USPSTF Draft Recommendation

Counseling Helps Prevent Perinatal Depression in High-risk Women

August 31, 2018, 11:51 am Chris Crawford – Perinatal depression is one of the most common complications of pregnancy and the postpartum period, affecting as many as one in seven pregnant women.

"For the first time, the task force is recommending counseling to prevent perinatal depression in high-risk women," said USPSTF member Aaron Caughey, M.D., M.P.P., M.P.H., Ph.D., in a news release. "Clinicians should use patient history and risk factors to identify women who are most likely to benefit."

This recommendation applies to pregnant women and women who gave birth within the last year who are at increased risk for depression. There currently is no accurate screening tool available to identify women at risk of perinatal depression. The most common risk factors used in the studies included a history of depression, current depressive symptoms and socioeconomic risk factors such as being a young or single parent.

Note, too, that this draft recommendation statement does not apply to women who are already diagnosed with depression.

Scope of Review

The USPSTF commissioned a systematic evidence review to evaluate the evidence on the potential benefits and harms of preventive interventions in pregnant or postpartum women or their children.

The review included studies of women with mental health symptoms or disorders. However, it excluded studies that focused on women with a depression diagnosis, high levels of depressive symptoms, or psychotic or developmental disorders, as well as those that focused on women who were currently being treated for a depressive disorder.

The USPSTF also reviewed contextual information on the accuracy of tools used to identify women at increased risk of perinatal depression and the most effective timing for preventive interventions.

Interventions reviewed included counseling, health system interventions, physical activity, education, supportive interventions and other behavioral interventions, such as infant sleep training and expressive writing. Pharmacological approaches included the use of nortriptyline, sertraline and omega-3 fatty acids.

Counseling Interventions

The studies the USPSTF reviewed on counseling interventions to prevent perinatal depression mainly included cognitive behavioral therapy and interpersonal therapy.

Cognitive behavioral therapy focuses on managing negative thoughts, beliefs and attitudes and increasing positive events and activities to positively change mood and behavior, the draft recommendation said.

Common related therapeutic techniques include patient education, goal-setting, interventions to identify and modify maladaptive thought patterns, and behavioral activation.

Interpersonal therapy focuses on treating interpersonal issues that are thought to contribute to the development or maintenance of psychological disorders, the USPSTF explained.

Common related therapeutic techniques include the use of exploratory questions (i.e., open-ended and clarifying questions), role-playing, decision analysis and communication analysis.

The task force said the interventions it reviewed varied in setting, intensity, format and intervention staff; most counseling sessions were initiated during pregnancy, ranged from four to 20 meetings (median eight meetings) and lasted four to 70 weeks.

Counseling usually involved in-person visits with group and individual sessions, with intervention staff including midwives, nurses, psychologists and other mental health professionals.

Counseling intervention trials included a mix of patients at increased risk for perinatal depression and those not at risk.

The USPSTF found limited or mixed evidence that other studied interventions, such as physical activity, education, pharmacotherapy, dietary supplements and health system interventions, were effective in preventing perinatal depression.

Family Physician Expert's Perspective

AAFP Commission on Health of the Public and Science member Jeffrey Quinlan, M.D., of Alexandria, Va., told AAFP News that perinatal depression (including depression in the first 12 months following delivery) is very common, occurring in about 15 percent of patients.

"During the past 25 years, I have seen numerous patients who have had symptoms ranging from 'mild depression' to full-blown psychosis (which puts both the mom and infant at risk)," he said.

Quinlan said he starts talking to patients about the possibility of perinatal depression during the late second trimester or early third trimester of pregnancy.

"We discuss the signs and symptoms and what to do if she feels like she is developing them," he said. "I try to include her partner in these conversations, so they can be on the lookout, as well."

Following delivery, Quinlan said his practice screens its patients for peripartum depression using the Edinburgh Postnatal Depression Scale at the postpartum visit and each well-baby visit. "I also inquire about moods and bonding with the baby independent of the questionnaire," he added.

And while any woman who has given birth is at risk for perinatal depression, there are several factors that are known to place patients at increased risk.

"These include a history of depression, history of physical or sexual abuse including intimate partner violence (IPV), complications during pregnancy (such as preterm labor, diabetes and hyperemesis) and the pregnancy being unintended or unwanted," Quinlan said.

Quinlan said counseling has definitely been helpful for his patients who have had perinatal depression.

"It's typically my first-line treatment so that I can minimize the use of medications that might cross into breast milk and affect the baby," he said.

Both cognitive behavioral therapy and interpersonal therapy are evidence-based interventions for depression, and specifically perinatal depression, Quinlan said.

"The choice of which to use usually comes down to the psychologist's preference and comfort with each of the interventions," he said. "I haven't seen one work better than the other and I am unaware of any research that would demonstrate that one is better than the other."

Quinlan noted it's important for clinicians to remember that rates of IPV increase during pregnancy and that routine peripartum depression may actually stem from IPV.

Fathers are at increased risk of depression during the first year of their child's life as well, he added. "The numbers aren't as high as they are for women, but clinicians should be mindful of this risk in fathers," Quinlan said.

Finally, Quinlan said the USPSTF's draft recommendation statement should reinforce how family physicians are already treating their perinatal patients.

"The recommendations highlight the need to be diligent in the screening and evaluation of patients for perinatal depression and to intervene where needed with evidence-based interventions," he concluded.

Up Next

The USPSTF is inviting comments on its draft recommendation statement and draft evidence review. The public comment window is open until 8 p.m. EDT on Sept. 24. All comments received will be considered as the task force prepares its final recommendation.

The AAFP will review the USPSTF's draft recommendation statement and supporting evidence, and will provide comments to the task force. The Academy will release its own recommendation on the topic after the task force finalizes its guidance.

Related AAFP News Coverage
Number of Women With OUD in Labor/Delivery Quadruples
CDC Data Show Increases in All States Studied
(8/21/2018)

More From AAFP
American Family Physician: Identification and Management of Peripartum Depression
(5/15/2016)

American Family Physician: Editorials: Opportunities to Detect and Manage Perinatal Depression in Men
(5/15/2016)

Additional Resources
American College of Obstetricians and Gynecologists: Committee Opinion No. 630, May 2015 (Screening for Perinatal Depression)