Importance: Depression during pregnancy and postpartum is relatively common and can have negative effects on the child as well as the mother.
Objective: To systematically review the benefits and harms of primary care-relevant interventions to prevent perinatal depression (i.e., depression during pregnancy and postpartum depression) to inform the United States Preventive Services Task Force.
Data Sources: MEDLINE, PubMED (for publisher-supplied records only), PsycINFO, and the Cochrane Central Register of Controlled Trials; references of relevant publications, government Web sites.
Study Selection: English-language controlled trials of interventions to prevent perinatal depression in general populations of pregnant and postpartum individuals (up to 1 year) or in those at increased risk of perinatal depression. We included trials of behavior-based interventions, including those targeting a health system or providers, as well as those examining antidepressants and dietary supplements.
Data Extraction and Synthesis: Two investigators independently reviewed abstracts and full-text articles, then we extracted data from studies rated as fair- and good-quality, based on predetermined criteria. Random-effects meta-analysis was used to estimate the benefits of the interventions. Strength-of-evidence ratings were made based on consistency, precision, study quality, and evidence of reporting bias, taking into account the size of the evidence base and other noted limitations.
Results: We identified 50 trials (N=22,385) that met our inclusion criteria. Counseling interventions were the most widely studied interventions; they reduced the likelihood of the onset of perinatal depression by 39 percent (pooled risk ratio [RR]=0.61 [95% confidence interval (CI), 0.47 to 0.78], k=17, n=3094, I2=39%) and showed a 1.5-point greater reduction in depression symptom levels than control conditions (weight mean difference in change between groups (WMD)= −1.51 [95% CI −2.84 to −0.18], k=14, n=1367, I2=61%). The absolute reduction in the risk of perinatal depression was highly variable across studies (range 1.3% greater reduction in the control group to 31.8% greater reduction in the intervention group), due to both variability in population differences in outcome measures reported. Two specific counseling approaches were studied in four or more separate trials in the United States, targeting high-risk women and including a substantial proportion of Black and Latina participants: the “Mothers and Babies” course, based on cognitive-behavioral therapy, and an interpersonal therapy-based approach developed by Zlotnick and colleagues, “Reach Out, Stand Strong, Essentials for new mothers” (ROSE). Pooled effects for these interventions were even larger than the overall pooled results for counseling interventions, but with overlapping confidence intervals. Health system and physical activity interventions showed similar pooled effects to the counseling interventions, but the effects were not statistically significant. In addition, none of the three health system interventions were conducted in the United States and applicability of the interventions to the United States was limited. Some other types of behavior-based interventions showed promising results (e.g., physical activity, peer counseling); however, few showed statistically significant group differences and even fewer have been replicated. None of the behavior-based interventions reported on harms directly, but the other reported outcomes did not suggest a risk of increased harm. In two studies of prophylactic use of antidepressants initiated immediately after childbirth, sertraline showed a statistically significant benefit at 20 weeks postpartum in one very small study (n analyzed=22), but with an increased risk of side effects to the mother. There was no benefit of nortriptyline use. Two trials each found that that debriefing interventions and omega-3 fatty acids (particularly docosahexaenoic acid [DHA]) are not effective in preventing perinatal depression.
Conclusion: Counseling interventions can be effective in preventing perinatal depression, although most evidence was limited to persons at increased risk for perinatal depression. A variety of other intervention approaches provided some evidence of effectiveness but lacked a robust evidence base and need further research.