Clinical Review & Education

JAMA | US Preventive Services Task Force | EVIDENCE REPORT

Interventions to Prevent Perinatal Depression

Evidence Report and Systematic Review
for the US Preventive Services Task Force
Elizabeth O’Connor, PhD; Caitlyn A. Senger, MPH; Michelle L. Henninger, PhD; Erin Coppola, MPH; Bradley N. Gaynes, MD, MPH

Editorial page 550

IMPORTANCE Depression during pregnancy and the postpartum period is relatively common Author Audio Interview
and can have adverse effects on both mother and child.
Related article page 580 and
JAMA Patient Page page 620
OBJECTIVE To systematically review benefits and harms of primary care–relevant
interventions to prevent perinatal depression, a major or minor depressive episode during Supplemental content
pregnancy or up to 1 year after childbirth, to inform the US Preventive Services Task Force. Related articles at
jamainternalmedicine.com
DATA SOURCES MEDLINE, PubMED (for publisher-supplied records only), PsycINFO, and the jamapediatrics.com
Cochrane Central Register of Controlled Trials; surveillance through December 5, 2018. jamapsychiatry.com

STUDY SELECTION Randomized clinical trials (RCTs) and nonrandomized controlled

intervention studies of interventions (eg, behavior-based, antidepressants, dietary
supplements) to prevent perinatal depression in general populations of pregnant and
postpartum individuals or in those at increased risk of perinatal depression. Large cohort
studies were considered for harms of antidepressant use only.

DATA EXTRACTION AND SYNTHESIS Two investigators independently reviewed abstracts and
full-text articles and quality rated included studies. Random-effects meta-analysis was used
to estimate the benefits of the interventions.

MAIN OUTCOMES AND MEASURES Depression status; depression symptoms; maternal, infant,
and child health outcomes.

RESULTS Fifty studies (N = 22 385) that met inclusion criteria were identified. Counseling
interventions were the most widely studied interventions. Compared with controls,
counseling interventions were associated with a lower likelihood of onset of perinatal
depression (pooled risk ratio [RR], 0.61 [95% CI, 0.47-0.78]; 17 RCTs [n = 3094]; I2 = 39.0%).
The absolute difference in the risk of perinatal depression ranged from 1.3% greater reduction
in the control group to 31.8% greater reduction in the intervention group. Health system
interventions showed a benefit in 3 studies (n = 5321) and had a pooled effect size similar to
that of the counseling interventions, but the pooled effect was not statistically significant
using a method appropriate for pooling a small number of studies (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%). None of the behavior-based interventions reported on harms directly. Author Affiliations: Kaiser
A smaller percentage of participants prescribed sertraline had a depression recurrence Permanente Research Affiliates
compared with those prescribed placebo (7% vs 50%, P = .04) at 20 weeks postpartum in 1 Evidence-Based Practice Center,
Center for Health Research, Kaiser
very small RCT (n = 22 analyzed) but with an increased risk of adverse effects to the mother.
Permanente, Portland, Oregon
(O’Connor, Senger, Henninger,
CONCLUSIONS AND RELEVANCE Counseling interventions can be effective in preventing Coppola); University of
perinatal depression, although most evidence was limited to women at increased risk for North Carolina at Chapel Hill
School of Medicine (Gaynes).
perinatal depression. A variety of other intervention approaches provided some evidence of
Corresponding Author: Elizabeth
effectiveness but lacked a robust evidence base and need further research.
O’Connor, PhD, Kaiser Permanente
Research Affiliates Evidence-based
Practice Center, The Center for
Health Research, Kaiser Permanente
Northwest, 3800 N Interstate Ave,
Portland, OR 97227 (Elizabeth.
JAMA. 2019;321(6):588-601. doi:10.1001/jama.2018.20865 [email protected]).

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 USPSTF Evidence Report: Interventions to Prevent Perinatal Depression US Preventive Services Task Force Clinical Review & Education

P
erinatal depression is a common condition that was esti- evant systematic reviews. After February 2018, ongoing surveil-
mated in 2012 to affect more than 180 000 new mothers lance continued through article alerts and targeted searches of
(11.5%) annually in the United States and that can have a dev- high-impact journals to identify major studies published in the
astating effect on the mother as well as the infant.1 Perinatal de- interim that could affect the conclusions or understanding of the
pression is defined as the occurrence of a major or minor depres- evidence and affect the related USPSTF recommendation. The last
sive episode during pregnancy or up to 1 year after childbirth.2 In surveillance was conducted on December 5, 2018, and resulted in
addition to the typical symptoms of depressive disorders (eg, feel- the addition of no new studies.
ing hopeless, loss of interest in activities that used to be enjoyed,
withdrawing from friends and family), other symptoms in the peri- Study Selection
natal period may include persistent doubt of the ability to take care Two reviewers independently reviewed abstracts and full-text ar-
of the infant, trouble bonding with the infant, and thoughts of self- ticles against specified inclusion criteria (Figure 2). Studies were eli-
harm or harm of the infant.3 gible if they were published in English, conducted in countries ranked
Risk factors that can be used to identify individuals at risk for peri- as having “very high” human development according to the World
natal depression include a history of depression,4-7 history of physi- Health Organization, and included pregnant persons or mothers up
cal or sexual abuse,5 unplanned or unwanted pregnancy,8 stressful to a maximum of 1 year postpartum. Studies limited to persons with
life events,1,5,9 intimate partner violence,10,11 and complications during mental health symptoms or disorders (eg, anxiety disorders) were
pregnancy.12 Additionally, low socioeconomic status, lack of social sup- eligible; however, studies limited to perinatal individuals currently
port, and bearing children during adolescence have been associ- experiencing or being treated for a depressive episode were ex-
ated with a greater risk of developing perinatal depression after cluded, as were studies limited to persons with psychotic or devel-
delivery.5,6,8,13 Numerous interventions have been proposed to pre- opmental disorders. In addition, studies limited to persons with a
vent perinatal depression; however, there is no commonly agreed-on medical condition (eg, HIV/AIDS), and those limited to persons in in-
method of prevention. Thus, there is likely substantial variation in clini- stitutions (eg, psychiatric inpatients) or long-term care or residen-
cal practice. Although there are risk factors for perinatal depression tial facilities were excluded because of generalizability concerns.
and interventions exist that may help prevent perinatal depression, Studies that included a subset of these types of participants were
the effectiveness of these interventions and the subpopulations included; however, it was required that the number not exceed 50%
who could most benefit need further evaluation. of the total sample to be considered for inclusion.
There are currently no clinical guidelines on how to prevent peri- Studies were required have a primary or secondary aim to pre-
natal depression and no prior US Preventive Services Task Force vent perinatal depression. The following interventions were in-
(USPSTF) recommendation on this topic. This systematic review was cluded: counseling (eg, cognitive-behavioral therapy [CBT], inter-
conducted to synthesize the evidence related to the effectiveness personal therapy [IPT]), psychoeducation, or other supportive
of interventions in preventing perinatal depression to support a new interventions (eg, peer mentoring); care delivery models targeting
USPSTF recommendation. improved mental health outcomes; prophylactic use of antidepres-
sants; widely available physical activity or complementary and al-
ternative therapies; and hormonal therapy. Pharmacotherapy harms
were only to be evaluated for medications that were found to sup-
Methods
port the prevention of perinatal depression and were to be exam-
Scope of Review ined only during the phase (pregnancy or postpartum) in which the
The USPSTF commissioned this review to evaluate direct evidence evidence was identified. Interventions composed of general par-
from trials and large cohort studies (for harms of antidepressant use enting education without a mental health component (eg, prenatal
only) on interventions to reduce the risk of perinatal depression ini- or infant care classes) were excluded.
tiated during pregnancy or the first year postpartum. Specifically, Depression diagnosis (determined through a clinical interview)
the 2 key questions (KQs) (Figure 1) aimed to identify the benefits or symptoms (measured using a validated instrument) were a re-
(KQ1) and harms (KQ2) of interventions to prevent perinatal depres- quired outcome for included studies. Other maternal health out-
sion for pregnant or postpartum individuals and their children. Ad- comes, infant and child outcomes, birth outcomes, and any informa-
ditional methodological details regarding the review search strate- tion reported on harms were also abstracted. Relevant outcomes
gies, detailed study inclusion criteria, quality assessment, excluded reported at least 6 weeks after the baseline assessment or interven-
studies, and description of data analyses are publicly available in the tion initiation were included, although harms outcomes reported any
full evidence report at http://www.uspreventiveservicestaskforce. time after the intervention was initiated were considered.
org/Page/Document/UpdateSummaryFinal/perinatal-depression- Interventions that were conducted in or recruited from pri-
preventive-interventions. mary care or a health care system, or that could potentially be imple-
mented in or referred from primary care, were included. This in-
Data Sources and Searches cluded interventions taking place in primary care clinics; prenatal
Comprehensive literature searches were performed for primary lit- clinics; obstetrics/gynecology clinics; pediatric clinics; family plan-
erature in MEDLINE, PubMed (for publisher-supplied records only), ning clinics; military health clinics; school-based health clinics; men-
PsycINFO, and the Cochrane Collaboration Registry of Controlled tal health clinics; and research settings, homes, or other commu-
Trials from January 2012 through February 6, 2018. Database nity settings, including electronic or computer-based interventions.
searches were supplemented with suggestions from preidentified Studies conducted in correctional facilities, school classrooms,
experts in the field and by reviewing reference lists from other rel- worksites, and emergency departments were excluded.

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 Clinical Review & Education US Preventive Services Task Force USPSTF Evidence Report: Interventions to Prevent Perinatal Depression

Figure 1. Analytic Framework: Interventions to Prevent Perinatal Depression

Health outcomes
Interventions
Maternal
Pregnant or
1 Decreased incidence of perinatal depression symptoms
postpartum women
Improved HrQoL/functioning
Improvement of other specified health outcomes
2
Infant or child
Improved health or physical development
Improved psychosocial development Evidence reviews for the US
Decreased mortality, neglect, and abuse Preventive Services Task Force
Harms of interventions (USPSTF) use an analytic framework
to visually display the key questions
Key questions that the review will address to allow
the USPSTF to evaluate the
1 Do interventions to prevent perinatal depression improve health outcomes in pregnant or postpartum effectiveness and safety of a
women or their children? preventive service. The questions are
a. In trials that limit enrollment to high-risk women, how are participants identified as being at high risk
depicted by linkages that relate
of developing perinatal depression?
interventions and outcomes. Refer to
the USPSTF Procedure Manual for
2 What harms are associated with interventions to prevent perinatal depression in pregnant or interpretation of the analytic
postpartum women? framework.14 HrQoL indicates
health-related quality of life.

Figure 2. Literature Search Flow Diagram: Interventions to Prevent Perinatal Depression

79 Citations identified from search of existing 1739 Citations identified through KQ literature 167 Citations identified through other sources
systematic reviews (January 1, 2012- database searches (January 1, 2012- (eg, reference lists, experts)
November 27, 2015) February 6, 2018)

1036 Citations screened after duplicates removed

789 Citations excluded based on

review of title and abstract

247 Full-text articles assessed for eligibility

for KQ1 and KQ2

183 Articles excluded for KQ1a 245 Articles excluded for KQ2a
14 Aim 14 Aim
24 Setting 24 Setting
9 Comparative effectiveness 9 Comparative effectiveness
11 Insufficient follow-up 11 Insufficient follow-up
19 Outcomes 83 Outcomes
28 Population 28 Population
22 Intervention 23 Intervention
12 Study design 9 Study design
1 Non-English 1 Non-English
12 Abstract only 12 Abstract only
1 Unable to locate 1 Unable to locate
30 Quality 30 Quality

64 Articles (50 studies) included for KQ1b 2 Articles (2 studies) included for KQ2b

KQ indicates key question. incomplete outcomes. Population: Study was not conducted in an included
a
Reasons for exclusion: Aim: Study aim was not relevant. Setting: Study was not population. Intervention: Intervention was out of scope. Design: Study did not
conducted in a country relevant to US practice, or not conducted in, recruited use an included design. Language: Publication not in English. Quality: Study
from, or feasible for primary care or a health system. Comparative was poor quality. Unable to locate: Review staff was unable to locate article.
b
effectiveness: Active comparator (eg, liquid-based cytology vs conventional Studies may appear in more than 1 KQ.
cytology alone). Outcomes: Study did not have relevant outcomes or had

Data Extraction and Quality Assessment assigned a quality rating of “good,” “fair,” or “poor.” Discordant
Two reviewers applied USPSTF design-specific criteria14 to assess quality ratings were resolved by discussion or by a third reviewer
the methodological quality of all eligible studies. Each study was and adjudicated as needed. Studies were rated as poor quality

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 USPSTF Evidence Report: Interventions to Prevent Perinatal Depression US Preventive Services Task Force Clinical Review & Education

and excluded if there was a major flaw such as very high attrition
(generally >40%), differential attrition between intervention groups Results
(generally >20%); substantial lack of baseline comparability be-
tween groups without adjustment; or major concerns about the Two reviewers independently assessed 1036 abstracts and
trial conduct, analysis, or reporting of results. One investigator reviewed 247 full-text articles. In total, 50 studies (8 good quality,
extracted study-level data using data entry forms developed in 42 fair quality; N = 22 385; 49 randomized clinical trials [RCTs]16-64
DistillerSR (Evidence Partners) and a second investigator con- and 1 nonrandomized controlled intervention study 65 ) were
firmed the accuracy of the data. included (Figure 2; eTable 1 in the Supplement). Of the 50 included
studies, 20 (40%) were conducted in the United States, and most
Data Synthesis and Analysis recruited women from primary care or obstetrics/gynecology prac-
Summary tables showing study, population, intervention charac- tices (33/50 [66%]) or from other clinical settings (13/50 [26%])
teristics, and outcomes were created. Studies were examined over- such as in the hospital postdelivery, through electronic medical rec-
all and grouped according to intervention type: counseling, health ords, or in clinic- or hospital-based childbirth education classes
system, physical activity, education (without counseling, extensive (Table 1; eTable 2 in the Supplement). Twenty-six of the included
skills practice, or other supportive interventions), support (without studies (52%) recruited pregnant women, 22 (44%) recruited post-
counseling or skill-building), infant sleep, debriefing (exploring the partum women, and 2 (4%) recruited women who were pregnant
events and emotions of the birth experience, with a counselor pro- as well as those up to 26 weeks postpartum.16,17 Most studies
viding normalization and education), other behavior-based (42/50 [84%]) were limited to women 18 years or older, but 1
approaches, antidepressants, and supplements. The intervention was limited to adolescents18 and 7 had no age restrictions.19-25
categories were developed post hoc, and some trials were difficult The studies assessed the effect of a wide range of intervention
to categorize and could possibly have fit into more than 1 category. approaches, including counseling, health system–level interven-
The one that appeared to have the best fit was chosen by the pri- tions, physical activity, supportive interventions, education, infant
mary investigator. sleep advice, birth-experience postpartum debriefing, expressive
Because of its clinical utility, depression status was chosen writing, yoga, omega-3 fatty acids, sertraline, and nortriptyline.
as the primary outcome. Most trials reported a related dichot- For all KQs, additional descriptive and outcome data are available
omous depression outcome: cumulative incidence of depres- in the full report.
sion, prevalence, or the proportion scoring above a cutoff on a Twenty-seven studies (54%) selected women at increased
symptom severity scale. Since most trials excluded women with risk for perinatal depression, such as having a personal or family
depression or high symptom levels at baseline, it was assumed that history of depression (or perinatal depression), elevated depressive
most cases of depression identified after the start of the study symptoms, or socioeconomic (eg, low income, single, young,
would be new-onset cases, but not necessarily first-onset cases, recent intimate partner violence) or mental health (eg, elevated
since many women had previous episodes of depression. anxiety symptoms) risk factors (Table 1). The most common
Strength of evidence was rated for each key question, based approach was to select women on the basis of depression symp-
on consistency (similarity of effect direction and size), precision toms or history.16,17,26-35 The Edinburgh Postnatal Depression Scale
(degree of certainty around an estimate), reporting bias (potential (EPDS; range, 0-30; higher score indicates greater distress) and the
for bias related to publication, selective outcome reporting, or se- Center for Epidemiologic Studies Depression Scale (CES-D; range,
lective analysis reporting), and study quality (ie, study limitations). 0-60; higher score indicates greater distress) were the most widely
Random-effects models on both the main outcome of used tools for identifying women at risk for developing postpartum
depression status and continuous measures of depression symp- depression in the included studies.
tom severity were conducted, both overall and separately Although the majority of participants in the included studies
by intervention. The DerSimonian and Laird model for pool- were non-Hispanic white (69% of all participants in trials that re-
ing was used, and I2 and Q statistic were calculated to test for ported race/ethnicity), 2 trials were limited to Latina women,27,28
heterogeneity. In addition, because the DerSimonian and and 8 had majority black and Latina samples.16-18,36-40 In addition,
Laird method is prone to insufficient coverage of the full 95% 13 studies (26%) were primarily or entirely composed of economi-
confidence intervals when the number of studies is small cally disadvantaged women.16,17,22,27,28,37-44
and statistical heterogeneity is high, restricted maximum likeli-
hood models with the Knapp-Hartung correction for small Benefits of Preventive Interventions
samples were used when fewer than 10 trials were pooled and Key Question 1. Do interventions to prevent perinatal depres-
the DerSimonian and Laird model showed a statistically signifi- sion improve health outcomes in pregnant or postpartum women
cant effect. For the full body of evidence, a funnel plot was gener- or their children?
ated and the Egger test was performed to explore small-study Key Question 1a. In trials that limit enrollment to high-risk women,
effects, which can be related to publication bias.15 Additionally, how are participants identified as being at high risk of developing
meta-regression and sensitivity analyses were conducted to perinatal depression?
explore factors associated with effect size for the dichotomous
depression status outcome. Counseling Interventions
Stata version 15.1 (StataCorp LP) was used for all analyses. All Twenty RCTs (2 good quality, 18 fair quality) of counseling inter-
significance testing was 2-sided, and results were considered sta- ventions were identified (n = 4107). Seventeen of these reported
tistically significant if the P value was .05 or less. incidence, prevalence, and exceeding symptom cutoff and are

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 592
Table 1. Summary of Study Characteristics, by Intervention Type

No. of Studies (%)

Intervention
Group Population Excluded
No. of Studies Conducted Initiated Selection Depression Primarily
Intervention (No. of in the During Screening Depression Population Diagnosis/High Majority Low-SES
Category Participants) Good Quality United States Pregnancy Adults Only or Outreacha Only Unselected Symptomsb Nonwhite Participants
Overall 50 (22 385) 8 (16) 20 (40) 26 (52) 42 (84) 42 (84) 12 (24) 23 (46) 20 (40) 11 (22) 13 (26)
Counseling 20 (4107) 2 (10) 12 (60) 17 (85) 17 (85) 17 (85) 6 (30) 5 (25) 13 (65) 8 (40) 10 (50)
Health system 3 (5321) 0 0 1 (33.3) 2 (66.7) 3 (100) 0 3 (100) 1 (33.3) 0 0
Physical activity 3 (1200) 1 (33.3) 0 2 (66.7) 3 (100) 3 (100) 0 3 (100) 0 0 0
Education 6 (2949) 2 (33.3) 2 (33.3) 2 (33.3) 5 (83.3) 6 (100) 1 (16.7) 5 (83.3) 1 (16.7) 2 (33.3) 1 (16.7)
Support 7 (4569) 2 (28.6) 0 2 (28.6) 5 (71.4) 7 (100) 2 (28.6) 3 (42.9) 2 (28.6) 0 2 (28.6)
Sleep 3 (980) 0 1 (33.3) 0 3 (100) 2 (66.7) 0 1 (33.3) 0 1 (33.3) 0
Debriefing 2 (2786) 0 0 0 1 (50) 2 (100) 0 1 (50) 0 0 0
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Expressive 1 (120) 0 0 0 1 (100) 1 (100) 0 1 (100) 0 0 0
writing
Yoga 1 (46) 0 1 (100) 1 (100) 1 (100) 0 0 0 0 0 0
Antidepressants 2 (80) 0 2 (100) 0 2 (100) 1 (50) 2 (100) 0 2 (100) 0 0
Omega-3 2 (227) 1 (50) 2 (100) 1 (50) 2 (100) 0 1 (50) 1 (50) 1 (50) 0 0
fatty acids
b
Abbreviation: SES, socioeconomic status. Studies excluded persons with a diagnosis of depressive disorder or who met an a priori threshold for symptoms
a of depression (eg, exceeded a specified score on a screening test).
Number recruited via screening or outreach vs volunteer opt-in.

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USPSTF Evidence Report: Interventions to Prevent Perinatal Depression
 USPSTF Evidence Report: Interventions to Prevent Perinatal Depression US Preventive Services Task Force Clinical Review & Education

Figure 3. Depression Incidence, Prevalence, or Exceeding a Symptom Cutoff for Counseling and Health System Interventions,
Sorted by Follow-up Time

Planned
Follow-up, No. With Depression/Total (%) Risk Ratio Favors Favors
Source Intervention wka Outcome Intervention Control (95% CI) Intervention Control
Counseling
Kozinszky et al,50 2012 CBT, IPT p06 LQ ≥12 54/609 (8.9) 77/829 (9.3) 0.95 (0.69-1.33)
Leung and Lam,48 2012 IPT p06 EPDS >12 25/78 (32.1) 24/78 (30.8) 1.04 (0.66-1.66)
Ortiz Collado et al,42 2014b Tourne p09 EPDS ≥12 24/92 (34.3) 27/58 (45.5) 0.56 (0.36-0.87)
Milgrom et al,47 2011 CBT p12 BDI-II ≥14 6/47 (12.8) 16/42 (38.1) 0.34 (0.14-0.78)
Brugha et al,19 2000 CBT p13 Prevalence 3/94 (3.0) 6/96 (6.0) 0.51 (0.13-1.98)
Zlotnik et al,39 2011 IPT p13 Incidence 6/25 (24.0) 5/21 (23.8) 1.01 (0.36-2.84)
Zlotnik et al,37 2001 IPT p13 Incidence 0/17 (0) 6/18 (33.0) 0.08 (0.00-1.34)
Zlotnik et al,38 2006 IPT p13 Incidence 2/46 (4.3) 8/40 (20.0) 0.22 (0.05-0.96)
Cooper et al,49 2015 NR p18 Prevalence 16/80 (20.0) 15/79 (19.0) 1.05 (0.56-1.98)
Dimidjian et al,29 2016 CBT, MT p26 Incidence 8/43 (18.4) 22/43 (50.2) 0.36 (0.18-0.72)
Muñoz et al,28 2007 CBT p26 Prevalence 0/21 (0) 2/20 (10.0) 0.19 (0.01-3.75)
Phipps et al,18 2013 IPT p26 Incidence 6/48 (12.5) 13/52 (25.0) 0.50 (0.21-1.21)
Gorman,21 1997 IPT p26 Prevalence 3/20 (15.0) 4/17 (23.5) 0.64 (0.17-2.46)
Zlotnik et al,40 2016 IPT p26 Incidence 16/101 (16.0) 30/96 (31.0) 0.51 (0.30-0.87)
Tandon et al,17 2011 CBT p32 Incidence 3/32 (9.4) 9/27 (33.3) 0.28 (0.08-0.94)
Tandon et al,16 2014 CBT p40 Incidence 6/41 (14.6) 11/34 (32.4) 0.45 (0.19-1.10)
Le et al,27 2011 CBT p52 Incidence 6/77 (7.8) 7/73 (9.6) 0.81 (0.29-2.30)
Subtotal 0.61 (0.47-0.78)
I 2 = 39.0%; χ2 test for heterogeneity, P = .051
Health system
Fontein-Kuipers et al,65 2016 Prenatal g37 EPDS ≥10 14/218 (6.4) 42/215 (19.5) 0.33 (0.19-0.58)
MacArthur et al,23 2002 Postpartum p17 EPDS ≥13 156/1087 (14.4) 208/977 (21.3) 0.68 (0.55-0.84)
Brugha et al,51 2011 Home visitor p26 EPDS ≥12 113/1474 (7.7) 83/767 (10.8) 0.71 (0.53-0.95)
Subtotal 0.60 (0.43-0.83)
I 2 = 66.3%; χ2 test for heterogeneity, P = .051

0.001 0.01 0.1 1 10

Risk Ratio (95% CI)

a
Weights are from random-effects analysis. BDI-II indicates Beck Depression ”g” indicates during gestation and “p” indicates postpartum; thus, for example,
Inventory II; CBT, cognitive-behavioral therapy; EPDS, Edinburgh Postnatal g37 indicates 37 weeks’ gestation and p12 indicates 12 weeks postpartum.
Depression Scale; IPT, interpersonal therapy; LQ, Leverton Questionnaire; b
Study-reported adjusted analysis was not statistically significant, although
MT, motivational therapy; NR, not reported; RR, risk ratio. effect size shown in the forest plot, based on unadjusted data, is statistically
significant. Tourne indicates a psychosomatic humanist group intervention
developed by Dr Claude-Emile Tourne.

included in this pooled estimate; the 3 studies43,45,46 that did not and the IPT-based Reach Out, Stand Strong, Essentials for New
report these dichotomous measures all reported continuous Mothers (ROSE) program (used in 5 studies18,37-40). The Mothers
measures of depressive symptoms, with mixed findings. The and Babies program involved 8 to 17 group sessions during preg-
pooled risk ratio (RR) for counseling interventions was 0.61 when nancy and postpartum, with a goal of helping participants create a
the outcomes of incidence, prevalence, and exceeding symptom healthy physical, social, and psychological environment for them-
cutoff were combined (95% CI, 0.47 to 0.78; 17 trials [n = 3094]; selves and their infants. The ROSE program involved 4 to 6 ses-
I 2 = 39.0%) (Figure 3). The proportion of participants with sions during pregnancy and postpartum, covering topics such as
depression according to any of the dichotomous depression out- stress management, development of a social support system, role
comes at the main time point of 26 weeks postpartum (or the transitions and changes associated with role transitions, and types
closest to this time point) ranged from 0% to 34% in the inter- of interpersonal conflicts common around childbirth.
vention groups, compared with 6% to 50% in the control groups, When limited to trials that only included women at increased
with absolute risk differences (ARDs) ranging from 1.3% greater risk of perinatal depression, the pooled RR was 0.55 (95% CI, 0.44
reduction in the control group to 31.8% greater reduction in the to 0.68; 14 trials [n = 1411]; I2 = 0%) (Table 2). There was a statisti-
intervention group. Of these 17 trials, 13 (76%) reported an out- cally significant small-studies effect for the counseling trials (Egger
come of major depressive disorder diagnosis based on a clinical test, −1.52; P = .01). Smaller trials were more likely to limit inclusion
interview. Trials reported depression outcomes over a wide range to populations selected for increased risk of perinatal depression,
of follow-up time points, ranging from 6 to 52 weeks postpartum. which may have been a major source of the association between
Effects were largest for CBT- and IPT-based interventions effect size and study size.
(Table 2), and the 2 most commonly used approaches were the Overall, counseling interventions were associated with a small
CBT-based Mothers and Babies program (used in 4 studies16,17,27,28) beneficial effect in symptom score measures, amounting to a pooled

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 Clinical Review & Education US Preventive Services Task Force USPSTF Evidence Report: Interventions to Prevent Perinatal Depression

Table 2. Summary of Pooled Effects of Subgroup Analyses for Counseling Interventions,

Organized by Counseling Approach
No. of Studies
(No. of Pooled RR
Counseling Approach Participants) (95% CI) I2, % τ2
All counseling trials 17 (3094) 0.61 (0.47-0.78) 39 0.09
CBT 8 (2128) 0.51 (0.33-0.79) 49 0.17
CBT Moms and Babies Program 4 (325) 0.47 (0.26-0.84) 0 0.0
IPT 8 (2095) 0.71 (0.50-1.00) 42 0.09
Abbreviations: CBT, cognitive-
IPT ROSE program 5 (464) 0.50 (0.32-0.80) 12 0.04 behavioral therapy;
All counseling trials, 14 (1411) 0.55 (0.44-0.68) 0 0.0 IPT, interpersonal therapy;
limited to trials targeting ROSE, Reach Out, Stand Strong,
women at increased risk Essentials for New Mothers;
of perinatal depression RR, risk ratio.

standardized effect size of 0.2, which would generally be consid- used CBT or IPT approaches. Information on adherence for coun-
ered a small effect,66 or a 1.5-point greater reduction in depression seling and other intervention approaches is available in the full
symptom severity than control conditions (standardized mean dif- evidence report.
ference, −0.21 [95% CI, −0.40 to −0.02]; 13 trials [n = 1367];
I2 = 57.2%) [eFigure 1 in the Supplement]; weighted mean differ- Health System Interventions
ence in change between groups, −1.51 [95% CI, −2.84 to −0.18]; 13 Three fair-quality studies (n = 5321; 2 RCTs,23,51 1 nonrandomized
trials [n = 1367]; I2 = 61.3% [eFigure 2 in the Supplement]). This analy- controlled intervention study65) examined the effects of health
sis combined a variety of instruments with 30- to 63-point ranges. system–level interventions. All 3 programs showed beneficial
Thirteen trials reported continuous symptom score measures and effects on depression, with RRs ranging from 0.33 (95% CI, 0.19 to
showed a wide range of results; however, group differences were 0.58; n = 433; ARD, −13.1%) to 0.71 (95% CI, 0.53 to 0.95; n = 2241;
statistically significant in only 5 trials.16,17,29,37,42 ARD, −3.1%) for exceeding a specified depression symptom level at
Most of the counseling trials also reported other maternal or follow-up. The pooled RR for health system interventions was 0.60
child outcomes; however, there was a wide variety of outcome mea- (95% CI, 0.43 to 0.83; 3 studies [n = 4738]; I2 = 66.3%) (Figure 3).
sures and little consistency across studies. Stress and anxiety were However, this association was not statistically significant with the
the most commonly reported other maternal or child outcome. For restricted maximum likelihood analysis, which better accounts for
example, 4 trials42,46-48 reported a measure of stress, but most did the small number of studies pooled (RR, 0.58 [95% CI, 0.22 to
not show statistically or clinically important differences between 1.53]). None were conducted in the United States, so applicability
groups. Other outcomes, generally reported by only 1 or 2 studies, to this country may be limited. Additionally, none limited their
included measures of functioning (general,19,38 maternal,21 and sample to women at increased risk of depression, suggesting that
family 21,42,48 ), quality of life, 48 social support, 16,42 trauma some universal prevention programs may be effective.
symptoms,39 mental health treatment,40 breastfeeding,38 child Health outcomes were sparsely reported in these studies and
development,49 child attachment,49 birth weight,42 and preterm showed mixed results (see full evidence report for more details). No
birth.42 Of these, 1 trial (n = 184) showed statistically significant ben- infant or child outcomes were reported in these trials.
efits on birth weight (between-group difference, 283 g; P = .01) and
incidence of preterm birth (RR, 0.19 [95% CI, 0.06 to 0.65]).42 No Other Intervention Approaches
other outcomes were statistically significant. A wide variety of other intervention approaches were identified.
Fifteen of the 20 trials of counseling interventions (75%) were Some of these approaches showed benefit in some trials, but most
limited to women who were known to be at increased risk of peri- trials did not find statistically significant group differences (Figure 4,
natal depression, owing to depression history or symptoms (6/20 for studies reporting sufficient data to plot). The intervention focus
[30%]), non–depression-related risk factors (3/20 [15%]), or either of these studies included physical activity (3 RCTs [n = 1200]),52-54
depression-related or other risk factors (6/20 [30%]). Thirteen of education (without counseling or extensive support; 6 RCTs
the 20 trials (65%) excluded women who met diagnostic criteria [n = 2949]),20,30,41,55-57 supportive interventions (without formal
for current major depression or scored above a prespecified cutoff counseling; 7 RCTs [n = 4569]),22,24,31,44,58,59 infant sleep advice (3
on a symptom severity scale. The trials that did not exclude women RCTs [n = 980]),36,60,61 birth-experience postpartum debriefing (2
with a depression diagnosis or high symptom level used either RCTs [n = 2786]),25,62 expressive writing (1 RCT [n = 120]),63 anti-
unselected populations or selected participants based on non– depressants (2 RCTs [n = 80]), 33,34 supplements (2 RCTs
depression-related criteria, so the proportion with depression was [n = 227]),35,64 and yoga (1 RCT [n = 46]).26
estimated or reported to be well below 50%. Of these approaches, the physical activity interventions con-
Counseling interventions lasted a median of 8 weeks (range, sistently reported point estimates in the direction of benefit (ARDs
4-70 weeks), included a median of 8 sessions (range, 4-20 ses- ranged from −1.3% to −12.5%), but only 1 trial found statistically sig-
sions), and had an estimated median of 12 hours of contact nificant group differences.53 Birth-experience debriefing25,62 and
(range, 4-23.3 hours). Fifteen (75%) included group sessions, 11 omega-3 fatty acid supplementation35,64 showed no benefit (study
(55%) included individual sessions, and 3 intervened with couples RRs ranged from 0.99 [95% CI, 0.87 to 1.11] [n = 1745] to 2.70 [95%
(eTable 2 in the Supplement).19,45,50 Most of the interventions CI, 0.56 to 13.09] [n = 79]). Additional sensitivity and subgroup

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 USPSTF Evidence Report: Interventions to Prevent Perinatal Depression US Preventive Services Task Force Clinical Review & Education

Figure 4. Depression Incidence, Prevalence, or Exceeding a Symptom Cutoff for Other Intervention Approaches, Sorted by Follow-up Time

Planned
Intervention Follow-up, No. With Depression/Total (%) Risk Ratio Favors Favors
Source Subtype wka Outcome Intervention Control (95% CI) Intervention Control
Physical activity
Perales et al,53 2015 g39 CES-D ≥16 11/90 (12.2) 19/77 (24.7) 0.49 (0.25-0.97)
Songøygard et al,54 2012 p13 EPDS ≥13 4/379 (1.1) 8/340 (2.4) 0.45 (0.14-1.48)
Norman et al,52 2010 p16 EPDS >13 7/62 (11.0) 12/73 (16.0) 0.69 (0.29-1.64)
Education
Maimburg and Vaeth,57 2015 Prenatal PPD p06 EPDS ≥12 39/543 (7.2) 42/526 (8.0) 0.90 (0.59-1.37)
module
Heh and Fu,30 2003 PPD booklet p13 EPDS ≥10 14/35 (40.0) 24/35 (68.6) 0.58 (0.37-0.93)
Howell et al,56 2014 PPD education p13 EPDS ≥10 12/235 (5.1) 15/232 (6.5) 0.79 (0.38-1.65)
Howell et al,41 2012 PPD education p26 EPDS ≥10 19/214 (8.9) 29/209 (13.7) 0.64 (0.37-1.10)
Fisher et al,20 2016 Postpartum p26 Prevalence 1/185 (0.5) 1/173 (0.6) 0.94 (0.06-14.88)
general education
Support
Kenyon et al,22 2016b Case management p08 EPDS ≥13 61/489 (12.0) 87/519 (17.0) 0.74 (0.55-1.01)
Dennis,31 2003 Peer support p18 EPDS >12 3/20 (15.0) 11/22 (52.4) 0.30 (0.10-0.92)
Stamp et al,59 1995 Support group p26 EPDS >12 9/60 (15.0) 6/61 (9.8) 1.52 (0.58-4.02)
Reid et al,58 2002 Support group p26 EPDS ≥12 49/339 (14.5) 46/370 (12.4) 1.16 (0.80-1.69)
Wiggins et al,44 2004 Community p61 EPDS ≥12 43/155 (27.7) 90/303 (29.7) 0.93 (0.69-1.27)
referral
Home visitor p61 EPDS ≥12 38/149 (25.5) 90/303 (29.7) 0.86 (0.62-1.19)
Sleep
Hiscock et al,60 2014 p26 EPDS >9 31/392 (7.9) 51/395 (12.9) 0.61 (0.40-0.94)
Debriefing
Small et al,25 2000 p26 EPDS ≥13 81/467 (17.3) 65/450 (14.4) 1.20 (0.89-1.62)
Priest et al,62 2003 p52 Incidence NR (17.8) NR (18.2) 0.99 (0.87-1.11)
Expressive writing
Blasio et al,63 2015 p13 BDI-II 13-28 5/57 (8.8) 9/56 (16.0) 0.55 (0.20-1.53)
Antidepressants
Wisner et al,33 2001 Nortriptyline p17 Incidence 6/26 (23.1) 6/25 (24.0) 0.96 (0.36-2.59)
Wisner et al,34 2004b Sertraline p20 Incidence 3/14 (21.4) 4/8 (50.0) 0.43 (0.13-1.45)
Supplements
Mozurkewich et al,35 2013 EPA-rich fish oil p06 Incidence 3/39 (7.7) 2/41 (4.9) 1.58 (0.28-8.94)
DHA-rich fish oil p06 Incidence 5/38 (13.2) 2/41 (4.9) 2.70 (0.56-13.09)
Llorente et al,64 2003 DHA p78 Incidence 4/23 (17.4) 3/22 (13.6) 1.28 (0.32-5.06)
supplementation

0.01 0.1 1 10 100

Risk Ratio (95% CI)

a
Weights are from random-effects analysis. BDI-II indicates Beck Depression ”g” indicates during gestation and “p” indicates postpartum; thus, for example,
Inventory II; CES-D, Center for Epidemiologic Studies Depression Scale; g37 indicates 37 weeks’ gestation and p12 indicates 12 weeks postpartum.
DHA, docosahexaenoic acid; EPA, eicosapentaenoic acid; EPDS, Edinburgh b
Study-reported adjusted analyses were statistically significant, although
Postnatal Depression Scale; NR, not reported; PA, physical activity; effect size shown in the forest plot, based on unadjusted data, are not
PPD, postpartum depression; RR, risk ratio. statistically significant.

analyses exploring effect sizes by study and intervention character- weeks postpartum.34 Further, the time to recurrence was faster in
istics are available in the full report. those receiving placebo (hazard ratio, 0.11 [95% exact CI, 0.02 to
The 2 trials of antidepressants to prevent perinatal depression 1.02]; exact Wilcoxon-Gehan P = .02). In these trials, women with a
assessed the effects of nortriptyline (n = 58)33 and sertraline history of postpartum depression in the previous 5 years were ran-
(n = 22).34 Both trials were conducted in the United States. The domized to receive either an antidepressant (nortriptyline
trial of nortriptyline found that the drug offered no preventive ben- [75 mg/d]33 or sertraline [50 mg/d]34) or placebo for 17 weeks,
efits compared with placebo (Figure 4).33 Neither the rates of starting as soon as possible after birth, followed by a 3-week taper-
recurrence between participants taking nortriptyline and those tak- ing phase. Neither trial of antidepressants reported other maternal
ing placebo (23% vs 24%; between-group statistics not reported; health outcomes or child outcomes.
P > .99), nor the time to postpartum recurrence (detailed findings
not reported; exact log-rank ⱕ0.00; P = .83) differed between the Harms of Preventive Interventions
2 groups. The trial of sertraline found that a smaller percentage of Key Question 2. What harms are associated with interventions to
participants taking sertraline had a depression recurrence com- prevent perinatal depression in pregnant or postpartum women?
pared with those taking placebo (7% vs 50%; difference in recur- None of the nonpharmaceutical studies reported any global
rence rates, 0.43 [95% exact CI, −0.01 to 0.84]; P = .04) at 20 harms outcomes for either mothers or infants. Across all of these

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 Clinical Review & Education US Preventive Services Task Force USPSTF Evidence Report: Interventions to Prevent Perinatal Depression

studies, none of the outcomes reported showed any pattern of in- ated with a number of rare but serious adverse events, including
creased risk of harms, based on group means. suicidality (in young adults), hyponatremia, seizures, gastrointesti-
Both antidepressant trials systematically collected adverse nal tract bleeding, and serotonin syndrome.67,68 The decision to
event information. In the nortriptyline trial (n = 58),33 the authors use antidepressants in pregnant persons is complicated and is
stated that participants tolerated nortriptyline well, reporting no addressed by only a limited amount of evidence. The use of
differences in withdrawals attributable to adverse effects, with only second-generation antidepressants during pregnancy has been
1 person withdrawing from each group. They reported only the associated with a small but increased risk of a number of serious
number of events for 1 of the 11 adverse effects collected; constipa- pregnancy and neonatal outcomes.69 However, the clinical signifi-
tion differed between groups (78% of the women taking nortripty- cance of these increased risks is unclear70 and most guidelines rec-
line vs 22% taking placebo). In the sertraline trial (n = 22),34 partici- ommend antidepressants for severe depression, with a preference
pants receiving sertraline were more likely than those receiving for sertraline,71 especially for those breastfeeding.72
placebo to report dizziness (57% vs 13%, P = .05) and drowsiness The findings of this review are similar to those reported in other
(100% vs 50%, P = .02) but did not differ in rates of other adverse similarly scoped reviews. A 2013 review on psychosocial and psy-
events (but data were not shown). Three women stopped taking chological interventions to prevent perinatal depression found that
sertraline because of adverse effects (21%), compared with none in women who received a psychosocial intervention were 22% less
the control group; however, this difference was not statistically sig- likely to develop perinatal depression, compared with usual care
nificant. One participant taking nortriptyline and 1 taking sertraline (pooled RR, 0.78 [95% CI, 0.66 to 0.93]; 20 studies [n = 14 727]).73
converted to mania or hypomania, while no women taking a pla- Another review of interventions designed to prevent perinatal de-
cebo did so; this difference was not statistically significant for either pression found a pooled odds ratio of 0.67 for depressive episodes
agent, although the studies were not powered for this outcome. by 6 months postpartum, after excluding outliers (95% CI, 0.52 to
There were no additional studies that addressed harms of sertra- 0.85; 26 studies; I2 = 46%).74 That review found no study or inter-
line in postpartum women. Additional harms studies of nortripty- vention characteristic that showed a statistically significant asso-
line were not searched for because efficacy was not demonstrated ciation with effect size.
for this treatment in the included studies. Anidealmethodfordeterminingwhichinterventionswouldben-
No harms were associated with omega-3 fatty acids, although efit persons with varying risk profiles is lacking, but the most com-
reports of adverse events were collected spontaneously rather than mon approach in the included trials was to include women with a
systematically through a validated instrument and adherence was history of depression or current depressive symptoms as mea-
by self-report. No significant differences in the proportion of par- sured by instruments such as the EPDS or CES-D. One study inves-
ticipants reporting gastrointestinal adverse effects or adherence with tigating the accuracy of the EPDS to predict future perinatal depres-
the recommended intervention were reported. sion found that a cutoff of 9 or higher at 3 to 5 days postpartum had
82% sensitivity, 95% specificity, and a 43% positive predictive value
foradiagnosisofmajororminordepressionat8weekspostpartum.75
The literature on predicting future perinatal depression includes a
Discussion
variety of patient- and clinician-administered tools, but results have
The summary of evidence is reported in Table 3. This review found been modest in many cases and need to be replicated.
that counseling-based interventions, in particular depression- There were a number of limitations in the studies underlying this
focused CBT and IPT, may be effective in preventing perinatal review. There were relatively few good-quality trials, and approxi-
depression. This evidence was primarily limited to women at mately one-third of the trials within the scope of this review were
increased risk for perinatal depression, such as having current excluded because of their poor quality. Many of these appeared to
depressive symptoms, a history of depression, low socioeconomic be pilot studies not designed to provide data on effectiveness of the
status, and lack of support. The pooled RR of 0.61 for perinatal intervention or that used intervention approaches that proved in-
depression at up to 6 months postpartum for counseling interven- feasible or ineffective and so were abandoned in the form studied.
tions corresponds to a number needed to treat of 13.5 (95% CI, 9.9 Some of these studies, however, could have provided useful infor-
to 23.9), assuming a 19% baseline risk of developing perinatal mation had they been conducted and reported in such a way that
depression. Three different health system–level interventions were they met USPSTF quality standards.
also effective in health care settings outside the United States, sug- The health system–level interventions in this review had lim-
gesting that similar interventions developed in US-based health ited applicability to health systems in the United States, especially
care systems may have the potential to be effective and were not since they involved enhancing home-visiting services, which are
limited to women at increased risk of perinatal depression. In all 3 not routinely available in the United States. However, some home-
cases, usual care included home visitation, which may be a valuable visiting services are available in the United States, and these inter-
intervention, suggesting the potential for even greater benefit ventions also included other elements that would be relevant to
compared with usual care in the United States. Additionally, other US-based settings. Interventions designed for implementation in
intervention approaches, such as physical activity or educational health care systems could involve clinician training, electronic
approaches, reported some positive findings but lacked robust evi- medical records–based tools, and facilitated access to behavioral
dence bases. health specialists embedded in the primary care settings.
Only 2 studies of prophylactic use of antidepressants were Another limitation of the evidence was the small number of
identified, showing mixed results. Antidepressants can be an trials examining several potentially valuable interventions, such as
important tool for treatment of depression but have been associ- physical activity, infant sleep education, in-hospital perinatal

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 Table 3. Summary of Evidence by Key Question and Intervention Type
No. of Studies

jama.com
(No. of Consistency and Strength of
Intervention Observations) Summary of Findings Precision Other Limitations Evidence Applicability
KQ1: Benefits of Interventions to Prevent Perinatal Depression
Counseling 20 (4107) Counseling interventions reduced the risk of perinatal Reasonably Small studies effect suggests possible Moderate 60% conducted in the United States, most
depression, primarily using cognitive behavioral therapy consistent, overestimate of effect size, many targeting women at increased risk of PND,
and interpersonal therapy reasonably small trials, only 2 good-quality trials most initiating the intervention during
precise pregnancy
In pooled analyses, the likelihood of perinatal depression Dichotomous depression outcomes
was 39% lower in intervention than control participants are a mix of incidence, prevalence, Interventions are not widely available and
(pooled RR, 0.61 [95% CI, 0.47 to 0.78]; 17 trials and being above a severity cutoff require specialized training.
[n = 3094]; I2 = 39%)

Depression symptom severity was reduced by 1.5 points

more in intervention than control participants (WMD,
−1.51 [95% CI, −2.84 to −0.18]; 13 trials [n = 1367];
I2 = 61%; T2 = 2.9)
Health system 3 (5321) All 3 health system interventions reduced the risk of Reasonably One study reported results only for Low Problematic: all conducted outside the
perinatal depression by 29% to 69%, although the pooled consistent, the subset of women who had not United States in health care systems very
effect was not statically significant (REML RR, 0.58 [95% imprecise developed elevated symptoms by 6 different from the United States
CI, 0.22 to 1.53]; 3 studies [n = 4738]; I2 = 66.3%) weeks postpartum; no good-quality (eg, postpartum home visitors are part of
studies usual care)
One study each reported improvements in anxiety and
USPSTF Evidence Report: Interventions to Prevent Perinatal Depression

SF-36 mental health component scores, but the third One study was a nonrandomized
found no difference in SF-36 scores controlled intervention study
Physical activity 3 (1200) One of the physical activity trials demonstrated a Reasonably Small body of evidence; only 1 study Insufficient None conducted in the United States, only
statistical significant reduction in the risk of perinatal consistent, showed statistically significant included unselected populations; however,
depression, with 12.2% of intervention participants imprecise between-group differences studies included both pregnant and
exceeding an EPDS threshold vs 24.7% of control postpartum women
participants

Absolute risk differences were smaller and not

statistically significant in the other trials
Education 6 (2949) Most trials did not find a benefit; however, 1 of the 2 Inconsistent, Wide variety of approaches, minimal Insufficient Only 2 trials of the same intervention were
US-based trials found a promising short-term benefit of a imprecise replication or similar interventions; conducted in the United States
brief PND education session in the hospital after delivery, the 1 replicated intervention had

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with 1 brief follow-up telephone call (6.3% of mixed findings
intervention participants had EPDS scores ≥10, vs 11.4%
of controls; adjusted OR, 0.45 [95% CI, 0.21 to 0.92])

© 2019 American Medical Association. All rights reserved.

Effect size was smaller and not statistically significant
on replication
Supportive 7 (4569) Three trials showed benefits of treatment, although Inconsistent, Wide variety of approaches with Insufficient None conducted in the United States, some
interventions effects were either not large, of marginal statistical imprecise minimal replication; adherence was embedded in health care systems with very
significance, or based on a very small sample very low in 1 of 2 nondirective low applicability to the United States
support group interventions
Telehone-based support by trained peers with history of
PND showed most promise
Sleep 3 (980) Mixed results, but some promising findings, including a Inconsistent, Few studies, no good-quality studies Insufficient Only 1 small trial conducted in the United
43% reduction in the odds of PND in 1 study (adjusted imprecise States (n = 54); targeted both early and
OR, 0.57 [95% CI, 0.34 to 0.94]) later postpartum phases

(continued)

(Reprinted) JAMA February 12, 2019 Volume 321, Number 6

US Preventive Services Task Force Clinical Review & Education

597
 598
Table 3. Summary of Evidence by Key Question and Intervention Type (continued)
No. of Studies
(No. of Consistency and Strength of
Intervention Observations) Summary of Findings Precision Other Limitations Evidence Applicability
Yoga 1 (46) No statistically significant or potentially clinically Consistency NA, Single small fair-quality study Insufficient Conducted in the United States, among
important differences between groups in depression imprecise women with elevated anxiety and
severity (mean difference in change in depression depressive symptoms
symptoms at posttest, 0.1 [95% CI, −3.2 to 3.5])
or anxiety
Debriefing 2 (2786) No benefit of debriefing the birth experience (pooled RR, Reasonably Only 2 fair-quality trials Low Neither conducted in the United States
1.04 [95% CI, 0.88 to 1.22]; 2 trials [n = 2662]; consistent,
I2 = 27%) reasonably
precise
Expressive writing 1 (120) Expressive writing not clearly associated with PND risk in Consistency NA, Single fair-quality small study Insufficient Not conducted in the United States
single relatively small study (RR, 0.55 [95% CI, 0.20 to imprecise
1.53])
Antidepressants Sertraline: 1 (22) Sertraline may reduce the risk of PND, but nortriptyline is Consistency NA, Single very small fair-quality study Insufficient Conducted in the United States;
unlikely to reduce the risk of PND imprecise for each agent recruitment through health care setting,
Nortriptyline: women with a history of PND
1 (58)
Omega-3 fatty acids 2 (227) Supplementation with omega-3 fatty acids (DHA, EPA) is Reasonably Only 2 trials (1 good quality) Low Both US-based, unselected and at-risk
Clinical Review & Education US Preventive Services Task Force

JAMA February 12, 2019 Volume 321, Number 6 (Reprinted)

not associated with a reduced likelihood of PND (pooled consistent, populations, including pregnant and
RR, 1.71 [95% CI, 0.70 to 4.17]; 2 trials [n = 204]; reasonably postpartum women
I2 = 0%) precise
KQ2: Harms of Interventions to Prevent Perinatal Depression
Behavior-based 0 Adverse events were not reported in behavior-based Consistency NA, No studies directly reported Low
trials, but other outcomes consistently trended in imprecise on harms
direction of benefit or no effect
Omega-3 fatty acids 1 (126) No adverse events were reported in either treatment Consistency NA, Low (DHA)
group imprecise
Nortriptyline 1 (58) Nortriptyline was associated with constipation (78% vs Consistency NA, Underpowered to detect serious Insufficient Conducted in the United States
22%), but there were no differences in withdrawal imprecise adverse events such as conversion
because of adverse effects; 1 patient taking nortriptyline to mania
converted to mania (vs none taking placebo)

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Sertraline 1 (22) Sertraline with associated with an increased risk of Consistency NA, Underpowered to detect serious Insufficient Conducted in the United States
dizziness (57% vs 13%) and drowsiness (100% vs 50%); imprecise adverse events such as conversion
3 patients taking sertraline withdrew because of adverse to mania
effect (vs none taking placebo); 1 patient taking
sertraline converted to mania (vs none taking placebo)

© 2019 American Medical Association. All rights reserved.

Abbreviations: DHA, docosahexaenoic acid; EPA, eicosapentaenoic acid; EPDS, Edinburgh Postnatal Depression maximum likelihood model; RR, risk ratio; SES, socioeconomic status; SF-36, 36-Item Short Form Health Survey;
Scale; KQ, key question; NA, not applicable; OR, odds ratio; PND, perinatal depression; REML, restricted WMD, weighted mean difference.

jama.com
USPSTF Evidence Report: Interventions to Prevent Perinatal Depression
 USPSTF Evidence Report: Interventions to Prevent Perinatal Depression US Preventive Services Task Force Clinical Review & Education

depression education with follow-up, and peer counseling. In addi- depression as a specific aim, and some studies may have been
tion, larger-scale effectiveness trials of CBT and IPT approaches are included that added the depression prevention aim post hoc after
needed to explore the degree to which these interventions can be determining that their intervention was effective in preventing
scaled up, as well as their applicability to lower-risk, more general depression. Second, both the overall body of evidence and the
primary care populations. More research is also needed on the use counseling intervention trials had statistically significant small-
of antidepressants and dietary supplements in the role of prevent- studies effects. Smaller trials also tended to use interventions that
ing perinatal depression. more directly addressed depression and to offer more intensive
Another important deficit in the literature is a lack of good interventions, so the small-studies effect may be influenced by
information on the best way to identify individuals at risk for peri- these and other study characteristics. However, it could not be
natal depression. Measures of depression symptoms, such as the determined to what extent the effect might be biasing results and
EPDS, likely provide the most direct association with future perina- overestimating the effect sizes.
tal depression. However, evidence is lacking on whether and how
to incorporate other risk factors, as well as on who is most likely to
benefit from preventive interventions and how those individuals
Conclusions
are best identified.
Counseling-based interventions can be effective in preventing peri-
Limitations natal depression, although most evidence was limited to women at
The review has several limitations. First, it was challenging to deter- increased risk for perinatal depression. A variety of other interven-
mine whether prevention of perinatal depression was truly an a tion approaches provided some evidence of effectiveness but lacked
priori aim; it is possible that some studies were missed that had a robust evidence base and need further research.

ARTICLE INFORMATION of AHRQ or the US Department of Health and 3. Fitelson E, Kim S, Baker AS, Leight K. Treatment
Accepted for Publication: December 6, 2018. Human Services. of postpartum depression: clinical, psychological
Additional Contributions: We gratefully and pharmacological options. Int J Womens Health.
Author Contributions: Dr O’Connor had full access 2010;3:1-14.
to all of the data in the study and takes acknowledge the following individuals for their
responsibility for the integrity of the data and the contributions to this project: the AHRQ staff; the US 4. Bernazzani O, Saucier JF, David H, Borgeat F.
accuracy of the data analysis. Preventive Services Task Force; Brittany U. Carter, Psychosocial predictors of depressive
Concept and design: O’Connor, Senger, Coppola, DSc, MPH (Kaiser Permanente Care Management symptomatology level in postpartum women.
Gaynes. Institute), for her assistance with scoping; Meghan J Affect Disord. 1997;46(1):39-49. doi:10.1016/
Acquisition, analysis, or interpretation of data: Soulsby Weyrich, MPH (University of California, S0165-0327(97)00077-3
O’Connor, Henninger, Coppola, Gaynes. Davis), for her assistance with data abstraction; and 5. Wilson LM, Reid AJ, Midmer DK, Biringer A,
Drafting of the manuscript: O’Connor, Senger, Smyth Lai, MLS, and Katherine Essick, BS, for Carroll JC, Stewart DE. Antenatal psychosocial risk
Coppola, Gaynes. technical and editorial assistance at the Kaiser factors associated with adverse postpartum family
Critical revision of the manuscript for important Permanente Center for Health Research. USPSTF outcomes. CMAJ. 1996;154(6):785-799.
intellectual content: Henninger, Gaynes. members, peer reviewers, and federal partner
reviewers did not receive financial compensation 6. Myers ER, Aubuchon-Endsley N, Bastian LA,
Statistical analysis: O’Connor, Gaynes. Gierisch J, Kemper AR, Swamy GK, Wald MF,
Obtained funding: O’Connor, Gaynes. for their contributions.
McBroom AJ, Lallinger KR, Gray RN, Green C,
Administrative, technical, or material support: Additional Information: A draft version of this Sanders GD. Efficacy and Safety of Screening for
Senger, Henninger, Coppola. evidence report underwent external peer review Postpartum Depression. Rockville, MD: Agency for
Conflict of Interest Disclosures: Dr Henninger from 3 content experts (Sherryl Goodman, PhD, Healthcare Research and Quality; 2013. AHRQ
reported receiving grants from Pfizer IGLC outside Emory University; Michael O’Hara, PhD, University publication 13-EHC064-EF.
the submitted work. Dr Gaynes reported receiving of Iowa; Barbara Yawn, MD, University of
Minnesota) and 1 federal partner: the Centers for 7. Da Costa D, Larouche J, Dritsa M, Brender W.
personal fees from LivaNova and personal fees Psychosocial correlates of prepartum and
from Johnson and Johnson outside the submitted Disease Control and Prevention. Comments from
reviewers were presented to the USPSTF during its postpartum depressed mood. J Affect Disord.
work. No other authors reported disclosures. 2000;59(1):31-40. doi:10.1016/S0165-0327(99)
deliberation of the evidence and were considered in
Funding/Support: This research was funded under preparing the final evidence review. 00128-7
contract number HHSA-290-2015-00017-I, 8. Beck CT. Predictors of postpartum depression:
Task Order 3, from the Agency for Healthcare Editorial Disclaimer: This systematic review is
presented as a document in support of the an update. Nurs Res. 2001;50(5):275-285. doi:10.
Research and Quality (AHRQ), US Department of 1097/00006199-200109000-00004
Health and Human Services, under a contract to accompanying USPSTF Recommendation
support the USPSTF. Statement. It did not undergo additional peer 9. Venkatesh KK, Phipps MG, Triche EW, Zlotnick C.
review after submission to JAMA. The relationship between parental stress and
Role of the Funder/Sponsor: Investigators worked postpartum depression among adolescent mothers
with USPSTF members and AHRQ staff to develop REFERENCES enrolled in a randomized controlled prevention
the scope, analytic framework, and key questions trial. Matern Child Health J. 2014;18(6):1532-1539.
for this review. AHRQ had no role in study selection, 1. Ko JY, Rockhill KM, Tong VT, Morrow B, Farr SL.
Trends in postpartum depressive symptoms—27 doi:10.1007/s10995-013-1394-7
quality assessment, or synthesis. AHRQ staff
provided project oversight, reviewed the report to States, 2004, 2008, and 2012. MMWR Morb Mortal 10. Kornfeld BD, Bair-Merritt MH, Frosch E,
ensure that the analysis met methodological Wkly Rep. 2017;66(6):153-158. doi:10.15585/ Solomon BS. Postpartum depression and intimate
standards, and distributed the draft for peer review. mmwr.mm6606a1 partner violence in urban mothers: co-occurrence
Otherwise, AHRQ had no role in the conduct of the 2. Committee on Obstetric Practice. The American and child healthcare utilization. J Pediatr. 2012;161
study; collection, management, analysis, and College of Obstetricians and Gynecologists (2):348-53. doi:10.1016/j.jpeds.2012.01.047
interpretation of the data; and preparation, review, Committee Opinion No. 630: screening for perinatal 11. Wu Q, Chen HL, Xu XJ. Violence as a risk factor
or approval of the manuscript findings. The depression. Obstet Gynecol. 2015;125(5):1268-1271. for postpartum depression in mothers:
opinions expressed in this document are those of doi:10.1097/01.AOG.0000465192.34779.dc a meta-analysis. Arch Womens Ment Health. 2012;15
the authors and do not reflect the official position (2):107-114. doi:10.1007/s00737-011-0248-9

jama.com (Reprinted) JAMA February 12, 2019 Volume 321, Number 6 599

© 2019 American Medical Association. All rights reserved.

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 Clinical Review & Education US Preventive Services Task Force USPSTF Evidence Report: Interventions to Prevent Perinatal Depression

12. Josefsson A, Angelsiöö L, Berg G, et al. for pregnant women with symptoms of depression 40. Zlotnick C, Tzilos G, Miller I, Seifer R, Stout R.
Obstetric, somatic, and demographic risk factors for and anxiety. Complement Ther Clin Pract. 2015;21 Randomized controlled trial to prevent postpartum
postpartum depressive symptoms. Obstet Gynecol. (3):166-172. doi:10.1016/j.ctcp.2015.06.005 depression in mothers on public assistance. J Affect
2002;99(2):223-228. 27. Le HN, Perry DF, Stuart EA. Randomized Disord. 2016;189:263-268. doi:10.1016/j.jad.2015.
13. Kim S, Soeken TA, Cromer SJ, Martinez SR, controlled trial of a preventive intervention for 09.059
Hardy LR, Strathearn L. Oxytocin and postpartum perinatal depression in high-risk Latinas. J Consult 41. Howell EA, Balbierz A, Wang J, Parides M,
depression: delivering on what’s known and what’s Clin Psychol. 2011;79(2):135-141. doi:10.1037/ Zlotnick C, Leventhal H. Reducing postpartum
not. Brain Res. 2014;1580:219-232. doi:10.1016/j. a0022492 depressive symptoms among black and Latina
brainres.2013.11.009 28. Muñoz R, Le H, Ippen C, Diaz M, Urzar G, mothers: a randomized controlled trial. Obstet
14. US Preventive Services Task Force. US Preventive Soto J. Prevention of postpartum depression in Gynecol. 2012;119(5):942-949. doi:10.1097/AOG.
Services Task Force Procedure Manual. Rockville, MD: low-income women: development of the Mamás y 0b013e318250ba48
US Preventive Services Task Force; 2015. Bebés/Mothers and Babies course. Cogn Behav Pract. 42. Ortiz Collado MA, Saez M, Favrod J, Hatem M.
15. Egger M, Davey Smith G, Schneider M, Minder 2007;14:70-83. doi:10.1016/j.cbpra.2006.04.021 Antenatal psychosomatic programming to reduce
C. Bias in meta-analysis detected by a simple, 29. Dimidjian S, Goodman SH, Felder JN, Gallop R, postpartum depression risk and improve childbirth
graphical test. BMJ. 1997;315(7109):629-634. doi: Brown AP, Beck A. Staying well during pregnancy outcomes: a randomized controlled trial in Spain
10.1136/bmj.315.7109.629 and the postpartum: a pilot randomized trial of and France. BMC Pregnancy Childbirth. 2014;14:22.
mindfulness-based cognitive therapy for the doi:10.1186/1471-2393-14-22
16. Tandon SD, Leis JA, Mendelson T, Perry DF,
Kemp K. Six-month outcomes from a randomized prevention of depressive relapse/recurrence. 43. Dugravier R, Tubach F, Saias T, et al; CAPEDP
controlled trial to prevent perinatal depression in J Consult Clin Psychol. 2016;84(2):134-145. doi:10. Study Group. Impact of a manualized multifocal
low-income home visiting clients. Matern Child 1037/ccp0000068 perinatal home-visiting program using
Health J. 2014;18(4):873-881. doi:10.1007/s10995- 30. Heh SS, Fu YY. Effectiveness of informational psychologists on postnatal depression: the CAPEDP
013-1313-y support in reducing the severity of postnatal randomized controlled trial. PLoS One. 2013;8(8):
depression in Taiwan. J Adv Nurs. 2003;42(1):30-36. e72216. doi:10.1371/journal.pone.0072216
17. Tandon SD, Perry DF, Mendelson T, Kemp K,
Leis JA. Preventing perinatal depression in doi:10.1046/j.1365-2648.2003.02576.x 44. Wiggins M, Oakley A, Roberts I, et al. The Social
low-income home visiting clients: a randomized 31. Dennis CL. The effect of peer support on Support and Family Health Study: a randomised
controlled trial. J Consult Clin Psychol. 2011;79(5): postpartum depression: a pilot randomized controlled trial and economic evaluation of two
707-712. doi:10.1037/a0024895 controlled trial. Can J Psychiatry. 2003;48(2):115-124. alternative forms of postnatal support for mothers
doi:10.1177/070674370304800209 living in disadvantaged inner-city areas. Health
18. Phipps MG, Raker CA, Ware CF, Zlotnick C. Technol Assess. 2004;8(32):1-120. doi:10.3310/
Randomized controlled trial to prevent postpartum 32. Dennis CL, Hodnett E, Kenton L, et al. Effect of hta8320
depression in adolescent mothers. Am J Obstet peer support on prevention of postnatal depression
Gynecol. 2013;208(3):192.e1-192.e6. doi:10.1016/j. among high risk women: multisite randomised 45. Feinberg ME, Kan ML. Establishing family
ajog.2012.12.036 controlled trial. BMJ. 2009;338:a3064. doi:10.1136/ foundations: intervention effects on coparenting,
bmj.a3064 parent/infant well-being, and parent-child relations.
19. Brugha TS, Wheatley S, Taub NA, et al. J Fam Psychol. 2008;22(2):253-263. doi:10.1037/
Pragmatic randomized trial of antenatal 33. Wisner KL, Perel JM, Peindl KS, Hanusa BH, 0893-3200.22.2.253
intervention to prevent post-natal depression by Findling RL, Rapport D. Prevention of recurrent
reducing psychosocial risk factors. Psychol Med. postpartum depression: a randomized clinical trial. 46. Woolhouse H, Mercuri K, Judd F, Brown SJ.
2000;30(6):1273-1281. doi:10.1017/ J Clin Psychiatry. 2001;62(2):82-86. doi:10.4088/ Antenatal mindfulness intervention to reduce
S0033291799002937 JCP.v62n0202 depression, anxiety and stress: a pilot randomised
controlled trial of the MindBabyBody program in an
20. Fisher J, Rowe H, Wynter K, et al. 34. Wisner KL, Perel JM, Peindl KS, Hanusa BH, Australian tertiary maternity hospital. BMC
Gender-informed, psychoeducational programme Piontek CM, Findling RL. Prevention of postpartum Pregnancy Childbirth. 2014;14:369. doi:10.1186/
for couples to prevent postnatal common mental depression: a pilot randomized clinical trial. Am J s12884-014-0369-z
disorders among primiparous women: cluster Psychiatry. 2004;161(7):1290-1292. doi:10.1176/appi.
randomised controlled trial. BMJ Open. 2016;6(3): ajp.161.7.1290 47. Milgrom J, Schembri C, Ericksen J, Ross J,
e009396. doi:10.1136/bmjopen-2015-009396 Gemmill AW. Towards parenthood: an antenatal
35. Mozurkewich EL, Clinton CM, Chilimigras JL, intervention to reduce depression, anxiety and
21. Gorman L. Prevention of Postpartum Difficulties et al. The Mothers, Omega-3, and Mental Health parenting difficulties. J Affect Disord. 2011;130(3):
in a High Risk Sample [dissertation]. Iowa City: Study: a double-blind, randomized controlled trial. 385-394. doi:10.1016/j.jad.2010.10.045
University of Iowa; 1997. Am J Obstet Gynecol. 2013;208(4):313.e1-313.e9.
doi:10.1016/j.ajog.2013.01.038 48. Leung SS, Lam TH. Group antenatal
22. Kenyon S, Jolly K, Hemming K, et al. Lay intervention to reduce perinatal stress and
support for pregnant women with social risk: 36. Werner EA, Gustafsson HC, Lee S, et al. PREPP: depressive symptoms related to intergenerational
a randomised controlled trial. BMJ Open. 2016;6(3): postpartum depression prevention through the conflicts: a randomized controlled trial. Int J Nurs
e009203. doi:10.1136/bmjopen-2015-009203 mother-infant dyad. Arch Womens Ment Health. Stud. 2012;49(11):1391-1402. doi:10.1016/j.ijnurstu.
23. MacArthur C, Winter HR, Bick DE, et al. Effects 2016;19(2):229-242. doi:10.1007/s00737-015-0549- 2012.06.014
of redesigned community postnatal care on 5
49. Cooper PJ, De Pascalis L, Woolgar M, Romaniuk
womens’ health 4 months after birth: a cluster 37. Zlotnick C, Johnson SL, Miller IW, Pearlstein T, H, Murray L. Attempting to prevent postnatal
randomised controlled trial. Lancet. 2002;359 Howard M. Postpartum depression in women depression by targeting the mother-infant
(9304):378-385. doi:10.1016/S0140-6736(02) receiving public assistance: pilot study of an relationship: a randomised controlled trial. Prim
07596-7 interpersonal-therapy-oriented group intervention. Health Care Res Dev. 2015;16(4):383-397. doi:10.
24. Morrell CJ, Spiby H, Stewart P, Walters S, Am J Psychiatry. 2001;158(4):638-640. doi:10.1176/ 1017/S1463423614000401
Morgan A. Costs and effectiveness of community appi.ajp.158.4.638
50. Kozinszky Z, Dudas RB, Devosa I, et al.
postnatal support workers: randomised controlled 38. Zlotnick C, Miller IW, Pearlstein T, Howard M, Can a brief antepartum preventive group
trial. BMJ. 2000;321(7261):593-598. doi:10.1136/ Sweeney P. A preventive intervention for pregnant intervention help reduce postpartum depressive
bmj.321.7261.593 women on public assistance at risk for postpartum symptomatology? Psychother Psychosom. 2012;81
25. Small R, Lumley J, Donohue L, Potter A, depression. Am J Psychiatry. 2006;163(8):1443-1445. (2):98-107. doi:10.1159/000330035
Waldenström U. Randomised controlled trial of doi:10.1176/ajp.2006.163.8.1443
51. Brugha TS, Morrell CJ, Slade P, Walters SJ.
midwife led debriefing to reduce maternal 39. Zlotnick C, Capezza NM, Parker D. Universal prevention of depression in women
depression after operative childbirth. BMJ. 2000; An interpersonally based intervention for postnatally: cluster randomized trial evidence in
321(7268):1043-1047. doi:10.1136/bmj.321.7268.1043 low-income pregnant women with intimate partner primary care. Psychol Med. 2011;41(4):739-748. doi:
26. Davis K, Goodman SH, Leiferman J, Taylor M, violence: a pilot study. Arch Womens Ment Health. 10.1017/S0033291710001467
Dimidjian S. A randomized controlled trial of yoga 2011;14(1):55-65. doi:10.1007/s00737-010-0195-x

600 JAMA February 12, 2019 Volume 321, Number 6 (Reprinted) jama.com

© 2019 American Medical Association. All rights reserved.

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 USPSTF Evidence Report: Interventions to Prevent Perinatal Depression US Preventive Services Task Force Clinical Review & Education

52. Norman E, Sherburn M, Osborne RH, Galea MP. controlled trial. Birth. 1995;22(3):138-143. doi:10. primary care settings: a systematic evidence
An exercise and education program improves 1111/j.1523-536X.1995.tb00689.x review. Ann Intern Med. 2009;151(11):793-803. doi:
well-being of new mothers: a randomized 60. Hiscock H, Cook F, Bayer J, et al. Preventing 10.7326/0003-4819-151-11-200912010-00007
controlled trial. Phys Ther. 2010;90(3):348-355. early infant sleep and crying problems and 69. Alwan S, Friedman JM, Chambers C.
doi:10.2522/ptj.20090139 postnatal depression: a randomized trial. Pediatrics. Safety of selective serotonin reuptake inhibitors
53. Perales M, Refoyo I, Coteron J, Bacchi M, 2014;133(2):e346-e354. doi:10.1542/peds.2013-1886 in pregnancy: a review of current evidence.
Barakat R. Exercise during pregnancy attenuates 61. Hiscock H, Wake M. Randomised controlled trial CNS Drugs. 2016;30(6):499-515. doi:10.1007/
prenatal depression: a randomized controlled trial. of behavioural infant sleep intervention to improve s40263-016-0338-3
Eval Health Prof. 2015;38(1):59-72. doi:10.1177/ infant sleep and maternal mood. BMJ. 2002;324 70. Ross LE, Grigoriadis S, Mamisashvili L, et al.
0163278714533566 (7345):1062-1065. doi:10.1136/bmj.324.7345.1062 Selected pregnancy and delivery outcomes after
54. Songøygard KM, Stafne SN, Evensen KA, 62. Priest SR, Henderson J, Evans SF, Hagan R. exposure to antidepressant medication:
Salvesen KÅ, Vik T, Mørkved S. Does exercise during Stress debriefing after childbirth: a randomised a systematic review and meta-analysis. JAMA
pregnancy prevent postnatal depression? a controlled trial. Med J Aust. 2003;178(11):542-545. Psychiatry. 2013;70(4):436-443. doi:10.1001/
randomized controlled trial. Acta Obstet Gynecol jamapsychiatry.2013.684
Scand. 2012;91(1):62-67. doi:10.1111/j.1600-0412.2011. 63. Blasio PD, Camisasca E, Caravita SC, Ionio C,
Milani L, Valtolina GG. The effects of expressive 71. Molenaar NM, Brouwer ME, Duvekot JJ, et al.
01262.x Antidepressants during pregnancy: guideline
writing on postpartum depression and
55. Hayes BA, Muller R, Bradley BS. Perinatal posttraumatic stress symptoms. Psychol Rep. 2015; adherence and current practice amongst Dutch
depression: a randomized controlled trial of an 117(3):856-882. doi:10.2466/02.13.PR0.117c29z3 gynaecologists and midwives. Midwifery. 2018;61:
antenatal education intervention for primiparas. Birth. 29-35. doi:10.1016/j.midw.2018.02.018
2001;28(1):28-35. doi:10.1046/j.1523-536x.2001. 64. Llorente AM, Jensen CL, Voigt RG, Fraley JK,
Berretta MC, Heird WC. Effect of maternal 72. Weissman AM, Levy BT, Hartz AJ, et al. Pooled
00028.x analysis of antidepressant levels in lactating
docosahexaenoic acid supplementation on
56. Howell EA, Bodnar-Deren S, Balbierz A, et al. postpartum depression and information mothers, breast milk, and nursing infants. Am J
An intervention to reduce postpartum depressive processing. Am J Obstet Gynecol. 2003;188(5): Psychiatry. 2004;161(6):1066-1078. doi:10.1176/appi.
symptoms: a randomized controlled trial. Arch 1348-1353. doi:10.1067/mob.2003.275 ajp.161.6.1066
Womens Ment Health. 2014;17(1):57-63. doi:10. 73. Dennis CL, Dowswell T. Psychosocial and
1007/s00737-013-0381-8 65. Fontein-Kuipers YJ, Ausems M, de Vries R,
Nieuwenhuijze MJ. The effect of Wazzup Mama?! psychological interventions for preventing
57. Maimburg RD, Vaeth M. Postpartum an antenatal intervention to prevent or reduce postpartum depression. Cochrane Database Syst Rev.
depression among first-time mothers—results from maternal distress in pregnancy. Arch Womens Ment 2013;2(2):CD001134.
a parallel randomised trial. Sex Reprod Healthc. Health. 2016;19(5):779-788. doi:10.1007/s00737- 74. Sockol LE, Epperson CN, Barber JP. Preventing
2015;6(2):95-100. doi:10.1016/j.srhc.2015.01.003 016-0614-8 postpartum depression: a meta-analytic review.
58. Reid M, Glazener C, Murray GD, Taylor GS. 66. Cohen J. A power primer. Psychol Bull. 1992;112 Clin Psychol Rev. 2013;33(8):1205-1217. doi:10.1016/
A two-centred pragmatic randomised controlled (1):155-159. doi:10.1037/0033-2909.112.1.155 j.cpr.2013.10.004
trial of two interventions of postnatal support. BJOG. 75. Jardri R, Pelta J, Maron M, et al. Predictive
2002;109(10):1164-1170. doi:10.1111/j.1471-0528. 67. Gartlehner G, Hansen RA, Reichenpfader U,
et al. Drug Class Review: Second-Generation validation study of the Edinburgh Postnatal
2002.01306.x Depression Scale in the first week after delivery
Antidepressants: Final Update 5 Report. Portland:
59. Stamp GE, Williams AS, Crowther CA. Oregon Health & Science University; 2011. and risk analysis for postnatal depression. J Affect
Evaluation of antenatal and postnatal support to Disord. 2006;93(1-3):169-176. doi:10.1016/j.jad.2006.
overcome postnatal depression: a randomized, 68. O’Connor EA, Whitlock EP, Beil TL, Gaynes BN. 03.009
Screening for depression in adult patients in

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