Referral for counseling is key for women at risk.
In a new statement, the US Preventive Services Task Force (USPSTF) is recommending that clinicians refer pregnant and postpartum women at risk of perinatal depression for counseling. The guidance is based on a review of 50 studies that the organization said provided “convincing” evidence that counseling could help prevent perinatal depression.
Published in JAMA, the recommendation statement notes that depression is very common during pregnancy and postpartum, seen in 1 in 7 women, and that screening for depression and anxiety is recommended by the American College of Obstetricians and Gynecologists for all postpartum women. Preventive methods reviewed by USPSTF included counseling, health system interventions, physical activity, education, and supportive and behavioral techniques. Evidence on use of nortriptyline, sertraline, and omega-3 fatty acids also was reviewed.
Of the 50 studies assessed (49 randomized controlled trial, 1 nonrandomized controlled intervention study), 20 reported on counseling interventions. Most of the research involved use of cognitive behavioral or interpersonal therapy, in both group and individual settings. Median duration of counseling was 8 weeks and median contact time was 12 hours, largely via in-person visits.
Staff leading the interventions included psychologists, midwives, nurses, and other mental health professionals. Counseling had a larger positive effect in trials that enrolled women at increased risk of perinatal depression versus those that enrolled a lower-risk, unselected population, but the difference was not statistically significant.
The USPSTF panel reviewed four trials that looked at drug therapy for prevention of perinatal depression, one each on sertraline and nortriptyline and two on omega-3 fatty acids. No preventive benefits were found for nortriptyline or omega-3 fatty acids versus placebo, whereas sertraline decreased recurrence of depression compared with placebo (7% vs 50%; P= .04).
The only harms reported in the USPSTF analysis were for nortriptyline and sertraline. The former drug was associated with a 78% incidence of constipation and the latter with a 55% incidence of dizziness and 100% incidence of drowsiness, versus 22%, 13%, and 50%, respectively, for placebo.
USPSTF’s grade B recommendation for counseling indicates a “high certainty that the net benefit is moderate, or there is moderate certainly that the net benefit is moderate to substantial.” The organization underscored the need for “large-scale trials of cognitive behavioral therapy and interpersonal therapy interventions…to demonstrate whether these strategies are scalable and applicable to persons at lower risk.” They also acknowledged the lack of good-quality evidence on how to identify women at increased risk of perinatal depression who might benefit from preventive interventions.