Women at high risk for perinatal depression should be referred to counseling, the U.S. Preventive Service Task Force (USPSTF) suggested.
In a final recommendation statement published in JAMA — affirming a draft recommendation released in August 2018 — the Task Force determined with “high certainty” that counseling interventions have a “moderate net benefit” (Level B) to prevent perinatal depression in pregnant and postpartum women.
The statement extends to high-risk pregnant women and those who are less than a year postpartum without an existing diagnosis of depression. Factors bumping individuals into the high-risk category include current depressive symptoms, but not over the DSM-5 threshold; a history of depression or other mental health comorbidities; being a survivor of domestic violence; or socioeconomic factors like single parenthood, adolescence, or low income.
Some of the recommended counseling interventions aimed at prevention include cognitive behavioral therapy and interpersonal therapy. On the other hand, the group did not find enough evidence to recommend any treatment approaches other than counseling, such as pharmacological treatments including sertraline, nortriptyline, or omega-3 fatty acids.
As for recommended counseling, the group saw at least a moderate net benefit from sessions consisting of four to 20 meetings spanning across 4 to 70 weeks. The researchers recommended the “Mothers and Babies” program as one potential cognitive behavioral approach and the Reach Out, Stand Strong, Essentials for New Mothers (ROSE) program as a type of interpersonal therapy.
This recommendation was based on a systematic evidence review commissioned by the Task Force and conducted by Elizabeth O’Connor, PhD, of Kaiser Permanente in Portland, and colleagues. The review, which included 50 studies accounting for over 22,000 individuals, found a 39% lower risk for the onset of perinatal depression tied to such counseling interventions (pooled relative risk 0.61, 95% CI 0.47-0.78).
Putting these recommendations into practice may be a difficult challenge to overcome, however, said the author of an accompanying editorial, Marlene Freeman, MD, of Massachusetts General Hospital in Boston. She said that although the previous goal of universal screening for depression in adults was “straightforward,” it will be a “greater challenge to identify women at risk compared with those experiencing perinatal depression.”
“As the task force indicates, ‘there is no accurate screening tool for identifying women at risk of perinatal depression and who might benefit from preventive interventions,'” Freedman explained, adding that “unlike self-rated tools, it is more complex to perform a risk assessment based on a range of historical and demographic risk factors, and it is unclear to what degree these predict perinatal depression.”
This apprehension over screening implementation was echoed by Jennifer Felder, PhD, of the University of California, San Francisco, who in a related editorial in JAMA Internal Medicine, emphasized that the sheer number of available psychologists to undertake the amount of patients needing preventive counseling is simply not “universally accessible.”
“Although researchers have investigated a variety of alternative delivery formats, including by phone, during home visits, and via digital platforms, these adaptations currently have limited availability to the public,” Felder commented, adding that the interventions that showed such efficacy in the USPSTF’s review were undertaken in “tightly controlled … ideal circumstances. It is vital that researchers investigate effectiveness in real-world settings and disseminate effective interventions into practice,” she said.
Accessibility isn’t the only barrier to receiving this type of preventive perinatal depression intervention, either, as authors of another related editorial, in JAMA Psychiatry, highlighted the financial component to this implementation barrier.
“Despite modest momentum to fund preventive interventions across disease conditions and increased billing for postpartum depression screening and treatment through Medicaid’s Early Periodic Screening Diagnosis and Treatment provision, we have yet to realize widespread payment for postpartum depression preventive interventions,” wrote Katherine Wisner, MD, of Northwestern University Feinberg School of Medicine in Chicago, and colleagues.
They suggested that Medicaid and private insurers unite in order to “define best practices for reimbursement” in regards to such proven perinatal depression prevention strategies.
The evidence report was funded by the Agency for Healthcare Research and Quality and U.S. Department of Health and Human Services.
O’Connor reported no disclosures, but other report investigators did report various conflicts of interest.
Freeman reported relationships with Takeda, JayMac, Sage, Otsuka, Alkermes, Janssen, Sunovion, and the Global Organization for EPA & DHA Omega-3. Felder is supported by the National Center for Complementary and Integrative Health of the National Institutes of Health.