The effectiveness of antenatal interventions to prevent postnatal depression in high-risk women

Abstract

Background

Postnatal depression can have a major impact on the lives of women affected and on those around them. While effective treatments are available, it would be preferable to prevent the condition. The aim of this review was to examine the effectiveness of antenatal interventions designed to prevent postnatal depression in high-risk women.

Methods

Randomised controlled trials of interventions to prevent postnatal depression delivered to high-risk women in pregnancy were identified through an electronic database search and a reference list search. Information regarding the selection criteria, content and delivery of the interventions was extracted and synthesised.

Results

Eleven studies met the review inclusion criteria. Six described interventions that were significantly more effective in reducing the incidence and/or symptoms of postnatal depression than a control condition. Interventions were most likely to be effective when delivered to women who were depressed during pregnancy and when incorporating evidence-based psychological treatments for depression and addressing interpersonal difficulties.

Limitations

It is possible that unpublished trials of antenatal interventions to prevent postnatal depression exist that were not detected. Due to the recognised publication bias, these studies may have been less likely to find a significant effect of antenatal interventions on postnatal depression.

Conclusions

There is evidence to suggest that interventions delivered in pregnancy can be effective in preventing postnatal depression. However, these interventions may be better conceptualised as treatment than prevention as they were delivered to women experiencing antenatal depression. There is a need to identify pregnant women experiencing depression and deliver evidence-based psychological interventions.

Introduction

Postnatal depression (PND) is estimated to affect approximately 5–13% of women within the first year after the birth of a child (Gaynes et al., 2005), with the greatest risk occurring in the first five weeks after the birth (Cox et al., 1993). The aetiology of depression experienced in the postnatal period is not currently considered to be different from that of depression experienced at other times in a person's life (Ogrodniczuk and Piper, 2003, Phillips et al., 2010). Instead, the experience of PND is said to fit within the stress–vulnerability model of depression, where the arrival of the baby is the stressor that triggers depression (Riecher-Rossler and Hofecker Fallahpour, 2003).

While the symptoms of PND may not differ from other forms of depression, the implications of being depressed at this transitional time when a woman not only needs to care for herself but also for a new born child pose specific challenges. PND can have severe consequences, not only for the mother but also for those around her (Almond, 2009). PND has been associated with poor maternal attachment (Ogrodniczuk and Piper, 2003), increased depression in partners (Ballard et al., 1994) and negative effects on child development (Murray and Cooper, 1997) and behaviour (Fihrer et al., 2009). Depression has also been listed as one of the two leading causes of death in pregnant and postnatal women (Lewis, 2004).

Effective psychological and pharmaceutical treatments are known to exist for PND (Dennis and Hodnett, 2007, Hoffbrand et al., 2001). However, given the serious consequences of postnatal depression for the mother and those around her, it would be preferable to be able to prevent postnatal depression, rather than treating it once it is established. Research has identified factors that put women at risk of developing postnatal depression, including antenatal depression/anxiety, a history of depression, lack of support, and major life events (Milgrom et al., 2008). It follows that it may be possible to identify women with such risk factors in the antenatal period and intervene to prevent postnatal depression, and a variety of such interventions have been developed and tested.

Several reviews of the effectiveness of interventions to prevent postnatal depression have been conducted (Austin, 2003, Dennis, 2004, Dennis, 2005, Dennis and Creedy, 2004, Dimidjian and Goodman, 2009, Ogrodniczuk and Piper, 2003). The most comprehensive review to date, a Cochrane review, involved a meta-analysis of psychosocial and psychological interventions for preventing PND and concluded that preventive interventions are not effective in reducing PND (Dennis, 2005, Dennis and Creedy, 2004). This review covered a wide variety of preventive interventions, delivered in both the antenatal and postnatal period with varying degrees of success and the general conclusion that they are not successful appears to be an over generalisation. Furthermore, no details were provided on how women were identified as being at risk of PND, in order to determine who may benefit most from preventive interventions. The review has also been criticised for failing to identify key research that met its inclusion criteria (Matthey, 2005). A more recent review has also omitted major papers in the field and has not explored why some interventions work and others do not (Dimidjian and Goodman, 2009).

The aim of this work was therefore to conduct a more comprehensive review of the effectiveness of antenatal interventions to prevent postnatal depression. Secondary aims were to explore whether specific types of intervention are more effective than others and whether some women are more likely to benefit than others.