A new US Preventive Services Task Force (USPSTF) Recommendation Statement recommends that clinicians refer pregnant and postpartum women at risk for depression to counseling services. Because there is no accurate screening tool to identify who might benefit from preventive interventions, the USPSTF suggests a pragmatic approach, providing referral or counseling interventions to women with 1 or more risk factors such as adolescent or single parenthood, low income, or a history of depression or current depressive symptoms. The full guidelines were published in JAMA.1,2
USPSTF investigators independently reviewed abstracts and full-text articles regarding the benefits and potential harms of preventive psychotherapy interventions for perinatal depression in either pregnant or postpartum women and/or their offspring. The investigators reviewed both randomized clinical trials and nonrandomized controlled intervention studies that assessed several interventions, including counseling, pharmacotherapy, physical activity, and health system interventions, for the prevention of depression in these individuals. In addition, the researchers reviewed the accuracy of tools to identify pregnant or postpartum women at risk for depression. Investigators considered depression status, symptoms of depression, as well as maternal, infant, and child health outcomes.
Literature Review: Findings
An independent review of the literature by 2 investigators produced 50 relevant studies comprising a total of 22,385 individuals. The most widely reported and studied interventions included counseling services. The counseling lasted a median of 8 weeks (range, 4-70 weeks), included a median of 8 sessions (range, 4-20 sessions), and had an estimated median of 12 hours of contact (range, 4-23.3 hours). In 17 randomized clinical trials, which included a total of 3094 participants, counseling interventions were associated with a significantly lower likelihood for perinatal depression compared with the likelihood for depression in controls (pooled risk ratio [RR], 0.61; 95% CI, 0.47-0.78; I2 = 39.0%). Overall, there was an absolute difference in the risk for perinatal depression consisting of a 31.8% greater reduction with counseling vs a 1.3% greater reduction for perinatal depression in the control group.
A small cohort evaluating 22 women at 20 weeks postpartum found that a prescription of sertraline was associated with a lower rate of depression recurrence vs in patients taking placebo (7% vs 50%, respectively; P =.04). Patients who took sertraline, however, had a higher risk for adverse events. In addition, studies did not demonstrate that nortriptyline or omega-3 fatty acids were preventive of perinatal depression when compared with placebo.
Three trials (n=1200) examined physical activity programs consisting of group or individual exercise sessions. Two trials found statistically significant reductions in depression symptoms (weighted mean difference, −3.45; 95% CI, −4.99 to −1.91), although pooled analysis failed to demonstrate statistically significant reductions in depression diagnosis (RR, 0.54; 95% CI, 0.18-1.57).
In 3 studies, health system interventions such as home visits and screening and patient navigation services performed by midwives and nurses had a pooled effect size similar to that of counseling, but the effect was not significant (restricted maximum likelihood RR, 0.58; 95% CI, 0.22-1.53; n=4738; I2 = 66.3%; absolute risk reduction range, −3.1% to −13.1%).
The USPSTF found convincing evidence that counseling interventions are effective in preventing perinatal depression. Cognitive behavioral therapy and interpersonal therapy were mentioned as examples of effective prevention options. The USPSTF found inadequate evidence to assess the benefits and harms of other interventions.
Potential Barriers of Implementing Recommendations
Marlene P. Freeman, MD, noted that, “The ideal setting in which to identify women at risk for perinatal depression is where they receive care, because women have multiple visits during pregnancy and in the postpartum period and are often motivated for self-care and behavioral change.”3 Dr Freeman continued, “However, clinicians who provide obstetrical care may not have the expertise or time during clinical visits to perform assessments and tailor referrals to women who are identified.” Lyndsay A. Avalos, PhD, MPH, and colleagues, added that primary care clinicians may also lack the resources, including training and education, to screen and refer at-risk patients to counseling services.4 Furthermore, a successful referral of patients at risk for perinatal depression would place a substantial “pressure on existing mental health resources that already have a shortage of health care professionals.” Finally, Avalos and her colleagues emphasized that the stigma associated with depression may also represent a patient-level barrier to implementation of the USPSTF guidelines, making stigmatization initiatives imperative.
In another piece, Jennifer N. Felder, PhD, suggests that various legislation and support models, like the California Assembly Bill 2193 and the Massachusetts Child Psychiatry Access Program for Moms, may help initiate a dialogue and that the increased integration of “perinatal depression care into obstetric, pediatric, and primary care clinics will enable more comprehensive and holistic care.”5 According to Dr Felder, “a hopeful outcome of the USPSTF recommendation is that it may galvanize efforts to enact the policy and health system changes that are needed to prevent perinatal depression.”
According to Katherine L. Wisner, MD, MS, and colleagues, future policies may need to combine Medicaid with private insurers to identify the best strategies for reimbursement for interventions designed to prevent perinatal depression.6 They also advocate for consideration of a federal paid parental leave law to improve mental health outcomes. “This USPSTF recommendation serves as a platform for iterative improvement in our tools to implement preventive approaches that reduce the burden that childbearing women, their families, and society bear,” Dr Wisner wrote.
1. US Preventive Services Task Force. Interventions to prevent perinatal depression: US Preventive Services Task Force recommendation statement. JAMA. 2019;321(6):580-587.
2. O’Connor E, Senger CA, Henninger ML, Coppola E, Gaynes BN. Interventions to prevent perinatal depression: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2019;321(6):588-601.
3. Freeman MP. Perinatal depression recommendations for prevention and the challenges of implementation. JAMA. 2019; 321(6):550-552.
4. Avalos LA, Flanagan T, Li D. Preventing perinatal depression to improve maternal and child health—a health care imperative [published online February 12, 2019]. JAMA Pediatr. doi: 10.1001/jamapediatrics.2018.5491
5. Felder JN. Implementing the USPSTF recommendations on prevention of perinatal depression—opportunities and challenges [published online February 12, 2019]. JAMA Intern Med. doi: 10.1001/jamainternmed.2018.7729
6. Wisner KL, Miller ES, Tandon D. Attention to prevention—can we stop perinatal depression before it starts? [published online February 12, 2019]. JAMA Psychiatry. doi: 10.1001/jamapsychiatry.2018.4085