Psychosocial and psychological interventions for treating postpartum depression

For the estimated 13 percent of new mothers who experience postpartum depression, counseling and peer support groups appear to offer symptom relief without medication, a new review of research suggests.

However, at least one expert cautions against ruling out drug therapy altogether.

Postpartum depression — unlike the much more common “baby blues,” which affect 70 percent to 85 percent of new mothers — typically occurs from three days to six weeks after the baby's birth, but can develop any time during the first year after delivery. A woman with postpartum depression often struggles with feelings of sadness, anxiety, fatigue and restlessness.

Left untreated, postpartum depression poses serious health consequences for mothers, children and families. Not only are these mothers at a higher risk of developing future episodes of depression, but the condition can negatively affect interactions between babies and mothers. Children of depressed moms are at greater risk of language deficits, social difficulties and attention problems.

Although it can be treated with antidepressant medications, “research suggests that 50 percent of mothers will not take a pharmacological treatment for postpartum depression,” often due to concerns about medication side effects or passing the medicine to infants in breast milk, said Cindy-Lee Dennis, Ph.D., the review's lead author.

“We need an alternative to pharmacological interventions,” said Dennis, a perinatal researcher and associate professor at the University of Toronto, Ontario. Her review evaluated nine randomized controlled trials conducted in the United States, the United Kingdom, Canada and Australia.

The review appears in the latest issue of The Cochrane Library , a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

It turns out that providing a supportive environment could be a medication-free way to alleviate depression symptoms in new mothers, the results suggest.

The review included 956 women with symptoms of postpartum depression and found that, compared to usual postpartum care, mothers who received any type of psychosocial or psychological intervention had a 30-percent lower risk of still having depressive symptoms at the final study assessment, which occurred within the first year postpartum.

“Women prefer to talk to someone to help them work through their depression … Mother-to-mother or peer support is extremely important in the postpartum period. It provides realistic social norms of what it is like to be a mother,” Dennis said.

Previous studies have shown that there is a clear connection between postpartum depression and a lack of social support, but despite this relationship, few well-designed studies have evaluated the effect of support groups and counseling in alleviating new moms' depressive symptoms, according to Dennis.

Health care professionals facilitated all of the social and psychological interventions in this review, which were face-to-face except for one that involved telephone-based peer support.

Both social interventions (such as counseling and peer support) and psychological interventions (such as cognitive behavioral therapy) appeared to be similarly effective in reducing symptoms, based on results from the two trials that compared them.

“The review is helpful in some ways, but really points out the deficiency in research in this area in general,” said Jennifer Payne, M.D., co-director of the Women's Mood Disorders Center at Johns Hopkins School of Medicine.

Although the review results suggest that new moms with depression benefit from social and psychological interventions, the review authors said that the included trials could not offer data on whether these interventions reduced depression symptoms long-term.

As a result, drawing conclusions about how to treat depressed women is risky because we do not have all of the necessary data, Payne said.

Payne agreed with the authors' conclusions that psychosocial and psychological interventions are a viable treatment option for patients; however, what is not clear is which women need medications in addition to these therapies, she said.

“When you have someone with a first onset of depression and it's mild to moderate, those are usually the patients that I think about offering psychological intervention, but anytime someone is mildly to moderately depressed, you have to think about medication, usually in conjunction with a psychological intervention,” she said.

However, Payne added that even in cases of mild to moderate depression, health care providers might advise treatment with medication, often in conjunction with psychological intervention. Furthermore, in women who have severe symptoms or have a history of depression, treatment with medication is usually necessary to relieve depressive symptoms.

What is the take-home message here? Not only do additional support and psychological interventions work, but also, they are what new moms want, Dennis said.

“These psychosocial and psychological interventions are consistent with mother's treatment preferences . . . If treatment is linked to women's perceptions as to why they are depressed and they are interested in the type of treatment offered, they are more likely to be compliant,” Dennis said.

Overall, new mothers should remember that postpartum depression is a treatable condition. Simply choosing to live with depression symptoms is not in anyone's best interests, Payne said. Even if a depressed mother avoids exposing her baby to antidepressants, “the baby is still being exposed to a depressed mom and that's not good for the baby.”

Dennis C-L, Hodnett E. Psychosocial and psychological interventions for treating postpartum depression. (Review). Cochrane Database of Systematic Reviews 2007, Issue 4.

The Cochrane Collaboration is an international nonprofit, independent organization that produces and disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. Visit http://www.cochrane.org for more information.