Approximately 13% of women from diverse cultures will. Preventing Postpartum Depression Part II: A Critical Review of Nonbiological Interventions

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1 Review Paper Preventing Postpartum Depression Part II: A Critical Review of Nonbiological Interventions Cindy-Lee E Dennis, RN, PhD 1 Objective: To critically review the literature to determine the current state of scientific knowledge concerning the prevention of postpartum depression (PPD) from a nonbiological perspective. Methods: Databases searched for this review include Medline, PubMed, Cinahl, PsycINFO, Embase, ProQuest, the Cochrane Library, and the World Health Organization Reproductive Health Library. Studies selected were peer-reviewed English-language articles published between January 1, 1966, and December 31, Criteria used to evaluate the interventions were derived from the standardized methodology developed by the Canadian Task Force on Preventive Health Care. Results: Twenty-nine studies that met criteria were examined. These included studies evaluating interpersonal psychotherapy, cognitive-behavioural therapy, psychological debriefing, antenatal classes, intrapartum support, supportive interactions, continuity of care, antenatal identification and notification, early postpartum follow-up, flexible postpartum care, educational strategies, and relaxation with guided imagery. Conclusions: While this review demonstrates that no specific approach can be strongly recommended for clinical practice, many explicit research implications have been highlighted. To further address PPD as a public health problem, it is critical to include ethnically and socioeconomically diverse in research efforts examining the among depression symptoms, intervention response rates, and health service use. (Can J Psychiatry 2004;49: ) Information on funding and support and author affiliations appears at the end of the article. Clinical Implications Translating risk-factor research into predictive screening protocols and preventive interventions has met with limited success; complex interactions of biopsychosocial risk factors with individual variations need to be contemplated. No specific approach can be strongly recommended for clinical practice. It is critical to include ethnically and socioeconomically diverse in research efforts examining the among depression symptoms, intervention response rates, and health service use. Limitation Descriptive studies were excluded. Key Words: postpartum depression, prevention, critical review, randomized controlled trials, psychosocial, psychological Approximately 13% of from diverse cultures will twice as likely to experience future episodes of depression experience postpartum depression (PPD) within the first over a 5-year period (2), infants and children are particularly 12 weeks after childbirth (1). This hidden morbidity has vulnerable. PPD can cause impaired maternal infant well-documented health consequences for the mother, child, interactions (3) and negative perceptions of infant behaviour and family. While who have suffered from PPD are (4), which have been linked to attachment insecurity (5,6), 526

2 Preventing Postpartum Depression Part II: A Critical Review of Nonbiological Interventions Table 1 Canadian Task Force on Preventive Health Care research design and quality ratings Rating Description Design I II-1 II-2 II-3 III Quality (internal validity) Good Evidence from randomized controlled trials (RCTs) Evidence from controlled trial(s) without randomization Evidence from cohort or case control analytic studies, preferably from more than 1 centre or research group Evidence from comparisons between times or places with or without the intervention; dramatic results in uncontrolled experiments could be included here Opinion of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees A study (including metaanalyses or systematic reviews) that meets all design-specific criteria well Fair A study (including metaanalyses or systematic reviews) that does not meet (or does not clearly meet) at least 1 design-specific criterion but has no known fatal flaw Poor A study (including metaanalyses or systematic reviews) that has at least 1 design-specific fatal flaw or an accumulation of lesser flaws to the extent that the results of the study are not deemed able to inform recommendation emotional developmental delay (5,7), and social or interaction difficulties (8,9). Infants aged as young as 3 months have been shown to ably detect their mother s mood and to modify their own responses accordingly (10). While cognitive skills (11), expressive language development (12), and attention (13) have been negatively influenced by PPD, it has also been reported that children of mothers with depression are 2 to 5 times more likely to develop long-term behavioural problems (14,15). Child neglect and (or) abuse (16) and marital stress resulting in separation or divorce (17,18) are other reported outcomes. Maternal and infant mortality are rare but real consequences of PPD. Because of the potentially devastating and long-standing effects depression can have on the mother, her children, and the mother child relationship, preventing PPD is an important public health approach. Further, increased contact with health professionals during the perinatal period provides an ideal opportunity for preventive interventions. This paper critically reviews the literature to determine the current state of scientific knowledge concerning the prevention of PPD from a nonbiological perspective. Method Search Strategy Databases searched for this review include Medline, PubMed, Cinahl, PsycINFO, Embase, ProQuest, the Cochrane Library, and the World Health Organization Reproductive Health Library. As part of the quality assessment process and to measure the capture rate of relevant references, tables of contents of key journals were hand-searched for the past 2 years, graduate thesis abstracts were scanned, reference lists of included studies and relevant reviews were examined, and several PPD researchers were contacted via . In total, approximately 100 abstracts were examined for inclusion suitability. Inclusion and Exclusion Criteria The literature review systematically searched for peerreviewed English-language articles published between January 1, 1966, and December 31, Only research studies that focused on PPD (that is, inception of depression within the first year postpartum) were reviewed. Finally, research studies evaluating preventive interventions must have incorporated a PPD outcome assessment beyond the first week postpartum. Methodology for Synthesis Studies included were evaluated according to the published criteria used by the Canadian Task Force on Preventive Health Care (19) and were given research design and quality (that is, internal validity) ratings (Table 1). After the quality of evidence assessment was complete, each preventive approach was classified to determine clinical practice recommendations, according to the following grading scheme: A = there is good evidence to recommend this approach; B = there is fair evidence to recommend this approach; C = the evidence is conflicting and does not allow making a recommendation for or against use of this approach, though other factors may influence decision making; D = there is fair evidence to recommend against this approach; E = there is good evidence to recommend against this approach; I = there is insufficient evidence (in quantity and [or] quality) to make a recommendation, though other factors may influence decision making. Results For this critical review, 29 preventive studies were examined and classified into the following approaches: psychological, psychosocial, quality improvement, and other diverse interventions. Tables 2 5 present a comprehensive summary of each study including methodological limitations. While there are a modest number of studies reporting the prevention of PPD as the primary outcome, several additional investigations offer constructive data to ascertain whether limiting the Can J Psychiatry, Vol 49, No 8, August

3 The Canadian Journal of Psychiatry Review Paper influence of risk factors can decrease the incidence of PPD; these studies will also be presented to provide the most comprehensive review of potential preventive interventions. Psychological Interventions Interpersonal Psychotherapy (Table 2) Two studies were found that evaluated the principles of interpersonal psychotherapy (IPT). In a US trial, 37 pregnant were randomly assigned to receive either treatmentas-usual (n = 19) or a group intervention (4 weekly group sessions; n = 18) (20). Most of the in the intervention group (n = 15, 88%) attended 3 of the 4 sessions, and 35 participants completed both the Beck Depression Inventory (BDI) pre- and postintervention and the Structured Clinical Interview for DSM-III R (SCID) at 12 weeks postpartum. Six (33%) out of 18 in the control group developed PPD, compared with none of the 17 in the intervention group. In a similar study, 45 pregnant US with at least 1 PPD risk factor (for example, current or past history of depression) were randomly allocated to either an intervention group (consisting of 5 individual IPT sessions; n = 24) or a control group (consisting of standard care; n = 21) (21). At 4 weeks postpartum, significantly more mothers in the control group met DSM-III-R criteria for major depression than in the intervention group (25% vs 0%, P = 0.02). However, the prophylactic effects were not maintained through 24 weeks postpartum, as 3 (15%) mothers in the intervention group vs 4 (23.5%) mothers in the control group suffered from postpartum depression (P = 0.40). Cognitive-Behavioural Therapy (Table 2) Only 2 studies have evaluated cognitive-behavioural therapy (CBT). In a Finnish trial, 176 pregnant with a severe fear of childbirth were randomly allocated at 26 weeks gestation to either CBT therapy (n = 85) or conventional therapy (n = 91) (22). While birth-related concerns decreased in the CBT group, no significant group in BDI scores were found at 12 weeks postpartum. In a French study, the effect of CBT targeting both the prevention and treatment of PPD was evaluated (23); only the preventive component will be described here. Pregnant were screened during an obstetric clinic and at-risk (that is, those with an Edinburgh Postnatal Depression Scale [EPDS] score > 8) were alternately allocated to either a control group (consisting of usual care; n = 128) or an intervention group (consisting of 1 individualized CBT session; n = 113). At 4 to 6 weeks postpartum, 29/97 (29.8%) mothers in the intervention group vs 55/114 (48.2%) mothers in the control group scored over 11 on the EPDS ( 2 = 7.36, P = 0.007). Psychological Debriefing In a UK trial, 120 inhospital primiparous were randomized to receive either usual care (n = 60) or a midwife-led debriefing session before hospital discharge (n = 60) (24). Of the 114 who returned the Hospital Anxiety and Depression Scale (HADS), mailed at 3 weeks postpartum, significantly fewer mothers in the intervention group (n =5; %) exhibited depressive symptomatology, compared with the control group (n =31; 53.4%). Conversely, in a larger and well-executed Australian trial involving 1041 who had operative deliveries, inhospital midwife-led debriefing had a negative effect (25). In particular, more allocated to the debriefing group exhibited depressive symptomatology (n = 81, 17%) at 24 weeks postpartum, compared with allocated to usual postpartum care (n = 65, 14%), though the difference was not significant (odds ratio [OR] 1.24; 95%CI, 0.87 to 1.77). The possibility that this intervention contributed to emotional health problems for some cannot be excluded. In another Australian trial stratified for parity and delivery mode, 1745 were randomly allocated to receive either a standardized debriefing session within 72 hours of delivery (n = 875) or usual care (n = 870) (26). There were no significant between control and intervention groups in EPDS scores at 2, 6, or 12 months postpartum or in proportions of who met diagnostic criteria for major or minor depression during the postpartum year (intervention group, 17.8% vs control group, 18.2%; relative risk 0.99; 95%CI, 0.87 to 1.11). There were also no in median time to onset of depression (intervention group, 6 weeks [range 4 to 9 weeks] vs control group, 4 weeks [range 3 to 8 weeks]; P = 0.84), or in duration of depression (intervention group, 24 weeks [range 12 to 46 weeks] vs control group, 22 weeks [range 10 to 52 weeks]; P = 0.98). Though there was a high prevalence of depression among during the first year after childbirth, a session of midwife-led debriefing was not effective in preventing PPD. Finally, to study whether proactive educational counselling in addition to routine clinical care reduces psychological morbidity, a trial was conducted with Chinese who had unexpected antenatal, intrapartum, or postpartum events leading to suboptimal outcomes during pregnancy and childbirth (27). Based on the HADS, the General Health Questionnaire (GHQ), and the Clinical Global Impression (CGI), which were completed before and after counselling at 6 weeks and 6 months postdelivery, no significant group were found in psychological morbidity. In particular, 26 (9.8%) in the intervention group and 35 (14%) in the control group met the criteria of possible case of PPD, which was identified using a cut-off score of 4/5 in the GHQ. Psychosocial Interventions Antenatal and Postnatal Classes (Table 3) In a pioneering study, Gordon and Gordon conducted a quasi-experimental study to evaluate the effect of antenatal classes on the prevention of postpartum emotional problems (28). In the study, 161 pregnant US were allocated to either standard antenatal classes (n = 76) or standard antenatal classes plus 2 additional sessions (n = 85). Obstetricians assessed emotional problems, using a 4-point scale at 6 to 8 weeks postpartum. Only 15% of mothers in the intervention group experienced emotional problems, compared with 37% of mothers in the control group ( 2 = 7.3; P < 0.01). Only one-half the participants completed the 24-week follow-up, during which 1/46 (2%) mothers in the intervention group vs

4 Preventing Postpartum Depression Part II: A Critical Review of Nonbiological Interventions Table 2 Postpartum depression preventive intervention studies using interpersonal therapy, cognitive-behavioural therapy, and psychological debriefing Study, design, and participants Intervention Outcome measure Results Limitations Zlotnick and others (20): pilot RCT 37 US pregnant on public assistance with at least 1 risk factor for PPD Survival Skills for New Moms: 4 weekly 60-minute group sessions Interpersonal psychotherapy PPD at 12 weeks, BDI and SCID Gorman and others (21): RCT, stratification based on history of depression 45 US pregnant at risk for PPD 5 individual sessions beginning in late pregnancy and ending at approximately 4 weeks postpartum PPD at 4 and 24 weeks, SCID Cognitive-behavioural therapy (CBT) were found but effects were not maintained through 24 weeks postpartum. Saisto and others (22): RCT, random allocation using sealed envelopes, power analysis, intent-to-treat 176 Finnish pregnant with fear of childbirth CBT (mean 3.8, SD 1.0); sessions with CBT-trained obstetrician, 1 session with midwife, between-session telephone availability PPD at 12 weeks, BDI Chabrol and others (23): quasi-experimental, group allocation using alternate numbers 241 French with EPDS screening score 8 1 CBT session before hospital discharge provided by a therapist (included psychology graduate students) PPDat4to6 weeks, EPDS Psychological debriefing Lavender and others (24): RCT, random allocation using sealed envelopes, power analysis 120 primiparous UK 1 midwife-led debriefing session before hospital discharge, lasting 30 to 120 minutes PPD at 3 weeks, HADS Small and others (25): RCT, telephone randomization, power analysis, intent-to-treat 1041 Australian who had an operative birth: c/s, n = 624; forceps, n = 353; vacuum extraction, n = 64) 1 midwife-led debriefing session before hospital discharge PPD at 24 weeks, EPDS Priest and others (26): RCT, random allocation using sealed envelopes, power analysis, intent-to-treat 1745 Australian who delivered healthy term infants An individual, standardized debriefing session based on the principles of critical incident; stress debriefing conducted within 72 hours of delivery Tam and others (27): RCT, random allocation using sealed envelopes, power analysis 516 Hong Kong mothers who had unexpected perinatal events Educational counselling provided by a trained research nurse in the postnatal ward after delivery PPD at 8, 24, and 52 weeks, EPDS, diagnostic interview PPD at 6 and 24 weeks, HADS, GHQ Small sample size; 50% of eligible declined trial participation; inexplicit randomization process; atypical sample (77% of participants were single); intervention provider unknown Small sample size; inexplicit randomization process CBT intervention did not directly target PPD but rather fear of labour; statistical results related to PPD not reported Weak randomization method; a cut-off score of 8/9 rather than the recommended 9/10 was used to identify high-risk, and a cut-off score of 10/11 rather than the recommended 12/13 was used to assess for PPD Premature timing of outcome assessment; weak measure of PPD; atypical population (59.6% were single mothers) No serious limitations 31% of eligible mothers refused trial participation 32% of eligible mothers refused trial participation; unknown whether data analysis was based on intent-to-treat because of conflicting sample size numbers BDI = Beck Depression Inventory; C = control subjects; c/s = caesarean section; EPDS = Edinburgh Postnatal Depression Scale; GHQ = General Health Questionnaire; HADS = Hospital Anxiety and Depression Scale; I = intervention group; PPD = postpartum depression; RCT = randomized controlled trial; SCID = Structured Clinical Interview for DSM-III-R Can J Psychiatry, Vol 49, No 8, August

5 The Canadian Journal of Psychiatry Review Paper 10/36 (28%) mothers in the control group were experiencing emotional problems ( 2 =9;P < 0.01). Though this study has many limitations, it provided the basis for the antenatal class interventions described below. In an Australian trial, 144 high-risk pregnant, identified using a modified antenatal screening questionnaire, were randomized to receive either 3 midwife-led group sessions (n = 73) or standard antenatal care (n = 71) (29). The response rate for the mailed EPDS questionnaire was 92% at 6 and 12 weeks postpartum and 87% at 24 weeks postpartum. At 6, 12, and 24 weeks postpartum, the proportion of mothers in the intervention and control groups with EPDS scores above 12 was not significantly different, which indicates that the intervention did not reduce PPD. In a similar trial, which incorporated the screening of 1300 UK, 209 high-risk were randomized to evaluate the effect of a structured risk factor reducing program designed specifically to increase social support and problemsolving skills (30). The intervention (n = 103) comprised 6 structured 2-hour weekly antenatal classes and 1 postpartum class and was compared with routine antenatal care (n = 106). Incorporating diverse depressive measures, the follow-up rate exceeded 90%. The proportion of with an EPDS score above 10 did not differ significantly between the 2 groups. In another UK study, a more intensive intervention incorporating 11 monthly meetings was conducted (31). Women expecting their first or second child and who were designated as more vulnerable were allocated to either the Surviving Parenthood preventive intervention group (n = 47) or a control group (n = 52), according to the expected delivery date. Significant in EPDS scores at 12 weeks postpartum were found among primiparous, but not among multiparous. The mean EPDS score for primiparous in the intervention group was 3.0, SD 2.50, compared with 8.0, SD 4.53, in the control group (P = 0.005). For multiparous, no significant group were found; the intervention group s mean score was 6.5, SD 6.10, compared with the control group s score of 9.0, SD Notably, in all 3 preceding trials, the low group attendance rate was a significant limitation. In a pilot trial, primiparous Australian between 12 and 24 weeks gestation were screened, using a researcherdeveloped risk-factor scale (32). At-risk were randomly allocated to receive either standard antenatal classes (n = 21) or intervention classes (n = 23) consisting of 10 structured sessions. Participants completed questionnaires at 6 and 24 weeks postpartum; 16 (70%) mothers in the intervention group and 12 (57%) mothers in the control group completed the questionnaire administered at 24 weeks. No significant group in depressive symptomatology were found. Mean EPDS scores at 6 and 24 weeks postpartum for mothers in the intervention group were 7.40 and 7.57, compared with 9.06 and 8.09 for mothers in the control group (P > 0.05). Intrapartum Support (Table 3) A considerable number of experience labour without continuous support. Because labour is frequently viewed as a high-risk situation necessitating interventions and imposed 530 restrictions, it has been suggested that the clinical environment of childbirth may have an adverse effect on psychological outcomes. To test this hypothesis, 2 trials have been conducted that evaluate the effect of doula support (that is, support provided by an experienced lay woman). In a South African trial, 189 labouring alone were randomly allocated to receive either additional companionship (n = 92) or usual care (n = 97) (33). At 6 weeks postpartum, the Pitt Depression Inventory was completed during a postpartum visit; 40 mothers (21%) were lost to follow-up. Mothers in the intervention group had lower mean depression scores (mean score 10.4) than did mothers in the control group (mean score 23.3) (P < 0.001). This study was continued with an additional 73 enrolled, and the EPDS was administered at 1 year postpartum (34); only 50% of mothers completed this questionnaire. were found (intervention group mean 11, SD 5.31, vs control group mean 11, SD 0.60, P = 0.78). In a larger US trial involving 3 health maintenance organization managed hospitals, nulliparous were randomized to receive either usual care (n = 165) or support from a doula (n = 149) (35). Data were obtained from phone interviews conducted at 4 to 6 weeks postpartum, and the results showed no significant group in mean PPD scores. To evaluate the effectiveness of professional labour support, a well-designed, randomized controlled trial (RCT) with prognostic stratification by centre and parity was conducted (36). Thirteen Canadian and US hospitals randomized 6915 to receive either usual care (n = 3461) or continuous labour support by a specially trained nurse (n = 3454). The primary outcome measure was caesarean delivery rate, but maternal mood at 6 to 8 weeks postpartum was also included as an outcome measure. Of the 81% of participants who returned the follow-up questionnaire, 245 (8.7%) in the labour support group had EPDS scores > 12, compared with 277 (10.1%) in the usual care group (P = 0.08). Supportive Interactions (Table 4) Five trials have been conducted to evaluate the preventive effect of diverse supportive interventions. An Australian trial that targeted families where the child was at greater risk for poor health and developmental outcomes for environmental reasons (n = 181) evaluated the effect of extensive nursing home visits on PPD at 6 and 16 weeks postpartum (37,38). Women were recruited in the immediate postpartum period, according to self-reported vulnerability factors, and were randomly allocated to receive either a structured program of nursing home visits (n = 90) or standard community child health services (control group; n = 91). Mothers in the intervention group had lower EPDS scores (only 5.8% scored > 12 on the EPDS) at 6 weeks postpartum than did mothers in the control group (20.7% scored >12 on the EPDS). At the 16-week follow-up, 160 families were available for assessment, and the earlier difference in EPDS scores was not maintained. Recognizing a current trend in health care, and perinatal care in particular, a recent UK trial evaluated the effect of lay support in addition to usual postpartum care provided by

6 Preventing Postpartum Depression Part II: A Critical Review of Nonbiological Interventions Table 3 Postpartum depression preventive intervention studies using antenatal and postnatal classes and intrapartum support Study, design, and participants Gordon and others (28): quasi-experimental 161 pregnant US Two 40-minute antenatal classes in addition to standard prenatal classes, focusing on social and psychological adjustment Intervention Outcome measure Results Limitations Antenatal and postnatal classes PPD at 6 and 24 weeks, obstetrician evaluation using a 4-point scale Stamp and others (29): RCT, random allocation using sealed envelopes, power analysis, intent-to-treat 144 vulnerable pregnant Australian (modified antenatal screening questionnaire) 3 midwifery led group sessions (2 antenatally and 1 postnatally, at 6 weeks) PPD at 6, 12, and 24 weeks, EPDS Brugha and others (30): RCT, computer randomization, power analysis, intent-to-treat 209 high-risk pregnant UK (researcher-developed screening tool) I = 103 mothers C = 106 mothers Preparing for Parenthood: 6 structured, 2-hour weekly antenatal classes and 1 postnatal class provided by a trained nurse and occupational therapist PPD at 12 weeks, EPDS, GHQ-D, and clinical interview (SCAN) No significant group No significant group Elliott and others (31): quasi-experimental, allocation based on expected delivery date, intent-to-treat 99 vulnerable pregnant UK (Leverton Questionnaire or Crown Crisp Experiential Index) Buist and others (32): pilot RCT 44 at-risk primiparous Australian (researcher-developed screening tool) Surviving Parenthood:11 monthly meetings (5 antenatally and 6 postnatally) conducted by a psychologist and health visitor 10 structured classes (8 antenatally and 2 postnatally) facilitated by a midwife and either a psychologist or nurse, focusing on parenting and coping; facilitator support provided between sessions PPD at 12 weeks, EPDS and PSE PPD at 6 and 24 weeks, EPDS and BDI Intrapartum support for primiparous favouring the intervention group; unsuccessful for second-time No significant group Wolman and others (33) and Nikodem and others (34): RCT, random allocation using sealed envelopes 189 nulliparous inhospital South African labouring alone (73 additional mothers recruited later) Additional companionship from 1 of 3 volunteer labour companions recruited from the community a minimum of 5 hours of support PPD at 6 weeks, Pitt Depression Inventory; PPD at 52 weeks, EPDS Gordon and others (35): RCT, random allocation using sealed envelopes 314 nulliparous US delivering in 1 of 3 HMO-managed hospitals Provision of labour support from a trained doula PPD at 4 to 6 weeks, mental health index of SF-36 (5 items) Hodnett (36): RCT, computer randomization, power analysis, intent-to-treat 6915 Canadian and US Continuous labour support PPD at 6 to 8 weeks, by a specially trained nurse EPDS for a minimum of 80% of the time from randomization to delivery were found at 6 weeks but not 52 weeks No significant group No significant group Nonrandom group allocation; primary outcome defined as emotional upset; participant details lacking; unstandardized measure of PPD; high attrition at 24-week follow-up High number of mothers screened vulnerable (58%); only 31% of attended all 3 sessions Only 45% of attended sufficient sessions to potentially benefit Nonrandom group allocation; significant between participating and nonparticipating eligible ; low vulnerability mothers invited to provide viable group sizes; low group attendance for multiparous (36%) and primiparous (63%) mothers; study conducted from Small sample size; poor screening tool, untested and at no time did any participant score above 12 on the EPDS; inexplicit randomization process; significant group in baseline characteristics; unreported class attendance rate Poor measure of PPD at 6 weeks; high attrition at 52 week follow-up; change in study protocol before completion High number of in both groups excluded after randomization; weak measure of PPD; statistical results related to PPD not reported No serious methodological limitations HMO = Health Maintenance Organization; GHQ-D = General Health Questionnaire-Depression subscale; PSE = Present State Examination; SCAN = Schedules for Clinical Assessment in Neuropsychiatry; SF-36 = Short Form-36 See Table 2 for other abbreviations Can J Psychiatry, Vol 49, No 8, August

7 The Canadian Journal of Psychiatry Review Paper midwives (39). Mothers were randomly allocated to receive either usual care (n = 312) or additional support provided by trained community postnatal support workers (n = 311). At 6 weeks postpartum, there was a significant difference in EPDS scores, favouring the control group (intervention group mean 7.4, SD 5.2; control group mean 6.7, SD 5.5; P = 0.05). There was no difference at 24 weeks (intervention group mean 6.6, SD 5.1; control group mean 6.7, SD 5.6; P = 0.73). Finally, a trial with a 2 2 factorial design was conducted to evaluate 2 interventions: first, an invitation to a weekly postpartum support group; and second, a mailed postpartum support manual (40). A total of 1004 primiparous Scottish were recruited ( a total of 753 mothers in the 2 different intervention groups and 251 mothers in the control group), with 83% finishing the baseline questionnaire and 71% completing the 24-week follow-up. There were no significant in EPDS scores between the control and intervention groups at 12 and 24 weeks, either in the proportion scoring above 11 on the EPDS or in mean EPDS scores. Quality Improvement Interventions Continuity of Care (Table 4) According to policy-makers suggestions that continuity of care may increase s satisfaction, new models have been proffered. To compare midwife-managed care with shared care (for example, care divided among midwives, hospital physicians, and general practitioners [GPs]), a trial of 1299 pregnant with no adverse characteristics at booking was conducted (consent rate 82%); PPD was a psychosocial outcome with 60% of participants returning questionnaires at 7 weeks postpartum (41). Women in the midwife-managed group (n = 648) had significantly lower EPDS scores (mean score 8.1, SD 4.9), compared with mothers in the shared care group (n = 651) (mean score 9.0, SD 4.9; t = 2.6; 95%CI, 1.6 to 0.2; P = 0.01). However, nonsignificant group were found in EPDS scores above 12 (midwife-managed group, 71/426 [16.7%] vs shared care group, 84/362 [23.2%]). The effect of team midwifery was further evaluated in Australia, where low-risk in early pregnancy were randomly allocated to receive either team midwifery care (n = 495) or standard care (n = 505) (42). Physicians attended most in standard care where caregiver continuity was lacking. According to mailed questionnaires at 8 weeks postpartum, no significant group were found in depressive symptomatology: 16% of in the midwifery care group exhibited EPDS scores above 12, compared with 12% in the standard care group (P = 0.19). To evaluate the effectiveness of continuous midwifery care in reducing rates of PPD among with a history of 532 depression, 51 from a sample of 98 pregnant were randomly allocated at antenatal booking to continuous midwifery care. The remaining 47 received standard maternity care (43). In total, 87 (44 from the intervention group and 43 control subjects) completed baseline assessments after randomization and outcome assessments at 12 weeks postpartum. In pregnancy, 49% of had an episode of major or minor depression according to DSM-III-R criteria, 26% developed a new episode of illness after antenatal booking, and 23% suffered depression in the first 12 weeks postpartum. There were no between groups regarding total depression rates, rates of antenatal depression, depression that occurred postbooking, postpartum depression, or duration of depressive episodes. While continuous midwifery care did not prevent PPD, it was highly successful at engaging in treatment. Antenatal Identification and Notification (Table 4) Identifying PPD is often problematic because frequently fail to report symptoms to their family physician or public health nurse. Also, health professionals may fail to ask appropriate questions that could assist diagnosis in the postpartum period. While several attempts have been made to identify at-risk to evaluate antenatal interventions aimed at preventing PPD, these studies have been largely unsuccessful. This is partly because of researchers targeting antenatal classes, where poor attendance is common. One possible way to address this issue is to include any intervention as part of individualized antenatal care. To test this hypothesis, an RCT was conducted with Australian attending their first prenatal visit who were screened for PPD risk factors (44). The intervention consisted of 1) a booklet about PPD, which included contact numbers; 2) prenatal screening, using the EPDS; 3) a discussion with each identified woman about her risk of developing PPD; and 4) a letter to each woman s referring GP and local child health nurse, alerting them to the woman s risk for PPD. Of the 509 who were sent a follow-up questionnaire at 16 weeks postpartum, 371 (72.9%) responded. While 26% of reported an EPDS score >12, there was no significant difference among EPDS scores between the intervention (46/192, 24%) and control groups (50/177, 28.2%; OR 0.80; 95%CI, 0.50 to 1.28). This study is consistent with other research findings suggesting that efforts to prevent PPD by implementing interventions in the antenatal period are unsuccessful. Early Postpartum Follow-Up (Table 5) Traditionally, have been advised to attend a 6-week postpartum check-up with their primary health care provider. However, some researchers have hypothesized that postpartum care initiated earlier may either prevent or allow for the early identification and management of problems,

8 Preventing Postpartum Depression Part II: A Critical Review of Nonbiological Interventions Table 4 Postpartum depression preventive intervention studies using supportive interactions and antenatal identification and notification Study, design, and participants Intervention Outcome measure Results Limitations Supportive interactions Armstrong and others (37,38): RCT, random allocation by computer-generated numbers, power analysis 181 Australian families where the child was at a greater risk of poor health and developmental outcomes Extensive nursing home visits (weekly to 6 weeks, fortnightly to 12 weeks, and monthly to 24 weeks) PPD at 6 and 16 weeks, EPDS were found at 6 weeks favouring the intervention group but not at 16 weeks. Only 63% of mothers completed the pretrial screening questionnaire; significant group in baseline characteristics Morrell and others (39): RCT, random allocation using sealed envelopes, power analysis, intent-to-treat 623 UK Up to 10 home visits in the first postpartum month of up to 3 hours duration by a trained community postnatal support worker PPD at 6 and 24 weeks, EPDS Reid and others (40): RCT, computer randomization, power analysis, intent-to-treat 1004 primparous UK 2 interventions: 1) an invitation to a local postpartum support group run weekly by a trained midwife facilitator and 2) postpartum support manual mailed at 2 weeks postpartum PPD at 12 and 24 weeks, EPDS At 6 weeks postpartum, there was a significant difference in EPDS scores favouring the control group and no difference at 24 weeks. No serious methodological limitations but the supportive intervention was unstructured and did not specifically target PPD (instrumental rather than emotional [or] appraisal support was primarily provided) Only 40% of randomized to the support group attended 6 or more meetings; SES bias in group attendees (more middle than working class mothers attended the groups); researchers questioned the practice of recruiting antenatally for a postpartum intervention Shields and others (41): RCT, random allocation, intent-to-treat Continuity of care 1299 pregnant UK with no adverse characteristics Total midwife care: midwife aimed to provide most planned care throughout the antenatal, intrapartum, and postpartum period. Women also had an opportunity to discuss their feelings in a formal debriefing session during the last postpartum visit. PPD at 7 weeks, EPDS Women in the midwifery-managed group had significantly lower mean EPDS scores, but no significant group were found in relation to EPDS scores above 12 Waldenstrom and others (42): RCT, random allocation using sealed envelopes, intent-to-treat 1000 low-risk Australian in early pregnancy Marks and others (43): RCT 87 UK with a history of major depression Team midwifery care Continuous midwifery care PPD at 8 weeks, EPDS PPD at 12 weeks, clinical interview Inexplicit randomization process; a 9-item EPDS was used instead of the psychometrically tested 10-item EPDS; participants in the intervention group were more likely to return the postal questionnaires Demographic between questionnaire responders and nonresponders Small sample size Antenatal identification and notification Webster and others (44): RCT, random allocation using sealed envelopes, power analysis, intent-to-treat 600 pregnant Australian identified to be at risk for PPD PPD information booklet, EPDS screening, discussion with about risk to develop PPD; letter to s family physician or local child health nurse PPD at 16 weeks, EPDS Researchers unsure whether the actually visited the family physician or child health nurse that the alerting letter was sent to See Table 2 for abbreviations; SES = socioeconomic status Can J Psychiatry, Vol 49, No 8, August

9 The Canadian Journal of Psychiatry Review Paper including PPD. For example, in a US quasi-experimental study, the effect of early-initiated support by the mother s and the neonate s future primary care provider (such as a pediatrician or nurse practitioner) was evaluated (45). Mother neonate pairs were allocated to either a control group (consisting of routine postpartum care with a first clinic visit at 2 weeks postpartum; n = 122) or an intervention group (consisting of early postpartum communication; n = 129). All participants were interviewed at 8 weeks postpartum. Mothers in the intervention group had Center for Epidemiological Study of Depression Scale (CES-D) scores (mean 11.54) similar to those of mothers in the control group (mean 13.65) (P = 0.11), with 29% of mothers in the intervention group scoring above 16, compared with 39% of mothers in the control group (P = 0.18). In Australia, a trial incorporating 683 mothers was conducted to investigate whether an earlier postpartum checkup with a GP decreased depressive symptomatology and other negative health outcomes (46). All participants received a letter and appointment date to visit a GP for checkup. The intervention group received a date for 1 week after hospital discharge and the control group received a date for 6 weeks postpartum. According to postal questionnaires, the percentage of scoring above 12 on the EPDS at 12 weeks postpartum (intervention group, 16.6% vs control group, 13.6%; 2 = 0.8, P = 0.37) or 24 weeks postpartum (intervention group, 11.6% vs control group, 12.8%; 2 = 0.2, P = 0.69) did not differ significantly between the 2 groups. Flexible Postpartum Care (Table 5) In a well-designed cluster RCT that assessed community postpartum care and was redesigned to identify and manage individual needs, 36 UK GP practices were randomly allocated to either an intervention group (n = 17) or a control group (n = 19) (47). Of the 2064 participating, 1087 (53%) were in practices randomly assigned to the intervention group (consisting of extended midwifery care with no routine contact with GPs and incorporating the use of a symptom checklist and the EPDS), and 977 (47%) were in practices assigned to the control group (consisting of 7 midwifery home visits 10 to 14 days postpartum, care from health visitors thereafter, with GPs completing routine home visits, and a final 6- to 8-week checkup). In total, 801/1087 (77%) in the intervention group and 702/977 (76%) mothers in the control group returned the 16-week postal questionnaire. were found: 14.4% of mothers in the intervention group scored above 12 on the EPDS, compared with 21.3% of mothers in the control group (P = 0.01). The numerous study strengths indicate that redesigning care to be flexible and tailored to individual needs may help to improve s mental health outcomes. 534 Other Interventions Educational Strategies (Table 5) Frequent contact with health professionals during pregnancy presents an ideal situation for providing information. A trial was conducted in Australia to determine the effect of antenatal education on the prevention of PPD (48). A total of 206 primiparous 28 to 36 weeks gestation were randomized to either a control group (receiving usual antenatal care; n = 103) or an intervention group (receiving diverse educational materials; n = 103). Researchers assessed depressive symptomatology, using the Profile of Mood States (POMS) questionnaire. The questionnaire was administered once antenatally and twice postnatally, once between 8 and 12 weeks, and once between 16 and 24 weeks. A total of 188 mothers completed the study protocol. difference was found on the depression subscale: mean scores for both the intervention and control groups ranged from 4.0 to 5.0 at all time periods (P > 0.05). While this trial suggests that antenatal education may not prevent PPD, a small descriptive Japanese study (n = 40) found that an antenatal class provided by a psychiatrist and midwife as part of an obstetric psychiatric liaison service that includes PPD information and availability of postpartum resources may decrease the severity of PPD and the time between onset of depressive symptoms and seeking professional help (49). The preventive effect of additional information in the postpartum period was also examined. In a quasi-experimental study, 500 Taiwanese were screened at 4 weeks postpartum; those with an EPDS score above 10 were considered to be at risk for PPD and eligible to participate in the study (50). A total of 70 were allocated to either the experimental group (wherein a 3-page booklet was provided at 6 weeks postpartum; n = 35) or a control group (wherein the group received standard postpartum care; n = 35). While EPDS scores in both groups decreased significantly at 12 weeks postpartum, 24 (68.6%) mothers in the control group continued to have an EPDS score 10, compared with only 14 (40%) mothers who received the informational booklet. Relaxation With Guided Imagery (Table 5) To determine the effect of relaxation with guided imagery on anxiety, depression, and self-esteem, 60 primiparous US were recruited from a postpartum unit and randomly allocated to either a control group (receiving 15 minutes daily of tape-recorded music for 4 weeks; n = 30) or an intervention group (receiving 15 minutes daily of tape-recorded relaxation with guided-imagery protocol for 4 weeks; n = 30) (51). As measured by the CES-D, mothers in the intervention group (mean 1.37, SD 0.32) had less depressive symptomatology at 4 weeks postpartum than did mothers in the control group (mean 1.64, SD 0.53; t = 2.35, P = 0.01).

10 Preventing Postpartum Depression Part II: A Critical Review of Nonbiological Interventions Table 5 Postpartum depression preventive intervention studies using early postpartum follow-up, flexible postpartum care, educational strategies, and relaxation with guided imagery Study, design, and participants Intervention Outcome measure Results Limitations Early postpartum follow-up Serwint and others (45): quasi-experimental, group allocation based on 2-week period 251 healthy US Early Communication: routine postpartum care plus 1) visit hours after delivery from infant s future care provider, 2) special 24-hour telephone access to a physician via pager for 8 weeks, and 3) physician initiated telephone call 2 3 days post discharge to answer questions PPD at 8 weeks, CES-D Gunn and others (46): RCT, telephone randomization, power analysis, intent-to-treat 683 healthy Australian All participants received a letter and appointment date to see a GP for a check-up: the intervention group for 1 week after hospital discharge and the control group for 6 weeks postpartum PPD at 12 and 24 weeks, EPDS Flexible postpartum care Poor randomization method; weak measure of PPD Number of mothers randomized initially to the control and intervention groups not reported MacArthur and others (47): RCT, computer randomization, power analysis, intent-to-treat 2064 UK Only expected to move out of the general practice were excluded Midwifery care with no routine contact with GPs that was extended to 12 weeks postpartum and incorporated the use of the symptom checklist and the EPDS to identify health needs and guidelines for the management of these needs PPD at 16 weeks, EPDS No serious limitations Educational strategies Hayes and others (48): RCT, random allocation by computer-generated numbers, power analysis 206 Australian Educational package that primiparous who consisted of and information were between 28 and booklet, an audio tape of 1 36 weeks pregnant woman s story of PPD, and an experienced midwife to review the package Okano and others (49): descriptive study, 2 groups 40 Japanese who consulted a psychiatrist for PPD; 18 mothers had attended a PPD class prenatally 1 Mother s Class in late pregnancy to provide information about PPD, including preventive suggestions; mothers were encouraged to obtain early psychiatric contact, and resource information was provided. PPDat8to12 and 16 to 24 weeks, POMS Time of first psychiatric contact and interval between onset of illness and first interview Relaxation with guided imagery Weak measure of PPD; follow-up assessment completed by an unblinded research assistant Mothers who Small sample size; retrospective attended the group design initiated contact with psychiatric services sooner than nonattending mothers Rees and others (50): RCT, random allocation 60 US primiparous Every morning for a 4-week period followed a tape-recorded relaxation with guided imagery protocol for 15 minutes PPD at 4 weeks, CES-D were found Small sample size; inexplicit randomization and study procedures; weak measure of PPD CES-D = Center for Epidemiologic Studies Depression Scale; GP = general practitioner; POMS = Profile of Mood States See Table 2 for abbreviations Can J Psychiatry, Vol 49, No 8, August

11 The Canadian Journal of Psychiatry Review Paper Table 6 Summary quality of evidence and practice recommendations for nonbiological preventive interventions Intervention strategy Study Research design Classification of rating a Quality rating a recommendation b Psychological Interpersonal psychotherapy Zlotnick and others (20) Pilot RCT: I Poor I Gorman and others (21) RCT: I Fair I Cognitive-behavioural therapy Saisto and others (22) RCT: I Fair I Chabrol and others (23) RCT: I Poor I Psychological debriefing Lavender and others (24) RCT: I Poor D Small and others (25) RCT: I Good D Priest and others (26) RCT: I Good D Tam and others (27) RCT: I Fair D Psychosocial Antenatal classes Gordon and others (28) Quasi-experimental: II-1 Poor I Stamp and others (29) RCT: I Fair I Brugha and others (30) RCT: I Fair I Elliot and others (31) Quasi-experimental: II-1 Poor I Buist and others (32) Pilot RCT: I Poor I Intrapartum support Wolman and others (33) Nikodem and others (34) RCT: I Poor D Gordon and others (35) RCT: I Poor D Hodnett and others (36) RCT: I Good D Supportive interactions Armstrong and others (37,38) RCT: I Fair I Morrell and others (39) RCT: I Good I Reid and others (40) RCT: I Fair I Quality improvement Continuity of care Shields and others (41) RCT: I Fair D Walenstrom and others (42) RCT: I Good D Marks and others (43) RCT: I Fair D Antenatal identification and notification Webster and others (44) RCT: I Good D Early postpartum follow-up by general practitioners Serwint and others (45) Quasi-experimental: II-1 Poor D Gunn and others (46) RCT: I Good D Flexible postpartum care MacArthur and others (47) RCT: I Good B Other Educational strategies Hayes and others (48) RCT: I Poor I Okano and others (49) Descriptive: III Poor I Relaxation with guided imagery Rees and others (50) RCT: I Poor I a See Table 1 for Canadian Task Force on Preventive Health Care research design and quality ratings b A = there is good evidence to recommend this approach; B = there is fair evidence to recommend this approach; C = the existing evidence is conflicting and does not allow making a recommendation for or against use of this approach, though other factors may influence decision making; D = there is fair evidence to recommend against this approach; E = there is good evidence to recommend against this approach; I = there is insufficient evidence (in quantity and [or] quality) to make a recommendation, though other factors may influence decision making. Discussion The long-term consequences of PPD suggest preventive approaches are warranted. Manipulation of different risk factors may increase the associated likelihood of developing PPD in several different ways. The most obvious strategy is to 536 decrease the amount of exposure to a given risk factor or, alternatively, to reduce the strength or mechanism of the relation between the risk factor and PPD (52). However, translating risk-factor research into predictive screening protocols and preventive interventions has met with limited success, as