From the Journals

USPSTF recommends counseling for perinatal depression prevention

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Targeted, creative intervention can improve outcomes

A proactive approach to prevention and management of perinatal depression as recommended by the USPSTF can potentially improve outcomes for new mothers and their babies, Marlene P. Freeman, MD, wrote in an accompanying editorial. She identified three key challenges to implementing the USPSTF recommendations: identifying women at risk, connecting them to evidence-based treatment, and assessing outcomes after treatment.

Dr. Marlene P. Freeman of Massachusetts General, Boston

Dr. Marlene P. Freeman

The development of screening tools would help clinicians identify women at risk for perinatal depression, Dr. Freeman said. No such tool currently exists, but in the meantime, “women at risk may be identified by targeting those with histories of depression, subthreshold depressive symptoms, and certain sociodemographic factors (i.e., economically disadvantaged, single/young, unplanned pregnancy).”

The counseling interventions shown to be effective in preventing perinatal depression – cognitive behavioral therapy and interpersonal psychotherapy – require education and training outside the time limitations and expertise of many clinicians providing obstetric care, she noted.

“The delivery of effective care on a large scale will require creative solutions,” such as the use of telehealth and smartphone platforms, and the involvement of multidisciplinary teams to care for women with severe illness, Dr. Freeman said. “In addition, a substantial number of reproductive-aged women have serious psychiatric disorders and will be identified as at risk for perinatal depression, although their needs may be more comprehensive,” she wrote. “Women who are identified as at risk for perinatal depression may have psychotic disorders, bipolar spectrum disorders, anxiety disorders, and substance use disorders, and there is comorbidity among psychiatric disorders. Therefore, systematic provisions for referral and treatment for other psychiatric disorders should be considered.” Further research is needed to explore treatment options including pharmacotherapy for women with severe psychiatric disorders.

However, she expressed optimism that the recommendations for screening and counseling for perinatal depression are valuable, and they “may return great dividends in the form of enhanced well-being of mothers and their offspring.”

Dr. Freeman is affiliated with the department of psychiatry at Massachusetts General Hospital, Boston. She commented in an editorial accompanying the article by Curry et al. (JAMA. 2019 Feb 12;321[6]:550-2). Dr. Freeman disclosed relationships with companies including Takeda, JayMac, Sage, Otsuka, Alkermes, Janssen, and Sunovion; she also disclosed serving on an independent data safety and monitoring committee for Janssen (Johnson & Johnson); and editing the GOED (Global Organization for EPA & DHA Omega-3) newsletter.


 

FROM JAMA

Pregnant and postpartum women who are at increased risk of developing perinatal depression should undergo a counseling intervention, according to a B recommendation from the U.S. Preventive Services Task Force.

Pregnant woman talking with obstetrician monkeybusinessimages/Thinkstock

The Task Force determined that counseling interventions are effective in preventing perinatal depression, defined as a major or minor depressive episode during pregnancy or within the first year after delivery. The condition affects an estimated 12% of new mothers in the United States each year, according to lead author Susan J. Curry, PhD, of the University of Iowa, Iowa City, and her colleagues.

The recommendation, published in JAMA, applies to “pregnant persons and persons who are less than 1 year postpartum who do not have a current diagnosis of depression but are at increased risk of developing depression,” according to the authors (JAMA. 2019 Feb 12;321(6):580-7).

Risk factors for development of perinatal depression include:

  • Past history of depression.
  • Current depressive symptoms (that do not reach a diagnostic threshold).
  • History of physical or sexual abuse.
  • Unplanned or unwanted pregnancy.
  • Stressful life events.
  • Lack of social and financial support.
  • Intimate partner violence.
  • Pregestational or gestational diabetes.
  • Complications during pregnancy.
  • Adolescent parenthood.
  • Low socioeconomic status.
  • Lack of social support.

After reviewing the evidence, the USPSTF found a moderate net benefit for counseling interventions, particularly cognitive behavioral therapy and interpersonal therapy, for preventing perinatal depression in women at risk. Counseling sessions reviewed for this recommendation ranged from 4 to 20 meetings (median, 8 meetings).

The USPSTF found inadequate evidence to assess the harms and benefits of other noncounseling interventions, including pharmacologic therapy.

In the evidence review accompanying the recommendations, Elizabeth A. O’Connor, PhD, of Kaiser Permanente, Portland, Ore., and her colleagues analyzed data from 50 studies including 22,385 individuals; 20 of these studies were randomized, controlled trials of counseling interventions (JAMA. 2019 Feb 12;321(6):588-601).

Overall, the likelihood of perinatal depression was significantly lower among women who received counseling, compared with controls, among more than 3,000 women in those studies (pooled risk ratio 0.61). Absolute risk differences for perinatal depression ranged from a 1% increased reduction in controls to a 32% increased reduction among women who received counseling. The effects were strongest for cognitive behavioral therapy and interpersonal therapy as interventions. No adverse events were reported in the counseling intervention studies.

In three studies of health system interventions, the researchers found a benefit for interventions vs. controls, but the difference was not statistically significant.

Trials of most other alternative interventions including infant sleep advice, birth-experience postpartum debriefing, omega-3 fatty acid supplementation, expressive writing, antidepressants, and yoga did not show statistical significance in benefit for reducing perinatal depression.

Only one of three randomized controlled trials of physical activity found a statistically significant group difference.

A trial of nortriptyline to prevent perinatal depression showed no benefit, compared with placebo. A sertraline study of found “a smaller percentage of participants taking sertraline had a depression recurrence, compared with those taking placebo,” the investigators wrote. In these two studies, women who took nortriptyline showed no adverse effects, and those in a trial involving sertraline reported significantly more dizziness and drowsiness compared with placebo patients.

The evidence review was limited by the small number of quality studies, especially studies of alternative interventions. More research is needed; however, the findings support data from similar reviews and support the potential for counseling to prevent perinatal depression, particularly in women at increased risk for perinatal depression, Dr. O’Connor and her associates said.

The USPSTF is supported by the Agency for Healthcare Research and Quality. Coauthor Dr. Michelle L. Henninger reported receiving grants from Pfizer IGLC (Independent Grants for Learning & Change) outside the submitted work. Coauthor Dr. Bradley N. Gaynes reported receiving personal fees from LivaNova and Johnson & Johnson outside the submitted work. The remaining researchers had no financial conflicts to disclose.

SOURCE: Curry SJ et al. JAMA. 2019;321(6):580-7; O’Connor E et al. JAMA. 2019;321(6):588-601.

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