Primary prevention
Guidelines on prevention strategies vary in their approach. The US Preventive Services Task Force recommends counselling interventions, such as cognitive behavioural therapy (CBT) and interpersonal therapy, for the prevention of perinatal depression in women at increased risk (those with a history of depression, current depressive symptoms, or a disadvantaged socioeconomic status).[80][81] Examples listed by the American College of Obstetricians and Gynecologists (ACOG) of suitable programmes with a good evidence base for prevention include the Mothers and Babies Program (CBT) and the ROSE Program (Reach Out, Stay Strong, Essentials for mothers of newborns) (interpersonal therapy).[82] How clinicians can best identify and implement these psychotherapy-based interventions remains an area of active research.[82][83] In contrast, the UK National Institute for Health and Care Excellence does not recommend psychosocial interventions routinely as part of antenatal and postnatal care in the absence of a diagnosis of depression.[5][Evidence C]
There is evidence that professional home visits (e.g., by nurses or midwives), and peer-based phone support and interpersonal psychotherapy, both in pregnancy and after childbirth, are effective in reducing the risk of postnatal depression.[84] One Cochrane review found that the evidence was very uncertain about the effect of home visits on maternal and neonatal outcomes; however, the authors found that individualised care as part of a package of home visits probably improves maternal depression scores at 4 months, and that maternal satisfaction was possibly better with home visits.[85]
Moderate-intensity physical activity during pregnancy reduces the risk of subsequent symptoms of postnatal depression, according to two umbrella reviews of systematic reviews.[86][87] For women who have given birth in the past year, aerobic exercise (e.g., group exercise programmes or advice on an exercise of their choice) appears to reduce depression symptoms compared with usual care. In one systematic review, a moderate treatment effect was noted, regardless of whether the mothers had postnatal depression.[88]
An argument can be made for a lower threshold for access to psychological therapies during pregnancy and the postnatal period arising from the changing risk-benefit ratio for psychotropic medication at this time. One UK study demonstrated that provision of psychological interventions such as CBT by health visitors trained in the recognition of depressive symptoms using the Edinburgh Postnatal Depression Scale (EPDS) and face-to-face clinical assessment to women scoring <12 on the EPDS at 6 weeks postnatally reduces the risk of developing a score of ≥12 at 6 months postnatally.[89]
Clear documentation and care planning is important when women are assessed as being at higher risk of a severe postnatal depressive disorder, with a plan agreed with the woman about what will happen if she develops depressive symptoms. For example, UK guidance recommends that women at high risk because of a history of severe depressive disorder before or during their pregnancy should have a detailed written plan of psychiatric care for the late antenatal and postnatal periods, which should be agreed with the woman and shared with all relevant parties, including the maternity services, community midwifery team, GP, health visitor, and mental health professionals.[5] In the US, obstetricians typically play a key role in care planning and treatment coordination; perinatal psychiatry access programmes and support lines may assist the clinician in this role, dependant on state-wide service arrangements.[82] Massachusetts Department of Mental Health: MCPAP for Moms Opens in new window
Intensive professional postnatal support individually targeted at at-risk mothers may be beneficial. It may be appropriate to offer antidepressant prophylaxis to some women with a strong history of depression (including both previous postnatal and non-postnatal depression);[90] specialist advice is recommended, as there is limited evidence regarding which pharmacological interventions can reduce the risk of depression recurrence.[4] Decisions should be made on an individual basis.[91]
Secondary prevention
The same principles apply as for primary prevention. Women with a first episode of postnatal depression have a higher risk of subsequent postnatal depression (41% vs. 18%), but a lower risk of non-postnatal depression (38% vs. 62%).[187] Close monitoring and assessment for women with a history of perinatal mood disorders is therefore recommended. Due to a lack of suitable trials, it is not possible to draw clear conclusions about the effectiveness of antidepressants for preventing postnatal depression in women with a history of the condition.[196] It may be appropriate to offer antidepressant prophylaxis to some women with a strong history of depression (including both previous postnatal and non-postnatal depression); specialist advice is recommended, as there is limited evidence regarding which pharmacological interventions can reduce the risk of depression recurrence.[90][4] Decisions should be made on an individual basis.[91]
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