with a duration of 1-3 months (g = -0.36) had a greater effect in reducing stress than those with a longer duration (g = -0.11 for 3-6 months, -0.20 for >6 months). Intervention effects on reducing depression were significantly moderated by intervention component (p = .030). Cognitive behavioral therapy (g = -0.20) and mindfulness-based interventions (g = -0.16) resulted in greater effects in reducing depression than interventions focusing on parenting/life/self-care skills (g  =  0.003).

CONCLUSIONS

Previous stress management interventions have short-term beneficial effects on reducing parental stress and depression, but long-term follow-up effects are limited. Short-duration (1-3 months) mindfulness-based interventions and cognitive behavioral therapy in clinical settings are recommended for socioeconomically disadvantaged parents to reduce stress and depression.

A pilot study of a group-based perinatal depression intervention on reducing depressive symptoms and improving maternal-fetal attachment and maternal sensitivity

To conduct a pilot study of a group-based perinatal depression intervention, the Mothers and Babies Course, on depressive symptomatology, maternal-fetal attachment, and maternal sensitivity, 60 pregnant women with moderate to severe depressive symptomatology were randomized to a 6-week intervention or usual care group at their initial prenatal care visit. Measures of depressive symptomatology and maternal-fetal attachment were collected at baseline and 36 weeks gestation. At 12 weeks postpartum, participants completed a measure of depressive symptomatology, and an objective measure of maternal sensitivity was collected. Participants randomized to the intervention group completed an average of 5.2 sessions, and 70% of women completed all six sessions. Exploratory analyses showed that at 12 weeks postpartum, participants randomized to the intervention group had an 8.32-point decrease from baseline on the Edinburgh Postnatal Depression Scale (EPDS) as compared to a 4.59-point decrease among participants randomized to usual care. Participants randomized to the intervention group had a mean change score of 12.60 in maternal-fetal attachment via the Maternal Fetal Attachment Scale (MFAS) as compared to 4.60 among participants in usual care. Maternal sensitivity scores, assessed via the Nursing Child Assessment Satellite Training-Feeding Scale (NCAST-Feeding), were higher at 12 weeks postpartum for women in the intervention group as compared to women in usual care (59.2 and 51.8, respectively). Our pilot study findings provide preliminary support for the benefits of a perinatal depression intervention, delivered in a group setting, on reducing depressive symptomatology, and improving maternal-fetal attachment and maternal sensitivity. Further research, conducted with larger samples, is necessary to determine the effect of this intervention on indicators of maternal attachment.

Moving the dial on prenatal stress mechanisms of neurodevelopmental vulnerability to mental health problems: A personalized prevention proof of concept

Prenatal stress exposure increases vulnerability to virtually all forms of psychopathology. Based on this robust evidence base, we propose a "Mental Health, Earlier" paradigm shift for prenatal stress research, which moves from the documentation of stress-related outcomes to their prevention, with a focus on infant neurodevelopmental indicators of vulnerability to subsequent mental health problems. Achieving this requires an expansive team science approach. As an exemplar, we introduce the Promoting Healthy Brain Project (PHBP), a randomized trial testing the impact of the Wellness-4-2 personalized prenatal stress-reduction intervention on stress-related alterations in infant neurodevelopmental trajectories in the first year of life. Wellness-4-2 utilizes bio-integrated stress monitoring for just-in-time adaptive intervention. We highlight unique challenges and opportunities this novel team science approach presents in synergizing expertise across predictive analytics, bioengineering, health information technology, prevention science, maternal-fetal medicine, neonatology, pediatrics, and neurodevelopmental science. We discuss how innovations across many areas of study facilitate this personalized preventive approach, using developmentally sensitive brain and behavioral methods to investigate whether altering children's adverse gestational exposures, i.e., maternal stress in the womb, can improve their mental health outlooks. In so doing, we seek to propel developmental SEED research towards preventive applications with the potential to reduce the pernicious effect of prenatal stress on neurodevelopment, mental health, and wellbeing.

Perinatal mental health around the world: priorities for research and service development in the USA

The perinatal mental health field is growing rapidly, which has yielded innovations in both prevention and treatment. To realise the potential of these innovations to transform clinical practice, further investment in research and clinical service development is required. Clinical services must be expanded by providing increased access to specialty care and education for front-line clinicians. Research is needed to develop a personalised medicine approach to understanding the complex aetiologies of perinatal depression and optimising treatments to promote both remission and long-term recovery. Such initiatives will require policies to prioritise federal research funding and healthcare coverage for perinatal depression.

Effectiveness of a peer-delivered, psychosocial intervention on maternal depression and child development at 3 years postnatal: a cluster randomised trial in Pakistan

BACKGROUND

Maternal depression has a recurring course that can influence offspring outcomes. Evidence on how to treat maternal depression to improve longer-term maternal outcomes and reduce intergenerational transmission of psychopathology is scarce, particularly for task-shifted, low-intensity, and scalable psychosocial interventions. We evaluated the effects of a peer-delivered, psychosocial intervention on maternal depression and child development at 3 years postnatal.

METHODS

40 village clusters in Pakistan were randomly allocated using a computerised randomisation sequence to receive a group-based, psychosocial intervention and enhanced usual care for 36 months, or enhanced usual care alone. Pregnant women (≥18 years) were screened for moderate or severe symptoms of depression (patient health questionnaire-9 [PHQ-9] score ≥10) and were recruited into the trial (570 participants), and a cohort without depression (PHQ-9 score <10) was also enrolled (584 participants). Including the non-depressed dyads enabled us to determine how much of the excess risk due to maternal depression exposure the intervention could mitigate. Research teams responsible for identifying, obtaining consent, and recruiting trial participants were blind to the allocation status throughout the duration of the study, and principal investigators, site coordinators, statisticians, and members of the trial steering committee were also blinded to the allocation status until the analysis of 6-month data for the intervention. Primary outcomes were maternal depression symptoms and remission (PHQ-9 score <10) and child socioemotional skills (strengths and difficulties questionnaire [SDQ-TD]) at 36-months postnatal. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, NCT02658994.

FINDINGS

From Oct 15, 2014 to Feb 25, 2016 46 village clusters were assessed for eligibility, of which 40 (including 1910 mothers were enrolled. After exclusions, 288 women were randomly assigned to the enhanced usual care group and 284 to the intervention group, and 1159 women were included in a group without prenatal depression. At 36-months postnatal, complete data were available from 889 mother-child dyads: 206 (72·5%) in the intervention group, 216 (75·3%) in the enhanced usual care group, and 467 (80·0%) women who did not have prenatal-depression. We did not observe significant outcome differences between the intervention group and the enhanced usual care group for the primary outcomes. The standardised mean difference of PHQ-9 total score was -0·13 (95% CI -0·33 to 0·07), relative risk of patient health questionnaire-9 remission was 1·00 (95% CI 0·88 to 1·14), and the SDQ-TD treatment estimate was -0·10 (95% CI -1·39 to 1·19).

INTERPRETATION

Reduced symptom severity and high remission rates were seen across both the intervention and enhanced usual care groups, possibly masking any effects of the intervention. A multi-year, psychosocial intervention can be task-shifted via peers but might be susceptible to reductions in fidelity and dosage over time (which were not among the outcomes of this trial). Early intervention efforts might need to rely on multiple models (eg, collaborative care), be of greater intensity, and potentially targeted at mothers who are at high risk for depression to reduce the intergenerational transmission of psychopathology from mothers to children.

FUNDING

National Institutes of Health.

Antenatal psychological intervention for universal prevention of antenatal and postnatal depression: A systematic review and meta-analysis

BACKGROUND

The high prevalence and severe consequences of antenatal and postnatal depression makes their prevention critical. Previous systematic reviews and meta-analysis have shown the effects of psychological interventions on perinatal depression in individuals at risk. However, none have focused explicitly on universal prevention in the antenatal period. The purpose of this study is to conduct a systematic review and meta-analysis to clarify the effects of antenatal psychological interventions on perinatal depression, specifically focusing on universal prevention.

METHODS

Four electronic databases, the Cochrane Controlled Register of Trials (CENTRAL), Embase, PubMed, and PsycINFO, were used to search for published randomized controlled trials from inception to January 28, 2019. Twelve investigators conducted the first screening from title and abstract, individually, and then NY and ZN performed full-text review one by one. For the meta-analysis, a random effect model was conducted by using Review Manager 5.3 for Windows. Subgroup analyses were also conducted for studies that employed a cognitive behavioral (CB) based approach.

RESULTS

A total of 13,026 studies were initially searched. After removing duplicates, 9,919 studies were screened, and finally 18 studies met the inclusion criteria. The meta-analysis showed a significant effect of antenatal psychological intervention on both antenatal and postnatal depression (SMD = 0.28, 95% CI = 0.11 to 0.44, SMD = 0.37, 95% CI = 0.08 to 0.66) with moderate to high level of heterogeneity (I² = 61%, p = 0.01; I² = 84%, p < 0.001). For subgroup analysis, a significant effect of a CB based approach on antenatal depression was found in an antenatal period (SMD = 0.53, 95% CI = 0.13 to 0.94) with high heterogeneity (I² = 85%, p = 0.001), while non-significant results were shown on postnatal depression (SMD = 0.45, 95% CI = -0.03 to 0.92).

LIMITATIONS

Limitations include a language bias, as we included only studies published in English, and that the assessment of antenatal and postnatal depression using different methods caused high heterogeneity across studies.

CONCLUSIONS

Psychological intervention in an antenatal period could be effective for universal prevention of both antenatal and postnatal depression. However, the results were still inconclusive due to relatively low methodological quality in the included studies. The evidence from more well-designed trials is needed in future studies.

Effectiveness of the Thinking Healthy Programme for perinatal depression delivered through peers: Pooled analysis of two randomized controlled trials in India and Pakistan

BACKGROUND

The Thinking Healthy Programme (THP) is recommended to treat perinatal depression in resource-limited settings, but scale-up is hampered by a paucity of community health workers. THP was adapted for peer-delivery (THPP) and evaluated in two randomized controlled trials in India and Pakistan. Our aim was to estimate the effectiveness of THPP on maternal outcomes across these two settings, and evaluate effect-modification by country and other pre-defined covariates.

METHODS

Participants were pregnant women aged≥18 years with depression (Patient Health Questionnaire (PHQ-9) score≥10), randomized to THPP plus enhanced usual care (EUC) or EUC-only. Primary outcomes were symptom severity and remission (PHQ-9 score<5) 6 months post-childbirth. Secondary outcomes included further measures of depression, disability and social support at 3 and 6 months post-childbirth.

RESULTS

Among 850 women (280 India; 570 Pakistan), 704 (83%) attended 6-month follow-up. Participants in the intervention arm had lower symptom severity (PHQ-9 score adjusted mean difference -0.78 (95% confidence interval -1.47,-0.09)) and higher odds of remission (adjusted odds ratio 1.35 (1.02,1.78)) versus EUC-only. There was a greater intervention effect on remission among women with short chronicity of depression, and those primiparous. There were beneficial intervention effects across multiple secondary outcomes.

LIMITATIONS

The trials were not powered to assess effect-modifications. 10-20% of participants were missing outcome data.

CONCLUSIONS

This pooled analysis demonstrates the effectiveness, acceptability and feasibility of THPP, which can be scaled-up within a stepped-care approach by engaging with the existing health care systems and the communities to address the treatment gap for perinatal depression in resource-limited settings.

Preventing perinatal depression in Spain: a pilot evaluation of Mamás y Bebés

Objective: This pilot study evaluated the feasibility, acceptability, and preliminary effectiveness of a cognitive-behavioural intervention to prevent perinatal depressive symptoms in pregnant women at high risk for perinatal depression in Spain. Background: Perinatal depression (PD) can negatively affect maternal and infant outcomes. Mamás y Bebés/The Mothers and Babies Course (MBC) is an evidence-based CBT intervention aimed at teaching women at high risk for depression mood regulation skills to prevent depression in the United States, including Spanish-speaking perinatal women in the United States. However, there is limited research on preventive interventions for PD in Spain. Method: Pregnant women screened for high risk for PD were recruited in their first trimester in an obstetrics clinic at two urban hospitals in Spain. In a non-experimental design, 30 women completed eight weekly group sessions of the MBC. The Patient Health Questionnaire was the main depression outcome at four time points: pre-intervention, post-intervention, and at 3 months and 6 months postpartum. Participants completed an evaluation questionnaire at the end of each session to assess the acceptability of the intervention. Results: The MBC was effective in reducing depressive symptoms from baseline to all three time points: post-intervention, 3 and 6 months postpartum. Attendance was high (76.7% attended all eight sessions). Mothers reported positive feedback from the participating in the MBC. Conclusion: This pilot study suggests that the intervention is feasible, acceptable, and provides promising evidence for reducing depressive symptoms in urban Spanish perinatal women. Larger and rigorous randomised trials are needed to confirm these findings.

Addressing Maternal Depression, Substance Use, and Intimate Partner Violence in Home Visiting: a Quasi-Experimental Pilot Test of a Screen-and-Refer Approach

This quasi-experimental pilot study describes preliminary impacts of the "Home Visitation Enhancing Linkages Project (HELP)," a pragmatic screen-and-refer approach for promoting identification of and linkage to treatment for maternal depression (MD), substance use (SU), and intimate partner violence (IPV) within early childhood home visiting. HELP includes screening for MD, SU, and IPV followed by a menu of motivational interviewing and case management interventions aimed at linking clients to treatment, designed for delivery within routine home visiting. HELP was piloted within four counties of a statewide home visiting system that were implementing Healthy Families America. HELP clients (N = 394) were compared to clients in five demographically matched counties that received usual Healthy Families services (N = 771) on whether their home visitors (1) identified MD, SU, and IPV risk; (2) discussed MD, SU, and IPV during home visits; and (3) made referrals for MD, SU, and IPV. All data were extracted from the program's management information system. A significant impact of HELP was found on discussion of risk in home visits for all three risk domains with large effect sizes (MD OR = 4.08; SU OR = 15.94; IPV OR = 9.35). HELP had no impact on risk identification and minimal impact on referral. Findings provide preliminary support for HELP as a way of improving discussion of client behavioral health risks during home visits, an important first step toward better meeting these needs within home visiting. However, more intensive intervention is likely needed to impact risk identification and referral outcomes.

Master Clinician Review: Parental Depression and Family Health and Wellness: What Clinicians Can Do and Reflections on Opportunities for the Future

The study of parental depression in families with children who are depressed and the development of appropriate family prevention strategies to assist families with parents who are depressed have expanded and improved significantly over the past 30 years. This article highlights an evidence-informed approach for clinicians dealing with parents who are depressed in different settings, addressing when a parent presents with depression, and when parental depression is encountered in treating a child with behavior health concerns. Some reflections on key contextual, policy, and systems issues are offered, because these so often determine what is and is not possible in a clinical encounter.

Delivering the Thinking Healthy Programme for perinatal depression through peers: an individually randomised controlled trial in India

BACKGROUND

The Thinking Healthy Programme (THP) is a psychological intervention recommended for the treatment of perinatal depression. However, efforts to integrate the intervention at scale into the routines of community health workers who delivered the THP when it was first evaluated were compromised by the competing responsibilities of community health workers. We aimed to assess the effectiveness and cost-effectiveness of THP peer-delivered (THPP) in Goa, India.

METHODS

In this single-blind, individually randomised controlled trial, we recruited pregnant women aged 18 years or older who scored at least 10 on the Patient Health Questionnaire-9 (PHQ-9) from antenatal clinics in Goa. Participants were randomly allocated (1:1) to receive enhanced usual care (EUC; so-called because, in India, perinatal depression is not typically treated) only (control group) or THPP in addition to EUC (intervention group) in randomly sized blocks that were stratified by area of residence (urban or rural). Group allocations were concealed from participants and researchers before assignments were made by use of sequentially numbered opaque envelopes. The primary outcomes were the severity of depressive symptoms (assessed by PHQ-9 score) and the prevalence of remission (defined as a PHQ-9 score of less than 5) in participants with available data 6 months after childbirth, which was assessed by researchers who were masked to treatment allocations. We analysed outcomes by intention to treat, adjusting for covariates that were defined a priori or that showed imbalance at baseline. The trial is registered with ClinicalTrials.gov, number NCT02104232.

FINDINGS

Between Oct 24, 2014, and June 24, 2016, we assessed 118 260 women for their eligibility for screening, of whom 111 851 (94·6%) women were ineligible. 6409 (5·4%) women were eligible for screening and 6369 (99·4%) of these women consented to be screened with the PHQ-9 (40 women did not consent), of whom 333 (5·2%) screened positive for depression (defined as a PHQ-9 score of at least 10). We enrolled 280 (84·1%) women with perinatal depression; 140 women were assigned to the THPP and EUC group and 140 women to the EUC only group. The final treatment was given on May 27, 2017. The final 6-month outcome assessment was completed on June 9, 2017. At 6 months after birth, 122 (87%) women in the THPP and EUC group and 129 (92%) women in the EUC only group were assessed for the primary outcome. There was a higher prevalence of remission at 6 months after birth in the THPP and EUC group compared with the EUC only group (89 [73%] women in the intervention group vs 77 [60%] women in the control group; prevalence ratio 1·21, 95% CI 1·01 to 1·45; p=0·04), but there was no evidence of a difference in symptom severity between the groups (mean PHQ-9 score 3·47 [SD 4·49] in the intervention group vs 4·48 [5·11] in the control group; standardised mean difference -0·18, 95% CI -0·43 to 0·07; p=0·16). There was no evidence of significant differences in serious adverse events between the groups.

INTERPRETATION

THPP had a moderate effect on remission from perinatal depression over the 6-month postnatal period. THPP is relatively cheap to deliver and is cost-saving through reduced health-care, time and productivity costs.

FUNDING

National Institute of Mental Health (USA).