A systematic review of the efficacy of cognitive behavioral therapy for treating and preventing perinatal depression

New treatments: Opportunities and challenges

Across the spectrum of perinatal mental illness, there exist a variety of effective treatments. However, the available treatments are not always matched to the presentation, resources, constraints, or values of each patient. Furthermore, provider, local, and systemic factors complicate access to current treatment options. New and emerging approaches offer the potential of more effective treatment for specific perinatal psychiatric disorders. From neuroactive steroid medications to accelerated psychotherapy interventions, recent innovations have demonstrated enhanced efficacy on a faster timeline. Optimally, these developments will also lower barriers to care but this is not necessarily true. We review novel and upcoming interventions across perinatal mental illness and place them in the context of existing treatments and common challenges.

Study protocol: perinatal mood treatment study

Perinatal depression (PND) affects up to 20% of women and is associated with significant impairment and disability in affected women. In addition, perinatal depression is associated with broader public health and multigenerational consequences. Innovative approaches are needed to reduce the burden of perinatal depression through identification, tracking, and treatment of depressive symptoms during the perinatal period. This study is a randomized clinical trial comparing the relative efficacy of a multi-tiered system of care, Screening and Treatment of Anxiety and Depression (STAND) to perinatal care delivered by a reproductive psychiatrist in reducing symptoms of depression and anxiety. A sample of 167 individuals was randomized between week 28 of pregnancy and 6 months postpartum. A secondary aim compares the original online therapy intervention used in the first half of the study to a newer online therapy program used in the second half of the study for individuals assigned to the STAND treatment. The study measures, intervention groups, and analysis methods are described, as well as expected implications. The findings from this study may improve the methods for tracking symptom changes over time, monitoring treatment response, and providing personalized care for individuals with PND. As such, this study may improve the lives of patients with PND and their families and lower the related health care costs to society.Trial registration NCT: 9/24/2021NCT direct link: https://www.clinicaltrials.gov/study/NCT05056454?term=NCT05056454&rank=1&a=1 .

The HOPE cohort: cohort profile and evaluation of selection bias

The HOPE cohort is a Danish nationwide cohort with ongoing follow-up, holding information on postpartum depression (PPD) symptoms and diagnoses on 170,218 childbirths (142,795 unique mothers). These data have been linked with extensive register data on health and socioeconomic information on the mothers, their partners, parents, and children. This cohort profile aimed to provide an overview of the data collection and content, describe characteristics, and evaluate potential selection bias. PPD screenings, using the Edinburgh Postnatal Depression Scale, were collected from 67 of the 98 Danish municipalities, covering the period January 2015 to December 2021. This data was linked with register data on PPD diagnoses (identified through medication prescriptions and hospital contacts) as well as background information. Cohort characteristics were compared to the source population, defined as all childbirths by women residing in Denmark during the same period (452,207 childbirths). Potential selection bias was evaluated by comparing odds ratios of five well-established associations between the cohort and the source population. The HOPE cohort holds information on 170,218 childbirths (38% of the source population) involving 142,795 unique mothers. The HOPE cohort only differed slightly from the source population on most characteristics examined, but larger differences were observed on specific characteristics with an underrepresentation of the youngest and oldest age groups, women with more than three children or twins/triplets, and women born outside Denmark. Similar associations were identified across the two populations within the five well-established associations. There was no indication of selection bias on the five examined associations, and the HOPE cohort is representative of the source population on important perinatal characteristics.

Economic evaluation of Be a Mom, a web-based intervention to prevent postpartum depression in high-risk women alongside a randomized controlled trial

BACKGROUND

Postpartum depression (PPD) poses significant challenges, affecting both mothers and children, with substantial societal and economic implications. Internet-based cognitive behavioral therapy interventions (iCBT) offer promise in addressing PPD, but their economic impact remains unexplored. This study aimed to evaluate the cost-utility of Be a Mom, a self-guided iCBT intervention, compared with a waiting-list control among postpartum women at high risk of PPD.

METHODS

This economic evaluation was conducted alongside a 14-month randomized controlled trial adopting a societal perspective. Participants were randomized to Be a Mom (n = 542) or a waitlisted control group (n = 511). Self-report data on healthcare utilization, productivity losses, and quality-adjusted life years (QALYs) were collected at baseline, post-intervention, and 4 and 12 months post-intervention. Incremental cost-effectiveness ratios (ICERs) were calculated, and cost-effectiveness acceptability curves were generated using nonparametric bootstrapping. Sensitivity analyses were conducted to assess result robustness.

RESULTS

Over 14 months, Be a Mom generated a QALY gain of 0.0184 (0.0022, 0.0346), and cost savings of EUR 34.06 (-176.16, 108.04) compared to the control group. At a willingness to pay of EUR 20,000, Be a Mom had a 97.6 % probability of cost-effectiveness.

LIMITATIONS

Results have limitations due to self-selected sample, potential recall bias in self-reporting, missing data, limited follow-up, and the use of a waiting-list control group.

CONCLUSIONS

This study addresses a critical gap by providing evidence on the cost-utility of an iCBT intervention tailored for PPD prevention. Further research is essential to identify scalable and cost-effective interventions for reducing the burden of PPD.

Postpartum Depression: A Clinical Review of Impact and Current Treatment Solutions

Depression during the first year postpartum (postpartum depression) impacts millions of women and their families worldwide. In this narrative review, we provide a summary of postpartum depression, examining the etiology and consequences, pharmacological and psychological treatments, and potential mechanisms of change and current barriers to care. Psychological treatments are effective and preferred by many perinatal patients over medications, but they often remain inaccessible. Key potential mechanisms underlying their effectiveness include treatment variables (e.g., dosage and therapeutic alliance) and patient behaviors (e.g., activation and avoidance and emotional regulation). Among pharmacological treatments, the selective serotonin reuptake inhibitor (SSRI) sertraline is generally the first-line antidepressant medication recommended to women in the postpartum period due to its minimal passage into breastmilk and the corresponding decades of safety data. Importantly, most antidepressant drugs are considered compatible with breastfeeding. Neurosteroids are emerging as an effective treatment for postpartum depression, although currently this treatment is not widely available. Barriers to widespread access to treatment include those that are systematic (e.g., lack of specialist providers), provider-driven (e.g., lack of flexibility in treatment delivery), and patient-driven (e.g., stigma and lack of time for treatment engagement). We propose virtual care, task-sharing to non-specialist treatment providers, and collaborative care models as potential solutions to enhance the reach and scalability of effective treatments to address the growing burden of postpartum depression worldwide and its negative impact on families and society.

Effects of Two Group Prenatal Care Interventions on Mental Health: An RCT

INTRODUCTION

Perinatal depression and anxiety cost the U.S. health system $102 million annually and result in adverse health outcomes. Research supports that cognitive behavioral therapy improves these conditions, but barriers to obtaining cognitive behavioral therapy have prevented its success in pregnant individuals. In this study, the impact of a cognitive behavioral therapy-based intervention on anxiety, depression, stress, healthy lifestyle beliefs, and behaviors in pregnant people was examined.

STUDY DESIGN

This study used a 2-arm RCT design, embedded in group prenatal care, with one arm receiving a cognitive behavioral therapy-based Creating Opportunities for Personal Empowerment program and the other receiving health promotion content.

SETTING/PARTICIPANTS

Black and Hispanic participants (n=299) receiving prenatal care from 2018 to 2022 in New York and Ohio who screened high on 1 of 3 mental health measures were eligible to participate.

INTERVENTION

Participants were randomized into the manualized Creating Opportunities for Personal Empowerment cognitive behavioral therapy-based program, with cognitive behavioral skill-building activities delivered by advanced practice nurses in the obstetrical setting.

MAIN OUTCOME MEASURES

Outcomes included anxiety, depression, and stress symptoms using valid and reliable tools (Generalized Anxiety Disorder scale, Edinburgh Postnatal Depression Scale, and Perceived Stress Scale). The Healthy Lifestyle Beliefs and Behaviors Scales examined beliefs about maintaining a healthy lifestyle and reported healthy behaviors.

RESULTS

There were no statistically significant differences between groups in anxiety, depression, stress, healthy beliefs, and behaviors. There were significant improvements in all measures over time. There were statistically significant decreases in anxiety, depression, and stress from baseline to intervention end, whereas healthy beliefs and behaviors significantly increased.

CONCLUSIONS

Both cognitive behavioral therapy and health promotion content embedded in group prenatal care with advanced practice nurse delivery improved mental health and healthy lifestyle beliefs and behaviors at a time when perinatal mood generally worsens.

TRIAL REGISTRATION

This study is registered with clinicaltrials.gov NCT03416010.

Pregnancy stressors and postpartum symptoms of depression and anxiety: the moderating role of a cognitive-behavioural therapy (CBT) intervention

Background

Little is known about the association between stressors (especially positive stressors) during pregnancy and postpartum depression and anxiety.

Aims

We investigated the association between positive and negative stress events during different stages of pregnancy and postpartum mental health outcomes among low-income pregnant women with symptoms of anxiety in Pakistan and evaluated whether an intervention based on cognitive-behavioural therapy (CBT) had a regulatory effect.

Methods

Participants were 621 pregnant Pakistani women with mild anxiety. Using the Pregnancy Experience Scale-Brief Version, six scores were created to assess positive and negative stressors. We performed a multivariate linear regression to examine whether these six scores, measured both at baseline and in the third trimester, were associated with postpartum anxiety and depressive symptoms. The effect of the intervention on this relationship was examined by adding an interaction term to the regression model.

Results

Hassles frequency measured in the third trimester was positively associated with depression (B=0.22, 95% confidence interval (CI): 0.09 to 0.36) and anxiety (B=0.19, 95% CI: 0.08to 0.30). At the same timepoint, uplifts intensity was negatively associated with symptoms of depression (B=-0.82, 95% CI: -1.46 to -0.18) and anxiety (B=-0.70, 95% CI: -1.25 to -0.15), whereas hassles intensity was positively related to symptoms of depression (B=1.02, 95% CI: 0.36 to 1.67) and anxiety (B=0.90, 95% CI: 0.34 to 1.47). The intensity ratio of hassles to uplifts reported in the third trimester was positively related to both depression (B=1.40, 95% CI: 0.59 to 2.20) and anxiety (B=1.26, 95% CI: 0.57 to 1.96). The intervention strengthened the overall positive effects of uplifts and the negative effects of hassles. Pregnancy experiences at baseline during early pregnancy to mid-pregnancy were not associated with mental health outcomes.

Conclusions

Stressors in the third trimester but not earlier in pregnancy were associated with postpartum symptoms of anxiety and depression. The CBT intervention modified the association between pregnancy stressors and postpartum mental health outcomes. Programmes that promote positive experiences and reduce negative experiences, especially in late pregnancy, may mitigate postpartum mental health consequences.

Trial registration number

NCT03880032.

Efficacy of in-person versus digital mental health interventions for postpartum depression: meta-analysis of randomized controlled trials

AIM

This meta-analysis aimed to compare the efficacy of in-person and digital mental health interventions in addressing Postpartum Depression.

METHODS

Following PRISMA guidelines, the protocol for this meta-analysis was registered at the Open Science Framework (Retrieved from osf.io/wy3s4). This meta analysis included Randomized Controlled Trials (RCTs) conducted between 2013 and 2023. A comprehensive literature search identified 35 eligible RCTs from various electronic databases. Inclusion criteria focused on pregnant women over 18 years old, encompassing antenatal depression and up to two years postpartum. Diagnostic interviews or Edinburgh Postnatal Depression Scale (EPDS) were used to establish PPD. Digital interventions included telephonic, app-based, or internet-based approaches, while in-person interventions involved face-to-face sessions.

RESULTS

The meta-analysis revealed a moderate overall effect size of -0.69, indicating that psychological interventions are effective for PPD. Digital interventions (g = -0.86) exhibited a higher mean effect size than in-person interventions (g = -0.55). Both types of interventions displayed substantial heterogeneity (digital: I2 = 99%, in-person: I2 = 92%), suggesting variability in intervention content, delivery methods, and participant characteristics.

CONCLUSION

Digital mental health interventions show promise in addressing PPD symptoms, with a potentially greater effect size compared to in-person interventions. However, the high heterogeneity observed in both modalities underscores the need for further research to identify key drivers of success and tailor interventions to diverse populations. Additionally, the choice between digital and in-person interventions should consider individual needs and preferences. Ongoing research should further investigate and optimise intervention modalities to better serve pregnant women at risk of PPD.

Prevalence and associated risk factors of postpartum depression in India: A comprehensive review

Postpartum depression (PPD) is a psychological illness that affects women following delivery. According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), PPD is a serious form of depression that begins four weeks following birth and continues for one year. Pregnancy and the period after delivery can be hazardous for women. Mothers undergo significant biological, emotional, financial, and societal changes during this time. Some women are predisposed to mental health disorders such as melancholy and worry. Many postpartum women do not acknowledge the seriousness of their condition, and many depressed mothers go untreated. Untreated PPD is harmful to both the mother and the newborn. The exact cause of PPD is unclear; however, hormonal fluctuations during pregnancy and childbirth, genetic susceptibility, birth trauma as well as psychosocial and demographic factors may serve as potential risk factors. The objective of this study is to determine the prevalence and risk factors of PPD in India. The review evaluates English language literature on PPD using Scopus, PubMed, and Google Scholar databases searched electronically between 2000 and 2022. The keywords "postpartum depression," or "postnatal depression," and "prevalence," and "causes," and "risk factors," or "predisposing factors," or "predictive factors" were used to search the database. The prevalence of PPD varies in different geographical regions and study settings. In India, the overall prevalence of PPD is 22%. However, the greatest prevalence was in the southern regions (26%; 95% confidence interval [CI]: 19-32) and the lowest in the northern regions (15%; 95% CI: 10-21). This study outlines the burden of PPD in India. Comprehensive intervention programs should be implemented to address the disease at a national level. The national authorities should incorporate PPD screening in the National Mental Health Program and emphasize health promotion activities.

Efficacy of contextual therapies in perinatal depression and anxiety: A systematic review and meta-analysis

BACKGROUND

There are previous meta-analyses on the efficacy of cognitive behavioral therapy or mindfulness-based therapies in the perinatal period, but no previous review has focused on contextual therapies as a whole. The aim of this study was to carry out a systematic review and meta-analysis of the efficacy of contextual therapies on depressive and anxious symptoms in women in the perinatal period.

METHODS

A systematic search for randomized clinical trials has been carried out in the PUBMED, CINAHL, Psyc-INFO and Cochrane Library search engines. For the quantitative synthesis, the Morris effect size measure has been used.

RESULTS

A total of 34 RCTs have been found, of which 30 have been used for meta-analysis. The mean effect size of the studies on depression scores was dppc2 = -0.81 (95% CI = -1.12 to -0.50), while it was dppc2 = -1.04 (95% CI = -1.54 to -0.53) in the case of studies on anxiety scores. These effect sizes decreased to medium effect sizes when corrected for publication bias.

LIMITATIONS

The main limitations are the quality of the included studies, publication bias, and the limited number of studies on contextual therapies other than mindfulness-based therapies.

CONCLUSIONS

In conclusion, this systematic review found a large number of efficacy studies on mindfulness-based therapies and a small number of studies on the other contextual therapies. The effect sizes found are consistent with previous meta-analyses in the perinatal period.

The effect of digital health interventions on postpartum depression or anxiety: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

This study aimed to examine the effect of digital health interventions compared with treatment as usual on preventing and treating postpartum depression and postpartum anxiety.

DATA SOURCES

Searches were conducted in Ovid MEDLINE, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov.

STUDY ELIGIBILITY REQUIREMENTS

The systematic review included full-text randomized controlled trials comparing digital health interventions with treatment as usual for preventing or treating postpartum depression and postpartum anxiety.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two authors independently screened all abstracts for eligibility and independently reviewed all potentially eligible full-text articles for inclusion. A third author screened abstracts and full-text articles as needed to determine eligibility in cases of discrepancy. The primary outcome was the score on the first ascertainment of postpartum depression or postpartum anxiety symptoms after the intervention. Secondary outcomes included screening positive for postpartum depression or postpartum anxiety --as defined in the primary study --and loss to follow-up, defined as the proportion of participants who completed the final study assessment compared with the number of initially randomized participants. For continuous outcomes, the Hedges method was used to obtain standardized mean differences when the studies used different psychometric scales, and weighted mean differences were calculated when studies used the same psychometric scales. For categorical outcomes, pooled relative risks were estimated.

RESULTS

Of 921 studies originally identified, 31 randomized controlled trials-corresponding to 5532 participants randomized to digital health intervention and 5492 participants randomized to treatment as usual-were included. Compared with treatment as usual, digital health interventions significantly reduced mean scores ascertaining postpartum depression symptoms (29 studies: standardized mean difference, -0.64 [95% confidence interval, -0.88 to -0.40]; I2=94.4%) and postpartum anxiety symptoms (17 studies: standardized mean difference, -0.49 [95% confidence interval, -0.72 to -0.25]; I2=84.6%). In the few studies that assessed screen-positive rates for postpartum depression (n=4) or postpartum anxiety (n=1), there were no significant differences between those randomized to digital health intervention and treatment as usual. Overall, those randomized to digital health intervention had 38% increased risk of not completing the final study assessment compared with those randomized to treatment as usual (pooled relative risk, 1.38 [95% confidence interval, 1.18-1.62]), but those randomized to app-based digital health intervention had similar loss-to-follow-up rates as those randomized to treatment as usual (relative risk, 1.04 [95% confidence interval, 0.91-1.19]).

CONCLUSION

Digital health interventions modestly, but significantly, reduced scores assessing postpartum depression and postpartum anxiety symptoms. More research is needed to identify digital health interventions that effectively prevent or treat postpartum depression and postpartum anxiety but encourage ongoing engagement throughout the study period.

Comparing the effectiveness of mother-focused interventions to that of mother-child focused interventions in improving maternal postpartum depression outcomes: A systematic review

BACKGROUND

Most empirically researched interventions for postpartum depression (PPD) tend to target mothers' depression alone. Harmful effects of PPD on physical and mental health of both mother and child has led researchers to investigate the impact of interventions on PPD and child outcomes together. So far, the evidence is limited regarding how these interventions compare with those focusing only on mothers' depression. This review compares the effectiveness of PPD-improving interventions focusing only on mothers with those focusing on mother and child together.

METHODS

Nine electronic databases were searched. Thirty-seven studies evaluating mother-focused (n = 30) and mother-child focused interventions (n = 7) were included. Under each category, three theoretical approaches-psychological, psychosocial and mixed-were compared using standardized qualitative procedures. The review's primary outcome was maternal PPD.

RESULTS

A higher proportion of mother-focussed interventions [20/30 (66.7%)] brought significant reduction in PPD outcomes as compared to a lower proportion of mother-child focused interventions [4/7 (57.14%)]. Mother-focused mixed approaches [3/3 (100%)] performed better in improving PPD than psychological [16/24 (67%)] or psychosocial approaches [1/3 (33.3%)] alone. Amongst mother-child focused interventions, psychosocial approaches performed well with two-thirds demonstrating positive effects on PPD.

CONCLUSION

The evidence strongly favors mother-focused interventions for improving PPD with mixed interventions being more effective. Psychosocial approaches performed better with PPD once child-related elements were added, and also seemed best for child outcomes. Psychological approaches were most practiced and effective for PPD, irrespective of the intervention's focus. Further trials are needed to unpack intervention components that improve PPD and increase uptake, especially in lower-and middle-income countries.

A virtual mother-infant postpartum psychotherapy group for mothers with a history of adverse childhood experiences: open-label feasibility study

OBJECTIVES

Mothers with a history of adverse childhood experiences (ACE) are at elevated risk for postpartum mental illness and impairment in the mother-infant relationship. Interventions attending to maternal-infant interactions may improve outcomes for these parents and their children, but barriers to accessing in-person postpartum care limit uptake. We adapted a postpartum psychotherapy group for mothers with mental illness (e.g., mood, anxiety, trauma-related disorders) and ACE for live video-based delivery, and evaluated feasibility, acceptability, and preliminary efficacy in an open-label pilot study.

METHODS

We recruited adults with children (6-18 months) from a perinatal psychiatry program in Toronto, Canada. The intervention was a live video-based 12-week interactive psychotherapy group focused on maternal symptoms and maternal-infant relationships. The primary outcome was feasibility, including feasibility of recruitment and retention, fidelity of the intervention, and acceptability to patients and group providers. Maternal clinical outcomes were compared pre- to post-intervention, as secondary outcomes.

RESULTS

We recruited 31 participants (mean age 36.5 years (SD 3.9)) into 6 groups; 93.6% (n = 29) completed post-group questionnaires, and n = 20 completed an optional post-group acceptability interview. Mean weekly group attendance was 83% (IQR 80-87); one participant (3.2%) dropped out. All group components were implemented as planned, except for dyadic exercises where facilitator observation of dyads was replaced with unobserved mother-infant exercises followed by in-group reflection. Participant acceptability was high (100% indicated the virtual group was easy to access, beneficial, and reduced barriers to care). Mean maternal depressive [Edinburgh Postnatal Depression Scale: 14.6 (SD 4.2) vs. 11.8 (SD 4.2), paired t, p = 0.005] and post-traumatic stress [Posttraumatic Stress Disorder Checklist for DSM-5: 35.5 (SD 19.0) vs. 27.1 (SD 16.7)], paired t, p = 0.01] symptoms were significantly lower post vs. pre-group. No differences were observed on mean measures of anxiety, emotion regulation or parenting stress.

CONCLUSIONS

Recruitment and retention met a priori feasibility criteria. There were significant pre- to post-group reductions in maternal depressive and post-traumatic symptoms, supporting proceeding to larger-scale implementation and evaluation of the intervention, with adaptation of dyadic exercises.

Women's experiences of psychological treatment and psychosocial interventions for postpartum depression: a qualitative systematic review and meta-synthesis

BACKGROUND

To provide a comprehensive, systematic evaluation of the literature on experiences of psychological interventions for postpartum depression (PPD) in women. Depression is one of the most common postpartum mental disorders. Studies have identified that psychological interventions reduce depressive symptoms. However, less is known about the experiences of women who have received such treatments.

METHODS

A systematic review of the literature was conducted by searching five databases (CINAHL, Cochrane Library, EMBASE, Medline, PsycINFO), in August 2022. Studies with qualitative methodology examining women's experiences of professional treatment for PPD were included and checked for methodological quality. Eight studies (total N = 255) contributed to the findings, which were synthesized using thematic synthesis. Confidence in the synthesized evidence was assessed with GRADE CERQual.

FINDINGS

The women had received cognitive behavioral therapy (5 studies) or supportive home visits (3 studies). Treatments were individual or group-based. Two main themes were identified: Circumstances and expectations, and Experiences of treatment, with six descriptive themes. Establishing a good relationship to their health professional was important for the women, regardless of treatment model. They also expressed that they wanted to be able to choose the type and format of treatment. The women were satisfied with the support and treatment received and expressed that their emotional well-being had been improved as well as the relationship to their infant.

CONCLUSION

The findings can be helpful to develop and tailor patient-centered care for women who are experiencing postnatal depression.

Psychiatric illness and pregnancy: A literature review

Background

Women of reproductive age frequently suffer from psychiatric disorders. The risk of developing anxiety, bipolar, and depressive disorders is especially significant during the perinatal period.

Objectives

This article aims to identify and discuss the different psychiatric conditions that might affect pregnant women and update the mother's carers about the recent and updated bidirectional relationship between psychiatric disease and adverse pregnancy outcomes, As well as the most updates in diagnostic and management strategies.

Methods

A thorough analysis of the literature was conducted using database searches in EMBASE, Science Direct, Google Scholar, Scopus, and PubMed to obtain the objectives and aim of the study.

Results

The presence of maternal mental illness during pregnancy has been linked to preterm delivery, newborn hypoglycemia, poor neurodevelopmental outcomes, and disturbed attachment. Placental anomalies, small-for-gestational-age foetuses, foetal discomfort, and stillbirth are among more undesirable perinatal outcomes.

Conclusions

Pregnancy-related psychiatric disorders are frequent. The outcomes for pregnant women, infants, and women's health are all improved by proper diagnosis and treatment of psychiatric problems.

Can we influence the neurological development and hair cortisol concentration of offspring by reducing the stress of the mother during pregnancy? A randomized controlled trial

The objective was to evaluate the effects of a stress management cognitive behavioural therapy followed during pregnancy on subsequent childhood on hair cortisol at birth and on neurodevelopment and Hair Cortisol Concentrations (HCC) at 6 months of age. The study sample included 48 pregnant women, divided into two groups: 24 women in the Therapy Group (TG) and 24 women who received standard pregnancy care (control group (CG); CG). To test the therapy efficacy, an evaluation of the HCC and psychological stress, psychopathological symptomatology and resilience was conducted before and after the treatment. The level of cortisol in their hair was obtained during pregnancy and that of their babies at birth. Six months after birth, a cortisol sample was taken from the hair and the babies' neurodevelopment was evaluated based on a Bayley-III test. The TG presented reductions in psychological stress and psychopathological symptomatology after treatment. On the other hand, the CG increased their cortisol concentrations between the pre and post intervention, remaining stable in the TG. Moreover, results showed that TG babies had lower cortisol concentrations at birth and obtained significantly higher cognitive and motor development scores at 6 months. These findings support that providing psychological care to pregnant women may not only have a benefit on these women's mental state, but may also benefit the neurodevelopment of their offspring.

Effects of Recreational Therapy and 3D Ultrasonography for High-Risk Pregnancies on Psychological Well-Being during Hospitalization and in the Puerperal Phase

Hospitalization during pregnancy often produces psychosocial distress for pregnant women. In this study, 3D ultrasound and recreational therapy were compared to the standard treatment for their influence on depressive symptoms and anxiety. In this prospective one-year intervention study, women who were admitted to the hospital for any pregnancy complication, other than psychiatric, were included. A control group, with standard clinical treatment, and two intervention groups, both additionally receiving either 3D ultrasound or recreational therapy, were established. Psychological well-being was assessed at defined times by the PHQ-health-questionnaire. A total of 169/211 women were included: control group n = 79, 3D ultrasound group n = 43, and crochet group n = 83. A higher than estimated underlying depression was seen for all women on admission. The intervention groups showed less depression (p = 0.02762). No difference was seen between the intervention groups (p = 0.23029). Anxiety decreased throughout intervention, but not significantly. On admission, all women showed similar results of underlying depression, indicating that hospitalization itself already causes mild psychological stress. Both interventions decreased depressive symptoms. Intervention with either recreational therapy or 3D ultrasound can prevent the development of mild and major depression and decrease anxiety disorders, and therefore has a positive effect on well-being during hospitalization. These results emphasize the need to implement forms of interventions to improve the well-being of women, as this might improve pregnancy and neonatal outcome.

Preventing Perinatal Depression: Cultural Adaptation of the Mothers and Babies Course in Kenya and Tanzania

Pregnant women and mothers in sub-Saharan Africa are at high risk for perinatal depression, warranting a need to develop culturally tailored interventions to prevent perinatal depression. This paper documents the process of adapting an evidence-based preventive intervention developed in the United States, the Mothers and Babies Course (MBC), to fit the contexts of rural pregnant women and mothers of young children in Kenya and Tanzania using the updated Framework for Reporting Adaptations and Modifications-Enhanced (FRAME). Data from informant interviews and field observations from the planning and implementation phases were used to make adaptations and modifications of the MBC for perinatal women through the eight aspects of FRAME. Follow-up field visits and reflection meetings with case managers and intervention participants indicated that the adapted version of the MBC was well accepted, but fidelity was limited due to various implementation barriers. The FRAME provided an optimal structure to outline the key adaptations and modifications of a preventive intervention intended to maximize engagement, delivery, and outcomes for high-risk perinatal women in rural settings.

Perinatal Depression Treatment Guidelines for Obstetric Providers

Perinatal depression is the occurrence of depressive symptoms during the antenatal or postnatal period with an annual incidence of 10% to 20%. The consequences of untreated perinatal depression are significant and include negative impacts on maternal health, pregnancy outcomes, and maternal-infant outcomes. The purpose of this article is to provide perinatal pharmacologic and psychological treatment information to help first-line providers more confidently manage depression in the perinatal period. Treatment strategies including medication management using risk versus risk conversations, psychotherapy, and colocated perinatal mental health clinics are discussed.

Online peer-delivered group cognitive-behavioral therapy for postpartum depression: A randomized controlled trial

BACKGROUND

Postpartum depression (PPD) affects up to one in five mothers and birthing parents, yet just 10% receive evidence-based care. This randomized controlled trial aimed to determine if a synchronous online 9-week group cognitive-behavioral therapy (CBT) intervention delivered by mothers who have recovered from postpartum depression (i.e., peers) could effectively improve PPD and its comorbidities.

METHODS

Participants (n = 183) in this study lived in Ontario, Canada, were ≥18 years-old, had an infant <12 months, were fluent in English, and scored ≥10 on the Edinburgh Postnatal Depression Scale (EPDS). They were randomized to experimental (received intervention plus treatment as usual (TAU)) or waitlist control (TAU plus the intervention after a 9-week wait) groups. Depression, anxiety, social support, mother-infant bonding, and infant temperament were assessed at baseline and 9 weeks later. Outcomes were assessed in the experimental group 3 months post-intervention to assess stability.

RESULTS

Statistically significant reductions were observed in EPDS (B = 5.99; p < 0.001; d = 1.32) and Generalized Anxiety Disorder Questionnaire-7 scores (B = 5.94; p < 0.001; d = 1.22), improvements that remained stable 3 months post-intervention in the experimental group. Maternal social support (p = 0.02; d = 0.40), infant-focused anxiety (p = 0.02; d = 0.54), and infant negative emotionality (p < 0.01; d = 0.23) also improved post-intervention and remained stable 3 months later.

CONCLUSION

Online peer-delivered group CBT for PPD can effectively treat PPD and anxiety, and improve social support, infant-focused anxiety, and negative emotionality in infants. This intervention could provide the means to increase access to treatment for those experiencing PPD and improve outcomes for mothers, birthing parents, and families.

Feasibility and impact of a mental health chatbot on postpartum mental health: a randomized controlled trial

BACKGROUND

Perinatal mood disorders are common yet underdiagnosed and un- or undertreated. Barriers exist to accessing perinatal mental health services, including limited availability, time, and cost. Automated conversational agents (chatbots) can deliver evidence-based cognitive behavioral therapy content through text message-based conversations and reduce depression and anxiety symptoms in select populations. Such digital mental health technologies are poised to overcome barriers to mental health care access but need to be evaluated for efficacy, as well as for preliminary feasibility and acceptability among perinatal populations.

OBJECTIVE

To evaluate the acceptability and preliminary efficacy of a mental health chatbot for mood management in a general postpartum population.

STUDY DESIGN

An unblinded randomized controlled trial was conducted at a tertiary academic center. English-speaking postpartum women aged 18 years or above with a live birth and access to a smartphone were eligible for enrollment prior to discharge from delivery hospitalization. Baseline surveys were administered to all participants prior to randomization to a mental health chatbot intervention or to usual care only. The intervention group downloaded the mental health chatbot smartphone application with perinatal-specific content, in addition to continuing usual care. Usual care consisted of routine postpartum follow up and mental health care as dictated by the patient's obstetric provider. Surveys were administered during delivery hospitalization (baseline) and at 2-, 4-, and 6-weeks postpartum to assess depression and anxiety symptoms. The primary outcome was a change in depression symptoms at 6-weeks as measured using two depression screening tools: Patient Health Questionnaire-9 and Edinburgh Postnatal Depression Scale. Secondary outcomes included anxiety symptoms measured using Generalized Anxiety Disorder-7, and satisfaction and acceptability using validated scales. Based on a prior study, we estimated a sample size of 130 would have sufficient (80%) power to detect a moderate effect size (d=.4) in between group difference on the Patient Health Questionnaire-9.

RESULTS

A total of 192 women were randomized equally 1:1 to the chatbot or usual care; of these, 152 women completed the 6-week survey (n=68 chatbot, n=84 usual care) and were included in the final analysis. Mean baseline mental health assessment scores were below positive screening thresholds. At 6-weeks, there was a greater decrease in Patient Health Questionnaire-9 scores among the chatbot group compared to the usual care group (mean decrease=1.32, standard deviation=3.4 vs mean decrease=0.13, standard deviation=3.01, respectively). 6-week mean Edinburgh Postnatal Depression Scale and Generalized Anxiety Disorder-7 scores did not differ between groups and were similar to baseline. 91% (n=62) of the chatbot users were satisfied or highly satisfied with the chatbot, and 74% (n=50) of the intervention group reported use of the chatbot at least once in 2 weeks prior to the 6-week survey. 80% of study participants reported being comfortable with the use of a mobile smartphone application for mood management.

CONCLUSION

Use of a chatbot was acceptable to women in the early postpartum period. The sample did not screen positive for depression at baseline and thus the potential of the chatbot to reduce depressive symptoms in this population was limited. This study was conducted in a general obstetric population. Future studies of longer duration in high-risk postpartum populations who screen positive for depression are needed to further understand the utility and efficacy of such digital therapeutics for that population.

Risks of adverse perinatal outcomes in relation to maternal depressive symptoms: A prospective cohort study in Kenya

BACKGROUND

Evidence gaps remain regarding the influence of prenatal psychosocial factors on adverse pregnancy outcomes.

OBJECTIVE

The objective of this study is to evaluate relationships between psychosocial factors and adverse perinatal outcomes among Kenyan women.

METHODS

We analysed data from a prospective cohort study enrolling HIV-negative women in pregnancy (NCT03070600) in 20 antenatal clinics in Western Kenya. Study nurses assessed depressive symptoms using the Center for Epidemiologic Studies Depression Scale (CESD-10), social support using the Medical Outcomes Survey scale (MOS-SSS), intimate partner violence (IPV) with the Hurt, Insult, Threaten, Scream scale (HITS), and pregnancy outcomes at 6 weeks postpartum. Cox proportional hazards models were used to evaluate relationships between depressive symptoms (moderate-to-severe [MSD, CESD-10 ≥10] and mild-to-severe [Mild-SD, CESD-10 ≥5]), low social support (MOS-SSS <72), and IPV (HITS ≥10) with adverse perinatal outcomes of pregnancy loss, stillbirth, preterm birth (PTB), small for gestational age, and neonatal mortality. We also estimated the population attributable risk.

RESULTS

Among 4153 women, 23.9% (n = 994) had MSD, 54.7% (n = 2273) mild-SD, 37.3% (n = 1550) low social support, and 7.8% (n = 323) experienced IPV. Pregnancy loss was 5-fold higher among women with MSD (adjusted hazard ratio [HR] 5.04, 95% confidence interval [CI] 2.44, 10.42); 37.4% of losses were attributable to MSD. Mild-SD was associated with PTB (HR 1.39, 95% CI 1.03, 1.87). Stillbirth risk more than doubled among women reporting low social support (HR 2.37, 95% CI 1.14, 4.94).

CONCLUSIONS

Adverse perinatal outcomes were common and associated with prenatal depressive symptoms and low social support in this large cohort of Kenyan mother-infant pairs.

Anatomy of a Woebot® (WB001): agent guided CBT for women with postpartum depression

INTRODUCTION

Postpartum depression (PPD) is common, persistent, and stigmatized. There are insufficient trained professionals to deliver appropriate screening, diagnosis, and treatment.

AREAS COVERED

WB001 is a Software as a Medical Device (SaMD) based Agent-Guided Cognitive-Behavioral Therapy (AGCBT) program for the treatment of PPD, for which Breakthrough Device Designation was recently granted by the US Food and Drug Administration. WB001 combines therapeutic alliance, human-centered design, machine learning techniques, and established principles from CBT and interpersonal therapy (IPT). We introduce AGCBT as a new model of service delivery, whilst describing Woebot, the agent technology that enables guidance through the replication of some elements of human relationships. The profile describes the device's design principles, enabling technology, risk handling, and efficacy data in PPD.

EXPERT OPINION

WB001 is a dynamic and personalized tool with which patients may establish a therapeutic bond. Woebot is designed to augment (rather than replace) human healthcare providers, unlocking the therapeutic potency associated with guidance, whilst retaining the scalability and agency that characterizes self-help approaches. WB001 has the potential to improve both the quality and the scalability of care through providing support to patients on waiting lists, in between clinical encounters, and enabling automation of measurement-based-care.

The effectiveness of psychological interventions for anxiety in the perinatal period: A systematic review and meta-analysis

PURPOSE

Anxiety disorders are relatively common during pregnancy and the postnatal period. Despite their potential acceptability to users, psychological interventions research for this population is still in its infancy. The meta-analysis aimed to comprehensively evaluate the evidence of the effectiveness of psychological interventions for reducing perinatal anxiety.

METHOD

The review followed PRISMA guidelines. A total of 26 studies published between 2004 and 2022 fulfilled inclusion criteria of which 22 were included in the meta-analysis.

RESULTS

Results indicated that psychological interventions were more effective than control conditions in reducing symptoms of perinatal anxiety (equivalent to a medium post treatment effect size). Effect sizes were robust for cognitive, behavioural and mindfulness-based interventions. Targeting anxiety also appeared to impact on depression symptoms. There was substantial evidence of methodological heterogeneity.

CONCLUSIONS

This review demonstrates that psychological interventions are effective in reducing symptoms of both anxiety and comorbid anxiety and depression in both the antenatal and postnatal periods. Further research on longer-term effects, infant outcomes, treatment approach and modality are required.

Inpatient obstetric consultation-liaison services: Meeting unmet needs in perinatal mental health

Obstetric patients are at increased risk for psychological distress and the development or exacerbation of mental illness, particularly in the setting of pregnancy or delivery complications. Inpatient antepartum, labor and delivery, and postpartum hospitalization is an important opportunity for psychiatric support and intervention. The aims of this paper are to review the unmet mental health needs in obstetric inpatient care, examine the current state of obstetric consultation-liaison (OB CL) psychiatry services, present one existing model of such a service at the authors' institution, provide broad recommendations for the structure and implementation of this service, and detail areas of future research within the area of OB CL psychiatry. We argue that the inpatient obstetric setting is a critical space for mental health evaluation, education and intervention, and that dedicated OB CL psychiatry services are a potentially valuable tool in addressing the perinatal mental health crisis.

Mental health-related telemedicine interventions for pregnant women and new mothers: a systematic literature review

BACKGROUND

Pregnancy and the postpartum period are times when women are at increased risk for depression and mental problems. This may also negatively affect the foetus. Thus, there is a need for interventions with low-threshold access and care. Telemedicine interventions are a promising approach to address these issues. This systematic literature review examined the efficacy of telemedicine interventions for pregnant women and/or new mothers to address mental health-related outcomes. The primary objective was to analyse whether telemedicine interventions can reduce mental health problems in pregnant women and new mothers. The secondary aim was to clarify the impact of type of interventions, their frequency and their targets.

METHODS

Inclusion criteria: randomized controlled trials, with participants being pregnant women and/or new mothers (with infants up to twelve months), involving telemedicine interventions of any kind (e.g. websites, apps, chats, telephone), and addressing any mental health-related outcomes like depression, postnatal depression, anxiety, stress and others. Search terms were pregnant women, new mothers, telemedicine, RCT (randomised controlled trials), mental stress as well as numerous synonyms including medical subject headings. The literature search was conducted within the databases PubMed, Cochrane Library, Web of Science and PsycINFO. Screening, inclusion of records and data extraction were performed by two researchers according to the PRISMA guidelines, using the online tool CADIMA.

RESULTS

Forty four articles were included. A majority (62%) reported significantly improved mental health-related outcomes for participants receiving telemedicine interventions compared to control. In particular (internet-delivered) Cognitive Behavioural Therapy was successful for depression and stress, and peer support improved outcomes for postnatal depression and anxiety. Interventions with preventive approaches and interventions aimed at symptom reduction were largely successful. For the most part there was no significant improvement in the symptoms of anxiety.

CONCLUSION

Telemedicine interventions evaluated within RCTs were mostly successful. However, they need to be designed to specifically target a certain mental health issue because there is no one-size-fits-all approach. Further research should focus on which specific interventions are appropriate for which mental health outcomes in terms of intervention delivery modes, content, target approaches, etc. Further investigation is needed, in particular with regard to anxiety.

Psychological treatment of perinatal depression: a meta-analysis

BACKGROUND

Depression during pregnancy and after the birth of a child is highly prevalent and an important public health problem. Psychological interventions are the first-line treatment and, although a considerable number of randomized trials have been conducted, no recent comprehensive meta-analysis has evaluated treatment effects.

METHODS

We used an existing database of randomized controlled trials of psychotherapies for adult depression and included studies aimed at perinatal depression. Random effects models were used in all analyses. We examined the effects of the interventions in the short and long term, and also examined secondary outcomes.

RESULTS

Forty-three studies with 49 comparisons and 6270 participants between an intervention and control group were included. The overall effect size was g = 0.67 [95% confidence interval (CI) 0.45~0.89; numbers needed-to-be-treated = 4.39] with high heterogeneity (I2 = 80%; 95% CI 75~85). This effect size remained largely unchanged and significant in a series of sensitivity analyses, although some publication bias was found. The effects remained significant at 6-12 months follow-up. Significant effects were also found for social support, anxiety, functional limitations, parental stress and marital stress, although the number of studies for each outcome was low. All results should be considered with caution because of the high levels of heterogeneity in most analyses.

CONCLUSIONS

Psychological interventions are probably effective in the treatment of perinatal depression, with effects that last at least up to 6-12 months and probably also have effects on social support, anxiety, functional impairment, parental stress, and marital stress.

Effect of Remote Peer-Counsellor- delivered Behavioral Activation and Peer-support for Antenatal Depression on Gestational Age at Delivery: a single-blind, randomized control trial

BACKGROUND

Antenatal depression (AD) is the most common complication of pregnancy in developed countries and increases the risk of preterm birth (PTB). Many pregnant individuals with AD do not obtain treatment due in part to risks associated with antidepressant medications, the expense and wait times for psychological services, and perceived stigma. Accessible and timely treatment of antenatal depression is crucial to minimize foetal impacts and associated long-term child health outcomes. Previous studies show that behavioural activation and peer support are promising avenues of treatment for perinatal depression. Additionally, remote and paraprofessional counselling interventions show promise as more accessible, sustainable, and cost-effective treatment avenues than traditional psychological services. The primary aim of this trial is to test the effectiveness of a remote, behavioural activation and peer support intervention, administered by trained peer para-professionals, for increasing gestational age at delivery among those with antenatal depression. The secondary aims are to evaluate the effectiveness for treating AD prior to delivery, with persistence into the postpartum; improving anxiety symptoms; and improving parenting self-efficacy compared to controls.

METHODS

A two-arm, single-blinded, parallel groups randomized controlled trial (RCT) with repeated measures will be conducted. Participants scoring >10 on the Edinburgh Postnatal Depression Scale will be recruited from the larger P3 cohort and invited to enroll. Assessments will be conducted prior to 27 weeks' gestation at trial intake (T1), post-intervention, prior to delivery (T2), 5-6 months postpartum (T3), and 11-12 months postpartum (T4) and will include self-report questionnaires and linked medical records.

DISCUSSION

Our remote, peer paraprofessional-delivered behavioural activation plus peer support intervention has the potential to successfully reduce symptoms of AD, which may in turn decrease the risk of PTB and subsequent health impacts. The current trial builds on previous findings and uses a patient-oriented approach to address priorities for patient care and to provide a cost-effective, accessible, and evidence-based treatment to pregnant individuals with AD.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number (ISRCTN) registry (ISRCTN51098220) ISRCTN51098220. Registered on April 7, 2022.

Effectiveness of cognitive behavioural therapy-based interventions for maternal perinatal depression: a systematic review and meta-analysis

BACKGROUND

Depression during the perinatal period (during pregnancy and the year after childbirth) is common and associated with a range of negative effects for mothers, infants, family members, and wider society. Although existing evidence suggests cognitive behavioral therapy (CBT) based interventions are effective for perinatal depression, less is known about the effect of CBT-based interventions on important secondary outcomes, and a number of potential clinical and methodological moderators have not been examined.

METHODS

A systematic review and meta-analysis primarily examined the effectiveness of CBT-based interventions for perinatal depression on symptoms of depression. Secondary aims examined the effectiveness of CBT-based interventions for perinatal depression on symptoms of anxiety, stress, parenting, perceived social support, and perceived parental competence; and explored clinical and methodological moderators potentially associated with effectiveness. A systematic search of electronic databases and other sources was performed up to November 2021. We included randomized controlled trials comparing CBT-based interventions for perinatal depression with control conditions allowing for the isolation of the effects of CBT.

RESULTS

In total, 31 studies (5291 participants) were included in the systematic review and 26 studies (4658 participants) were included in the meta-analysis. The overall effect size was medium (hedges g = - 0.53 [95% CI - 0.65 to - 0.40]); with high heterogeneity. Significant effects were also found for anxiety, individual stress, and perceived social support, however few studies examined secondary outcomes. Subgroup analysis identified type of control, type of CBT, and type of health professional as significant moderators of the main effect (symptoms of depression). Some concerns of risk of bias were present in the majority of studies and one study had a high risk of bias.

CONCLUSIONS

CBT-based interventions for depression during the perinatal period appear effective, however results should be interpreted with caution given high levels of heterogeneity and low quality of included studies. There is a need to further investigate possibly important clinical moderators of effect, including the type of health professional delivering interventions. Further, results indicate a need to establish a minimum core data set to improve the consistency of secondary outcome collection across trials and to design and conduct trials with longer-term follow-up periods.

TRIAL REGISTRATION

CRD42020152254 .

The effect of mindfulness-based interventions during pregnancy on postpartum mental health: A meta-analysis

BACKGROUND

Mindfulness helps reduce negative emotions, but its ability to prevent postpartum psychological problems remains unclear. This study aimed to assess the effects of mindfulness-based interventions (MBIs) during pregnancy on postpartum mental health, especially postpartum depression.

METHODS

Online databases regarding the effect of mindfulness on pregnancy were searched and a meta-analysis was conducted.

RESULTS

Eight randomized controlled trials (RCTs) and a self-controlled study were included. We found consistent results showing that MBIs significantly improve the depressive symptoms of all pregnant women in both the case-control (SMD = -0.90, 95 % CI (-2.71, -1.82), p = 0.01) and self-control (SMD = 1.24, 95 % CI (0.37, 2.11), p = 0.005) comparisons. However, MBIs were ineffective for high-risk pregnant women with severe depressive symptoms before delivery in both the case-control (SMD = -1.07, 95 % CI (-3.40, 1.25), p = 0.36) and self-control comparisons (SMD = 2.10, 95 % CI (-0.26, 4.47), p = 0.08). Furthermore, MBIs did not have significant advantages over other intervention methods (SMD = -0.45, 95 % CI (-1.17, 0.28), p = 0.23).

LIMITATIONS

There were few high-quality RCTs, and the sample size was small.

CONCLUSION

MBIs can relieve maternal depressive and anxiety symptoms, especially for the prevention of postpartum depression in healthy pregnant women. However, MBIs do not have significant advantages over other interventions and may not be useful for all pregnant women. These findings contribute to the optimization of perinatal mental health intervention programs and the improvement of pregnancy outcomes, playing an important guiding role in clinical decision-making.

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.

In-person 1-day cognitive behavioral therapy-based workshops for postpartum depression: a randomized controlled trial

BACKGROUND

Postpartum depression (PPD) affects up to one in five mothers and birthing parents, yet as few as 10% access evidence-based treatment. One-day cognitive behavioral therapy (CBT)-based workshops for PPD have the potential to reach large numbers of sufferers and be integrated into stepped models of care.

METHODS

This randomized controlled trial of 461 mothers and birthing parents in Ontario, Canada with Edinburgh Postnatal Depression Scale (EPDS) scores ⩾10, age ⩾18 years, and an infant <12 months of age compared the effects of a 1-day CBT-based workshop plus treatment as usual (TAU; i.e. care from any provider(s) they wished) to TAU alone at 12-weeks post-intervention on PPD, anxiety, the mother-infant relationship, offspring behavior, health-related quality of life, and cost-effectiveness. Data were collected via REDCap.

RESULTS

Workshops led to meaningful reductions in EPDS scores (m = 15.77 to 11.22; b = -4.6, p < 0.01) and were associated with three times higher odds of a clinically significant decrease in PPD [odds ratio (OR) 3.00, 95% confidence interval (CI) 1.93-4.67]. Anxiety also decreased and participants had three times the odds of clinically significant improvement (OR 3.20, 95% CI 2.03-5.04). Participants reported improvements in mother-infant bonding, infant-focused rejection and anger, and effortful control in their toddlers. The workshop plus TAU achieved similar quality-adjusted life-years at lower costs than TAU alone.

CONCLUSIONS

One-day CBT-based workshops for PPD can lead to improvements in depression, anxiety, and the mother-infant relationship and are cost-saving. This intervention could represent a perinatal-specific option that can treat larger numbers of individuals and be integrated into stepped care approaches at reasonable cost.

Effectiveness of non-pharmacological treatments for postpartum depression: an umbrella review protocol

INTRODUCTION

Non-pharmacological treatments for postpartum depression have been investigated in various systematic reviews, and their efficacy has been evaluated. However, the quality of the evidence as a whole has not been quantified. The quality of this evidence may influence the choice of interventions and even cause misleading clinical decisions. This study aims to provide an objective presentation of the methodological bias and identify treatments supported by solid evidence.

METHODS AND ANALYSIS

For the purpose of conducting systematic reviews and meta-analyses, a comprehensive search of the relevant published literature will be conducted in English databases such as PubMed, Embase, Cochrane Library, PsycINFO and Scopus, as well as in four Chinese databases: the Chinese Biomedical Databases (CBM), Wan fang database, China National Knowledge Infrastructure and VIP Database (VIP). The time of publication will be limited from their inception to 31 May 2022. We will extract the following data from the included literature: title, first author, journal type of included literature, number and sample size, intervention/control measures, outcome indicators and main study outcomes. The Assessment of Multiple Systematic Reviews-2 will be used to measure the quality of the methods. In addition, we will use the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement to evaluate the quality of the reporting, as well as the Grading of Recommendations Assessment, Development and Evaluation to evaluate the quality of the evidence.

PROSPERO REGISTRATION NUMBER

CRD42021285470.

The Art of Holding Perinatal Women in Distress

Therapies like cognitive behavioral therapy and interpersonal psychotherapy are regarded as highly effective treatments for perinatal mood and anxiety disorders. Therapists appreciate robust research supporting the efficacy of these evidenced-based treatments and the structure of the tools these therapies provide for effective intervention. Less has been written on supportive psychotherapeutic techniques and few of those writings provide instruction or tools for therapists who wish to strengthen their skills in this therapeutic approach. This article describes The Art of Holding Perinatal Women in Distress™, a model of perinatal treatment developed by Karen Kleiman, MSW, LCSW. Kleiman instructs therapists to incorporate six "Holding Points" into their approach to therapeutic assessment and intervention for the purpose of establishing a holding environment conducive to the release of authentic suffering. This article reviews the Holding Points and provides a case study that elucidates how the holding points function within the context of a therapy session.

The impact of telemental health interventions on maternal mental health outcomes: a pilot randomized controlled trial during the COVID-19 pandemic

Background

The lethal potential of COVID-19 was often emphasized and repeatedly brought to the attention of pregnant women, leading to a higher level of anxiety, depression, and COVID-19-specific phobia among this population. Furthermore, legislation forced social distancing and isolation to interrupt the infection cycle. Together these factors resulted in higher maternal mental health distress requiring intervention. Nevertheless, there is a lack of evidence regarding the impact of low-intensity psychosocial telemental interventions on maternal mental health outcomes. Therefore, the objective of this pilot study is to assess the efficacy of video low-intensity psychosocial telemental maternal intervention on COVID-19-specific phobia, antenatal depression, and anxiety among pregnant women. We hypothesized that the intervention arm would be superior to the control arm. A parallel design randomized interventional controlled trial with 1:1 randomization was conducted at the Women Wellness and Research Center. We enrolled fifty-eight pregnant women in their second trimester who spoke English or Arabic. We assessed antenatal anxiety, depression, and Covid-19-specific phobia at baseline (T₀), and thirty-three pregnant women completed the follow-up after four weeks (T₁). Pregnant women receiving psychotropic medications and follow up in mental health services were excluded.

Results

A low-intensity psychosocial telemental maternal session helps reduce antenatal anxiety. We found statistically significant differences in antenatal anxiety scores between the intervention (2.4 ± 2.2) and control (4.2 ± 1.6) groups (p = 0.013) with a large effect size of Hedges' g value (0.96, 0.22-1.74). The absolute risk reduction was 27.27 percent. However, the intervention had no statistically significant effect on reducing antenatal depression or COVID-19-specific phobia.

Conclusions

Low-intensity psychosocial telemental maternal sessions effectively reduce antenatal anxiety. While our findings are promising, further RCTs are needed to replicate these findings.

Trial registration

2a-ClinicalTrials.gov identifier: NCT04594525.. Registered on 20/October/2020; updated 9/March/ 2022. Available from: Maternal Telemental Health Interventions in Response to Covid-19* - Full Text View - ClinicalTrials.gov.

A guide to prenatal counseling regarding neurodevelopment in congenital heart disease

Advances in cardiac surgical techniques taking place over the past 50 years have resulted in the vast majority of children born with congenital cardiac malformations now surviving into adulthood. As the focus shifts from survival to the functional outcomes of our patients, it is increasingly being recognized that a significant proportion of patients undergoing infant cardiac repair experience adverse neurodevelopmental (ND) outcomes. The etiology of abnormal brain development in the setting of congenital heart disease is poorly understood, complex, and likely multifactorial. Furthermore, the efficacy of therapies available for the learning disabilities, attention deficit, and hyperactivity disorders and other ND deficits complicating congenital heart disease is currently uncertain. This situation presents a challenge for prenatal counseling as current antenatal testing does not usually provide prognostic information regarding the likely ND trajectories of individual patients. However, we believe it is important for parents to be informed about potential issues with child development when a new diagnosis of congenital heart disease is disclosed. Parents deserve a comprehensive and thoughtful approach to this subject, which conveys the uncertainties involved in predicting the severity of any developmental disorders encountered, while emphasizing the improvements in outcomes that have already been achieved in infants with congenital heart disease. A balanced approach to counseling should also discuss what local arrangements are in place for ND follow-up. This review presents an up-to-date overview of ND outcomes in patients with congenital heart disease, providing possible approaches to communicating this information to parents during prenatal counseling in a sensitive and accurate manner.

Preventing Postpartum Depression in the Early Postpartum Period Using an App-Based Cognitive Behavioral Therapy Program: A Pilot Randomized Controlled Study

A large proportion of women experience depression during the postpartum period. Few studies have investigated the use of mobile technology to prevent postpartum depression in women. This study investigated the preliminary effectiveness of the CareMom program, a new app-based cognitive behavioral therapy program, on reducing the depressive symptoms of mothers during the very early postpartum period via a pilot randomized controlled study. The participants were recruited during birth hospitalization (within 3 days after giving birth) and randomized to the waiting-list control and CareMom groups. Over the four-week intervention period, the CareMom group was required to complete 28 daily challenges via CareMom. The depressive (via EPDS) and anxiety (via GAD-7) levels of participants were measured at baseline and every 7 days postbaseline for 4 weeks. A total of 112 eligible participants were randomly allocated to the two groups (CareMom: n = 57; control: n = 55). At week 4, the CareMom group achieved a significantly lower EPDS score than the control group at week 4 (p = 0.037). In addition, the EPDS (p < 0.001) scores of the CareMom group were significantly lower than the baseline values. However, the control group did not show any significant reduction in this measure. No significant reduction of GAD-7 scores was observed for CareMom and control groups at week 4. This study provides preliminary evidence of the effectiveness of CareMom in reducing depressive symptoms in the general postpartum population during the very early postpartum period.

The approach to managing perinatal anxiety: A mini-review

Perinatal Anxiety (PNA) is defined as anxiety occurring during pregnancy and up to 12 months post-partum and is estimated to affect up to 20% of women. Risk factors for PNA are multiple and can be classed as psychological, social and biological. PNA negatively impacts on the mother, child and family. PNA is not well-recognized and diagnosis of PNA can be challenging for clinicians. There is currently no validated case-finding or diagnostic test available for PNA. PNA has been less extensively researched than perinatal depression (PND). Clinical guidance currently recommends pharmacological and psychological therapies for the management of women with PNA, however the limited research available suggests that other intervention types may also be effective with some evidence on the effectiveness of non-pharmacological interventions in primary care for PNA. This article provides a mini-review of PNA, summarizing current evidence around PNA including risk factors, the impact of PNA, the process of diagnosis of PNA and focussing predominantly on available management options for PNA.

Efficacy of nondrug interventions in perinatal depression: A meta-analysis

Perinatal depression causes significant harm to mothers and unborn infants. Nondrug intervention is a common and acceptable method for reducing perinatal depression in pregnant women; however, it lacks an evidence-based basis. This study aimed to evaluate the effectiveness of nondrug interventions, such as cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), and yoga, in reducing perinatal depression. Randomized controlled trials (RCTs) of CBT, IPT, and yoga for improving perinatal depression were searched in the Cochrane Library, PubMed, Web of Science, Embase, ProQuest, ScienceDirect, ClinicalKey, Wanfang Data (Chinese database), and China Knowledge Resource Integrated Database. The retrieval time limit was set from the establishment of the database to December 2021. Twenty-one studies involving a total of 1981 participants were included.The present meta-analysis showed that CBT and IPT could effectively alleviate depressive symptoms in perinatal women, and the curative effect of IPT was better than that of CBT. There was no significant difference in the improvement effect of yoga on participants with depressive symptoms compared with that in the controls.This study was registered with the International Prospective Register of Systematic Reviews (PROSPERO, CRD42022307675).

Maternal prenatal psychological distress and vitamin intake with children's neurocognitive development

BACKGROUND

Maternal prenatal psychological distress (PPD) is increasingly linked to sub-optimal child neurodevelopment. Daily intake of prenatal vitamin during pre-conception and early pregnancy may ameliorate the effects of PPD on cognition in the offspring.

METHODS

PPD was assessed in early (12-16 weeks) and late (28-32 weeks) gestation in the Ontario Birth Study. Prenatal vitamin supplement intake information was collected in early gestation. Child cognition at 4 years was assessed using the NIH Toolbox. Poisson regression was used to investigate associations between PPD and/or prenatal vitamin intake and child cognition.

RESULTS

Four hundred and eighteen mother-child dyads were assessed. Moderate-severe PPD experienced during early gestation was associated with reduced cognition (adjusted incidence rate ratio (IRR_adj) = 3.71, 95% confidence interval (CI): 1.57-8.77, P = 0.003). Daily intake of prenatal vitamins was not associated with cognition (IRR_adj = 1.34, 95% CI: 0.73-2.46, P = 0.34). Upon stratification, the experience of mild-severe PPD with daily intake of prenatal vitamins was associated with higher incident rates of suboptimal cognition compared to children of women with daily prenatal vitamin intake without any episode of PPD (IRR_adj = 2.88, 95% CI: 1.1-7.4).

CONCLUSIONS

Moderate-severe PPD in early pregnancy is associated with poor cognition in children and daily intake of prenatal vitamin did not ameliorate this association.

IMPACT

Our findings expand on existing literature by highlighting that exposure to prenatal psychological distress (PPD), in moderate-to-severe form, in the early stages of pregnancy, can have detrimental effects on the offspring's cognitive development at 4 years. Overall, prenatal vitamin intake did not ameliorate the effects of PPD. Early screening and treatment of prenatal maternal mental illness is crucial.

Effect of transcutaneous auricular vagus nerve stimulation on major depressive disorder with peripartum onset: A multicenter, open-label, controlled proof-of-concept clinical trial (DELOS-1)

BACKGROUND

Postpartum depression has a high prevalence in the United States (~13 %) and often goes undertreated/untreated. We conducted a multicenter, open-label, proof-of-concept trial to assess the Nēsos wearable, non-invasive, transcutaneous auricular vagus nerve stimulation (taVNS) system for the treatment of major depressive disorder with peripartum onset (PPD).

METHODS

Women (n = 25), ages 18 to 45, within 9 months postpartum, and diagnosed with PPD were enrolled at 3 sites. The study included 6 weeks open-label therapy and 2 weeks observation. Efficacy outcomes included change from baseline (CFB) in Hamilton Rating Scale for Depression (HAMD17) total scores, HAM-D17 response and remission, and patient and clinician global impression of change (PGIC, CGIC) scores. Analysis included descriptive statistics and mixed-effects models for repeated measures.

RESULTS

The most common AEs (≥5 %) were discomfort (n = 5), headache (n = 3), and dizziness (n = 2); all resolved without intervention. No serious AEs or deaths occurred. Baseline mean HAM-D17 score was 18.4. Week 6 least squares (LS) mean CFB in HAM-D17 score was -9.7; 74 % achieved response and 61 % achieved remission. At week 6, at least some improvement was reported by 21 of 22 (95 %) clinicians on CGIC and 22 of 23 (96 %) participants on PGIC.

LIMITATIONS

This was a single-arm, open-label study, and enrollment was limited to participants with mild-to-moderate peripartum depression.

CONCLUSION

Results from this proof-of-concept study suggest that the Nēsos taVNS system is well tolerated and may be an effective non-invasive, non-pharmacological treatment for major depressive disorder with peripartum onset. Further evaluation in larger sham-controlled studies is needed.

CLINICALTRIALS

govNCT03972995.

Family History of Psychiatric Disorders as a Risk Factor for Maternal Postpartum Depression: A Systematic Review and Meta-analysis

Importance

Current evidence on the association between family history of psychiatric disorders and postpartum depression is inconsistent; family studies have identified familial risk of postpartum depression, whereas systematic reviews and umbrella reviews, compiling all risk factors for postpartum depression, often have not.

Objective

To investigate the association between family history of psychiatric disorders and risk of developing postpartum depression within 12 months post partum.

Data Sources

Literature searches were conducted in PubMed, Embase, and PsycINFO in September 2021 and updated in March 2022, accompanied by citation and reference search.

Study Selection

Studies eligible for inclusion comprised peer-reviewed cohort and case-control studies reporting an odds ratio (OR) or sufficient data to calculate one for the association between family history of any psychiatric disorder and postpartum depression. Study selection was made by 2 independent reviewers: title and abstract screening followed by full-text screening.

Data Extraction and Synthesis

Reporting was performed using the MOOSE checklist. Two reviewers independently extracted predefined information and assessed included studies for risk of bias using the Newcastle-Ottawa Scale. Data were pooled in a meta-analysis using a random-effects model. Heterogeneity was investigated with meta-regression, subgroup, and sensitivity analyses. Publication bias was investigated using a funnel plot, and GRADE (Grading of Recommendations Assessment, Development, and Evaluation) was used to evaluate the overall certainty of the findings.

Main Outcomes and Measures

The primary outcome was the pooled association between family history of psychiatric disorders and postpartum depression.

Results

A total of 26 studies were included, containing information on 100 877 women. Meta-analysis showed an increased OR of developing postpartum depression when mothers had a family history of psychiatric disorders (OR, 2.08; 95% CI, 1.67-2.59; I2 = 57.14%) corresponding to a risk ratio of 1.79 (95% CI, 1.52-2.09), assuming a 15% postpartum depression prevalence in the general population. Subgroup, sensitivity, and meta-regression analyses were in line with the primary analysis. The overall certainty of evidence was deemed as moderate according to GRADE.

Conclusions and Relevance

In this study, there was moderate certainty of evidence for an almost 2-fold higher risk of developing postpartum depression among mothers who have a family history of any psychiatric disorder compared with mothers without.

Internet-based cognitive therapy for women with antenatal depressive symptoms during the COVID-19 pandemic: protocol for a multi-center randomized controlled trial across China

Background

Depression and anxiety are common among pregnant women. Internet-delivered psychological therapies such as cognitive behavioral therapy (iCBT) have been developed to increase accessibility and address common help-seeking barriers, especially during pandemic period. The objective of this trial is to evaluate the short-term and long-term effects of iCBT on reducing depressive symptoms among pregnant women during the COVID-19 pandemic with the overall goal of preventing depression recurrence in the first 12 months postpartum.

Methods

A multi-site randomized controlled trial will be conducted where 300 pregnant women early in their third trimester will be screened for depression symptoms using the Edinburgh Postnatal Depression Scale (EPDS) during a routine obstetrical visit. Eligible and consenting women with a score greater than 9 will be randomly allocated (1:1) to either intervention group or control group. ICBT involving the completion of 7 weekly online modules will be delivered via a well-designed perinatal mental healthcare app. The primary objective is to evaluate the effect of iCBT on reducing depression symptoms among pregnant Chinese women starting from their third trimester. The secondary objectives are to examine the effect of iCBT on anxiety, sleep quality, social support, parenting stress, co-parenting relationship, and infant development.

Discussion

This multi-center randomized controlled trial has been planned in accordance with best practices in behavioral trial design. The internet-based intervention addressed the needs of pregnant women during a major pandemic where face-to-face therapy is not preferable. The trial has a relatively large sample size with sufficient power to evaluate the efficacy of iCBT intervention for the primary and secondary outcomes. One year follow-up evaluation in the study is designed to determine the longer-term effect of the intervention on both maternal and infant outcomes. Although a limitation is the assessment of depression and anxiety using self-report measures, these easily incorporated and maternal-preferred assessments allow for real-life scalability if the intervention is proven to be effective.

Ethics and dissemination

Ethics was approved by the institutional review board of International Peace Maternity and Child Health Hospital (GKLW2020-25). Dissemination of results will be published in peer-reviewed academic journals and presented at scientific conferences.

Trial status

The first patient was enrolled on 19 August 2020. To date, 203 participants have met eligibility requirements and been randomized to either the intervention group or control group. Data collection aims to be complete in September 2022. Date and version identifier: 2020715-version1.0.

Trial registration

ChiCTR2000033433. Registered 31 May 2020, http://www.chictr.org.cn/showproj.aspx?proj=54482.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06728-5.

Transdiagnostic Internet-Delivered Cognitive Behavioral Therapy for Symptoms of Postpartum Anxiety and Depression: Feasibility Randomized Controlled Trial

Background

Postpartum depression (PPD) and postpartum anxiety (PPA) are often comorbid and are associated with significant personal and economic costs. Fewer than half of the mothers experiencing PPD or PPA symptoms receive face-to-face treatment, suggesting a need for alternative delivery formats such as internet-delivered cognitive behavioral therapy (ICBT).

Objective

This pilot study aimed to examine the impact of a therapist-assisted, transdiagnostic ICBT program on symptoms of PPD and PPA, as there is only one previous study on transdiagnostic ICBT with this population, which did not include therapist assistance.

Methods

Clients endorsing the symptoms of PPD or PPA (N=63) were randomized to an 8-week transdiagnostic ICBT course (Wellbeing Course for New Moms) or to treatment as usual (TAU). Clients completed measures of depression, anxiety, stress, postnatal bonding, and relationship satisfaction, as well as measures of treatment satisfaction and therapeutic alliance, before treatment, after treatment, and at the 1-month follow-up. Outcome measures were also completed at the 6-month follow-up for clients who completed the ICBT course.

Results

Both the ICBT and TAU groups experienced statistically significant improvements over time. The ICBT group experienced larger improvements after treatment and at the 1-month follow-up on more measures than the TAU group, with medium between-group Cohen d effects on primary outcome measures for anxiety (Cohen d=0.65, 95% CI 0.13-1.17), PPD (Cohen d=0.52, 95% CI 0.01-1.04), and depression (Cohen d=0.56, 95% CI 0.05-1.08), and on secondary outcome measures of overall distress (Cohen d=0.69, 95% CI 0.17-1.21), anxiety (Cohen d=0.59, 95% CI 0.07-1.11), and stress (Cohen d=0.76, 95% CI 0.23-1.28). Time-by-group interactions for proportional reductions between groups over time were only significant after treatment and at the 1-month follow-up for the primary anxiety measure (P=.006). This study was underpowered for detecting small or medium effects. Overall, clients perceived the treatment as credible, and 95% (21/22) of the clients were satisfied with the treatment content and therapist support.

Conclusions

Findings from this pilot study provide preliminary support for transdiagnostic ICBT in treating PPD and PPA symptoms to improve access to psychological treatments.

Trial Registration

ClinicalTrials.gov NCT04012580; https://clinicaltrials.gov/ct2/show/NCT04012580

Consumer acceptance of using a digital technology to manage postpartum depression

The goal of the study was to evaluate the end user experience using the MamaLift Plus app for 2 weeks to support the treatment of their postpartum depression (PPD). A total of 14 participants completed the study and their experiences are reported in this publication. Participants reported that MamaLift Plus is an acceptable, highly usable, and practical mobile tool to use weekly for the management of their PPD. More research is warranted to evaluate the benefit of digital behavior health interventions, especially in patient populations where mental health care may be limited or harder to access by patients.

Randomized controlled trial of Sunnyside: Individual versus group-based online interventions to prevent postpartum depression

BACKGROUND

Postpartum depression (PPD) is a serious mental health problem that has a prevalence rate of nearly 20% in the first three months after delivery. The purpose of this study was to evaluate the benefit of Sunnyside, an internet-based cognitive-behavioral intervention, delivered in a group format compared to the same intervention delivered individually for the prevention of PPD.

METHOD

210 people between 20- and 28-weeks gestation and who scored between 5 and 14 on the PHQ-8 and who did not meet criteria for major depression were recruited online. The Inventory of Depression and Anxiety Symptoms (IDAS), the Hamilton Rating Scale for Depression (HAMD), and the depression and anxiety modules of the MINI were obtained at baseline, post-treatment, and 12-weeks postpartum. Intervention adherence was measured by site usage.

RESULTS

Across self-report and interview measures of depression there were no significant differences in outcome between the group and the individual versions of the program. Rates of major depression and generalized anxiety disorder in the postpartum period were low and adherence to the conditions was similarly high. Participants in the individual condition were significantly more satisfied than participants in the group condition (p < 0.05).

LIMITATIONS

The sample was predominantly white (85%) and recruited online, which may limit generalizability.

CONCLUSIONS

The group intervention was not more effective than the individual intervention. However, ignoring groups, many measures improved over time. The results of this study provide evidence that mood symptoms improve when participating in an online preventive intervention for postpartum depression.

"The Mental Health Piece is Huge": perspectives on developing a prenatal maternal psychological intervention for congenital heart disease

OBJECTIVES

Women carrying a fetus diagnosed with congenital heart disease often experience significant distress because of their medical diagnosis. Given the well-documented impact associated with elevated prenatal stress and critical importance of developing targeted interventions, this study aims to examine stressors, coping and resilience resources, and mental health treatment preferences in pregnant women receiving a congenital heart disease diagnosis to inform the development of a psychological intervention to reduce maternal distress prenatally.

METHODS

Three groups of participants were included consisting of two pregnant women carrying a fetus with congenital heart disease, five women of children (4-16 months) with congenital heart disease, and five paediatric cardiology medical providers. Responses were gathered via semi-structured interviews and analysed using qualitative thematic analysis.

RESULTS

Information regarding four broad areas were analysed of emotional distress during pregnancy; experience of initial diagnosis; coping and resilience; and perspectives on a mental health intervention in pregnancy. Anxiety regarding baby's future, guilt following diagnosis, and various coping strategies emerged as primary themes among the participant sample. Medical staff corroborated mothers' heightened anxiety and viewed a psychotherapeutic intervention during the prenatal period as essential and complimentary to standard of care.

CONCLUSION

We identified salient themes and preferred components for a future psychological intervention delivered prenatally.

PRACTICE IMPLICATIONS

Patients' and providers' perspectives regarding the nature of maternal distress, resilience and treatment preferences can inform the development of interventions to support the emotional well-being of pregnant women carrying a fetus with congenital heart disease to optimise care and potentially improve outcomes for fetal brain development.

Cost-utility of a web-based intervention to promote maternal mental health among postpartum women presenting low risk for postpartum depression

OBJECTIVES

Web-based interventions for the promotion of maternal mental health could represent a cost-effective strategy to reduce the burden associated with perinatal mental illness. This study aimed to evaluate the cost-utility of Be a Mom, a self-guided web-based cognitive behavioral therapy intervention, compared with a waiting-list control.

METHODS

The economic evaluation alongside a randomized controlled trial was conducted from a societal perspective over a 14-month time frame. Postpartum women presenting low risk for postpartum depression were randomized to the intervention (n = 191) or control (n = 176) group and assessed at baseline, postintervention and 4 and 12 months after postintervention. Data regarding healthcare use, productive losses and quality-adjusted life years (QALYs) were collected and used to calculate incremental cost-effectiveness ratios (ICERs). Uncertainty was accounted for with nonparametric bootstrapping and sensitivity analyses.

RESULTS

At 14 months, and after accounting for a 3.5 percent discount rate, the intervention resulted in a yearly cost-saving of EUR 165.47 (-361.77, 28.51) and a QALY gain of 0.0064 (-0.0116, 0.0244). Bootstrapping results revealed a dominant ICER for the intervention group. Although results were statistically nonsignificant, cost-effectiveness acceptability curves showed that at a EUR 0 willingness to pay threshold, there is a 96 percent probability that the intervention is cost-effective when compared with the control group. The sensitivity analyses generally supported the acceptable likelihood of the intervention being more cost-effective than the control group.

CONCLUSIONS

From a societal perspective, the implementation of Be a Mom among low-risk postpartum women could be a cost-effective way to improve perinatal mental health.

A Review of Treatments and Clinical Guidelines for Perinatal Depression

Perinatal depression occurs in approximately 1 in 7 women and is considered the most common complication of pregnancy and childbearing. Management of perinatal depression may include a combination of nonpharmacological and pharmacological therapies depending on the severity of symptoms, the stage of gestation, and maternal preference. Healthcare providers are recommended to review current guidelines and provide information to women during pregnancy and postpartum regarding the risks and benefits of nonpharmacological and pharmacological treatment options for perinatal depression. In addition, healthcare providers should consider common barriers to treatment including inadequate screening and social stigma. This article reviews common treatments of perinatal depression as well as the clinical guidelines provided by the American Association of Obstetricians and Gynecologists (ACOG), the American Psychiatric Association (APA), and the US Preventive Services Task Force (USPSTF). Discussion of nonpharmacological therapies includes cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). Pharmacological treatments are reviewed by drug class and include selective serotonin reuptake inhibitors (SSRIs), serotonin/norepinephrine reuptake inhibitors (SNRIs), norepinephrine/dopamine reuptake inhibitors (NDRIs), and tricyclic antidepressants (TCAs). Adjunctive treatments of severe depression, including second-generation antipsychotics (SGAs), are also discussed.

Predicting Remission among Perinatal Women with Depression in Rural Pakistan: A Prognostic Model for Task-Shared Interventions in Primary Care Settings

Perinatal depression is highly prevalent in low- and middle-income countries (LMICs) and is associated with adverse maternal and child health consequences. Task-shared psychological and psychosocial interventions for perinatal depression have demonstrated clinical and cost-effectiveness when delivered on a large scale. However, task-sharing approaches, especially in LMICs, require an effective mechanism, whereby clients who are not likely to benefit from such interventions are identified from the outset so that they can benefit from higher intensity treatments. Such a stratified approach can ensure that limited resources are utilized appropriately and effectively. The use of standardized and easy-to-implement algorithmic devices (e.g., nomograms) could help with such targeted dissemination of interventions. The present investigation posits a prognostic model and a nomogram to predict the prognosis of perinatal depression among women in rural Pakistan. The nomogram was developed to deliver stratified model of care in primary care settings by identifying those women who respond well to a non-specialist delivered intervention and those requiring specialist care. This secondary analysis utilized data from 903 pregnant women with depression who participated in a cluster randomized, controlled trial that tested the effectiveness of the Thinking Healthy Program in rural Rawalpindi, Pakistan. The participants were recruited from 40 union councils in two sub-districts of Rawalpindi and randomly assigned to intervention and enhanced usual care. Sixteen sessions of the THP intervention were delivered by trained community health workers to women with depression over pregnancy and the postnatal period. A trained assessment team used the Structured Clinical Interview for DSM-IV current major depressive episode module to diagnose major depressive disorder at baseline and post-intervention. The intervention received by the participants emerged as the most significant predictor in the prognostic model. Among clinical factors, baseline severity of core-emotional symptoms emerged as an essential predictor, followed by atypical symptoms and insomnia. Higher severity of these symptoms was associated with a poorer prognosis. Other important predictors of a favorable prognosis included support from one’s mother or mother-in-law, financial empowerment, higher socioeconomic class, and living in a joint family system. This prognostic model yielded acceptable discrimination (c-statistic = 0.75) and calibration to aid in personalized delivery of the intervention.