Am Fam Physician. 2019;100(4):244-245
Author disclosure: No relevant financial affiliations.
Clinical Question
Is cognitive behavior therapy (CBT) an effective treatment for postpartum depression?
Evidence-Based Answer
In women with postpartum depression, the addition of CBT reduces depressive symptoms more effectively than usual care alone (medication and other therapies), with a medium effect size at the end of the intervention and a residual small effect size six months later. (Strength of Recommendation: B, based on a meta-analysis of low-quality randomized controlled trials [RCTs] and two additional small RCTs.)
Evidence Summary
A 2016 systematic review and meta-analysis of 10 RCTs (N = 1,324) examined the effectiveness of psychological therapies (including but not limited to CBT) for postpartum depression compared with usual treatment.1 Women with postpartum depression who had infants younger than 12 months were recruited from primary care settings. CBT was delivered in 30-to 120-minute group or individual sessions (frequency not reported) by trained clinicians over one to eight months. Usual treatment included antidepressants, referral to subspecialists, continuation of preexisting counseling, or wait list control. Depression symptoms were measured by the Edinburgh Postnatal Depression Scale (EPDS; score range: 0 to 30) or the Beck Depression Inventory-II (BDI-II; score range: 0 to 63). An EPDS score of 12 or greater or a BDI-II score of 10 or greater was diagnostic for depression. Symptoms were assessed immediately after the intervention in all studies, and some studies included a final assessment up to five years later. Compared with usual treatment, patients receiving CBT had a reduction in depression symptoms immediately after the intervention (six trials; N = 616; standardized mean difference [SMD] = −0.36; 95% CI, −0.52 to −0.21). (An SMD of 0.80 or greater is considered a large effect, 0.50 is a medium effect, and 0.20 is a small effect.) At a median follow-up of six months, any psychological intervention reduced depression symptoms compared with usual treatment (four trials; N = 516; SMD = −0.21; 95% CI, −0.37 to −0.05); of note, 73% of the patients in the intervention group received CBT. Limitations included high attrition rates and potential confounding from concomitant medication use.
A 2014 RCT (N = 213) that was not included in the 2016 meta-analysis compared the effect of CBT in combination with systemic family therapy (which addresses an individual as part of multiple familial relationships) vs. usual care in patients with mild to moderate postpartum depression.2 Investigators enrolled primiparous Chinese women 19 to 40 years of age who were presenting for postpartum care up to 42 days after delivery of a singleton infant. Participants must have had depression lasting at least two weeks at presentation. CBT was delivered by certified counselors in the form of weekly 60-minute sessions over 13 weeks beginning two months after delivery. Additional follow-up assessments occurred six, 12, 18, and 24 months after delivery. Before the intervention, there were no significant differences in EPDS scores between the groups. Compared with usual care, the combination of CBT and systemic family therapy decreased EPDS scores from the end of the intervention until 24 months after delivery (Table 1).2 A 4-point difference was considered statistically significant.
| Postintervention follow-up point | Cognitive behavior therapy plus systemic family therapy (% reduction) | Usual care (% reduction) | P value |
|---|---|---|---|
| Immediately | 22 | 9 | < .01 |
| 6 months | 32 | 20 | < .01 |
| 12 months | 41 | 27 | < .01 |
| 18 months | 45 | 31 | < .01 |
| 24 months | 42 | 29 | < .01 |
A 2015 RCT (N = 45) published after the 2016 meta-analysis was completed evaluated the effectiveness of group CBT alone vs. in combination with sertraline (Zoloft) in the treatment of post-partum depression.3 The trial included postpartum women (parity undefined) 19 to 40 years of age who had been diagnosed with depression based on an EPDS score of 13 or greater. The trial included three arms: group CBT monotherapy (12 weeks of therapy with five to 10 women in each weekly session), sertraline monotherapy (50 to 200 mg daily), and CBT plus sertraline. Patients completed the BDI-II weekly during the 12 weeks of treatment and again at 24 weeks after study initiation. There were no statistically significant differences among the groups at any point, and all three groups improved vs. baseline. Small sample size and noncompliance with treatment in the sertraline arm were key limitations of the study, as was the large number of women who declined to participate.
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