Effectiveness of interpersonal psychotherapy in comparison to other psychological and pharmacological interventions for reducing depressive symptoms in women diagnosed with postpartum depression in low- and middle-income countries: A systematic review

Background

Postpartum depression (PPD) is a condition that can affect any woman regardless of ethnicity, age, party, marital status, income, and type of delivery. This condition is highly prevalent worldwide. PPD, if not treated timely, can affect the maternal-child bond and can have a detrimental impact on the future cognitive, emotional, and behavioral development of the child. Interpersonal psychotherapy (IPT) has been reported as an effective treatment of PPD in previous studies as this focuses on relationship and social support issues. Previous reviews conducted in developed nations have reported the superior efficacy of IPT in comparison to other treatment options. There is no systematic review conducted in low to middle-income countries on the efficacy of IPT on PPD. Therefore it was necessary to undertake a systematic review to assess the effectiveness of IPT in reducing the depression among postpartum women in low and middle-income countries (LMICs).

Objectives

The main aim of this systematic review was to assess the effectiveness of IPT alone or in conjunction with pharmacological therapy and/or other psychological and psychosocial interventions, in reducing depressive symptoms among women diagnosed with PPD residing in LMICs.

Search Methods

The systematic search encompassed several prominent databases and grey literature. Furthermore, experts specializing in the field of IPT were consulted to identify any relevant studies conducted in LMICs that fulfilled the predetermined eligibility criteria. The most recent search update was performed in July 2022.

Selection Criteria

The PICOS criteria were meticulously defined for this review as described. Participants: Postpartum women diagnosed with PPD in LMICs were included. Intervention: IPT either as a standalone treatment or in conjunction with pharmacological therapy was included. Comparison: any form of psychological therapy or pharmacological therapy, whether administered individually or in combination, was considered for comparison. Study designs: experimental and quasi-experimental, factorial designs, and quantitative components (experimental, quasi-experimental, factorial designs) of mixed methods designs were eligible to be included. Studies with single-group study designs and qualitative studies were excluded from the review.

Data Collection and Analysis

Two reviewers from our team conducted a rigorous screening process to determine the eligibility of articles for inclusion. This involved an initial evaluation of titles and abstracts, followed by a comprehensive assessment of the full text of selected articles. In instances where discrepancies arose between the two reviewers, resolution was achieved through discussion or consultation with a third author to establish a consensus. Following the screening process, two team members independently extracted pertinent information and data from the studies that met the inclusion criteria. The treatment effect of the intervention, in comparison to the control group, was subsequently analyzed utilizing the fixed effects model taking into account the small number of studies.

Main Results

A total of 17,588 studies were identified from various databases, and 6493 duplicate studies were removed. Subsequently, 9380 studies underwent independent title and abstract screening resulting in the exclusion of 9040 studies. 345 full texts were thoroughly assessed leading to the exclusion of 341 studies, finally including 4 studies for review. The four included trials were randomized trials and comprised a total sample size of 188 women diagnosed with PPD residing in LMICs. Among these studies, three compared IPT with usual treatment, while one study compared IPT with antidepressant medications (ADMs). In terms of the providers of IPT, in one study, IPT was administered by nurses, while psychologists delivered IPT in another study. In one study, community health workers were responsible for providing IPT. However, in one study, information regarding the specific providers of IPT was not available or reported. The primary outcome measure reported in all four studies was depression, assessed using the Edinburgh Postnatal Depression Scale (EPDS). The geographical distribution of the studies included; one conducted in Zambia, one in Kenya, one in Pakistan, and one in Iran. Out of the four studies, three were included in the meta-analysis, as missing data from one study could not be obtained. Based on the overall treatment effect, it was found that depression scores decreased significantly more in the IPT group compared to other interventions (usual treatment or ADMs) (standardized mean difference [SMD] -0.62, 95% confidence interval [CI] (-1.01, -0.23), Z = 3.13 (p = 0.002), χ 2 = 49.49; df = 2; p < 0.00001; I 2 = 96%; 3 studies, n = 136). Out of the three studies, two studies compared the effectiveness of IPT in reducing depression scores specifically when compared to the usual treatment, and in both studies, depression scores were reduced significantly in the IPT group as compared to the usual treatment group. Only one study directly compared the effectiveness of IPT with ADM, reporting that IPT was more effective than ADM in reducing depression scores among postpartum women. Regarding adverse outcomes, only one study reported suicidal ideation with one participant in the IPT group and two in the ADM group (RR 0.50, 95% CI (0.05, 5.30), p = 0.56, n = 78). The same study reported seven participants in the ADM group had adverse drug reactions as compared to none in the IPT group (RR 15.0, 95% CI (0.89, 254), p = 0.06, n = 78).

Authors' Conclusions

Our comprehensive search yielded a limited number of four studies conducted in such settings. Despite the scarcity of available evidence, the findings collectively suggest that IPT is indeed an effective treatment for reducing PPD when compared to usual treatment and pharmacological therapy. However given the low certainty of evidence, there is a need for further research in the form of well-designed randomized controlled trials with larger sample sizes and a reduced risk of bias. Such studies would greatly contribute to enhancing the strength and reliability of the evidence base regarding the effectiveness of IPT in the context of PPD in LMICs. The knowledge generated from future research endeavors would be highly valuable in guiding the development of more affordable and cost-effective treatment approaches for PPD in resource-limited settings.

Acupuncture at BL67 for Mild Postpartum Depression: A Prospective Case Series

Objective

The aim of this study was to explore the effects of acupuncture on mild postpartum depression (PPD).

Methods

15 patients diagnosed with PPD were enrolled in the study. Patients who satisfied the inclusion criteria received acupuncture therapy eight times over 4 weeks in the form of two 20-min treatment sessions per week. The treatment site was the BL67 acupuncture point (on the outside of the fifth toenail). After disinfecting the skin on the toes, sterile steel needles were gently inserted into the acupuncture point until the patient started to feel numb or swollen, a sensation known as de qi. Acupuncture was performed by the same doctor using HuanQiu stainless steel needles that were 0.2 mm in diameter and 40 mm in length. The Hamilton Depression Scale (HAMD) was used to evaluate the clinical effects of this therapy. Questionnaires were distributed to patients before therapy and 1 week after therapy and were immediately completed and checked.

Results

Treatment was associated with symptomatic improvement for all patients who adhered to therapy. The nine patients who completed treatment had an average pain score of 6.66 (SD 0.86); these patients’ average pre-treatment pain score was 10.83 (SD 1.47). Six patients who did not complete treatment had an average pain score of 11.23 (SD 1.48); the average pre-treatment pain score of these patients was 10.5 (SD 2.21). Thus, symptoms did not significantly improve for patients who failed to adhere to the therapy. There was no significant difference between the two groups with respect to HAMD score before treatment (P=0.363). By contrast, asignificant between-group difference in post-treatment HAMD score was detected (P=0.001). Two patients discontinued treatment due to haemorrhage at the site of needling, and four patients discontinued treatment due to the inconvenience of traffic. There were no significant complications.

Conclusion

Acupuncture therapy at BL67 may alleviate symptoms of mild PPD, however controlled clinical investigations are required to confirm its efficacy and effectiveness for this condition.

Psychopharmacological treatment of mood and anxiety disorders during pregnancy

Many women with psychiatric disorders want to become mothers and only a minority seek advise prior to becoming pregnant. In those women, in whom pregnancy can be planned, the decision, if a medication is required for stabilisation and which one to choose if this is the case, is easier to make than in women in whom pregnancy occurs unplanned. The physician has to weigh the risk that a relapse of the psychiatric disorder during pregnancy poses to the foetus against the reproductive risk of psychotropic drugs. This presentation is intended to assist in understanding the general principles of pharmacotherapy during pregnancy as well as the morphological, perinatal and neurobehavioural toxicity of antidepressants, antipsychotics, benzodiazepines and mood stabilisers.

Stigma and depression during pregnancy: does race matter?

Rates of depression treatment are low in pregnant women, particularly Black women. Stigma is an important barrier to treatment, but little research has examined how depression stigma differs in Blacks and Whites; a key purpose of this study. Participants were 532 pregnant women recruited in obstetrics settings, who responded to measures of stigma and mood. Black women reported more depression stigma than White women, regardless of their depression status, and were more likely to endorse the view that depression should be kept secret, than White women. In White women, stigma increased as a function of depression status (current, past, never). White women's perceptions of depression stigma were positively correlated with their beliefs about keeping depression secret. Secrecy and depression stigma were uncorrelated in Black women. There are important racial differences in the way depression stigma functions in pregnant women. Implications for engaging women in mental health treatment are discussed.

Postpartum depression

Postpartum depression (PPD) affects up to 15% of mothers. Recent research has identified several psychosocial and biologic risk factors for PPD. The negative short-term and long-term effects on child development are well-established. PPD is under recognized and under treated. The obstetrician and pediatrician can serve important roles in screening for and treating PPD. Treatment options include psychotherapy and antidepressant medication. Obstacles to compliance with treatment recommendations include access to psychotherapists and concerns of breastfeeding mothers about exposure of the infant to antidepressant medication. Further research is needed to examine systematically the short-term and long-term effect of medication exposure through breastmilk on infant and child development.

Psychothérapie interpersonnelle (PTI) et Counseling interpersonnel (CIP) pour le traitement de la dépression post-partum

La dépression périnatale est un trouble prévalent qui comporte un degré élevé de morbidité à la fois chez la mère et chez le nourrisson. De nos jours, on dispose de traitements validés empiriquement pour traiter tant la dépression post-partum que la dépression pendant la grossesse. Parmi ces traitements, la psychothérapie interpersonnelle (PTI) a démontré son efficacité à traiter la dépression post-partum, qu’elle soit légère ou grave. En fait, l’évidence limitée des preuves de l’efficacité de la médication et les préoccupations au sujet de ses effets secondaires ont porté certaines personnes à proposer que la PTI soit la première option retenue pour traiter les femmes souffrant de dépression et qui allaitent. Des préoccupations semblables persistent au sujet de l’usage de médicaments pendant la grossesse. De récentes expériences et recherches cliniques portent à croire que le counseling interpersonnel (CIP) pourrait aussi s’avérer efficace chez certaines femmes en dépression post-partum. Forme abrégée de la PTI, le CIP semble être efficace pour traiter la dépression légère à modérée, et a l’avantage potentiel d’être plus facile à dispenser dans le cadre des soins primaires ou des milieux obstétricaux.

A critical analysis of video tapes on postnatal depression

AIM

To watch videos on postnatal depression which are used by professionals, mothers and voluntary agencies and to review their quality, content, and themes.

BACKGROUND

To our knowledge there have been no previous studies of video tapes on postnatal depression for use by mothers and health care professionals during the antenatal and postnatal periods. A core group, consisting of a psychiatrist, health visitor and a mother, watched videos produced in the English language from Australia, South Africa, United States of America (USA) and the United Kingdom (UK). We found a similarity in all video tapes reviewed with regard to the feelings expressed by mothers and fathers. However, some of the context and culture differed in several countries where, during the management and treatment of postnatal depression, a medical rather than social model was preferred.