Perinatal depression—depression that occurs during pregnancy or after the birth of a child—is surprisingly common, affecting about 1 in 7 women. And, although depression is debilitating at any time, it may carry a particularly heavy public health burden during the transition to parenthood. Women with depression are less likely to obtain medical care for themselves and their babies, and may struggle to bond with their infants. It’s no wonder that the children of depressed mothers experience heightened long-term risk of emotional and behavioral problems.
Despite this grim picture, a new report from the US Preventive Services Task Force offers some hope. The USPSTF, a nonpartisan body of experts, reviews scientific research and makes recommendations for preventing disease. In the past, they’ve issued guidelines for lung cancer detection, aspirin use to prevent heart disease, and blood pressure screening. In a review recently published in the Journal of the American Medical Association (JAMA), the task force shared what they deemed “convincing evidence” that counseling (talk therapy) interventions can not just treat, but actually prevent, perinatal depression. This is exciting news given the high cost of depression during this time and the fact that, unlike other potential treatments for perinatal depression (like the new drug Zulresso), talk therapy is low-tech, relatively low-cost, and brings few side effects.
In their report, the USPSTF reviewed 50 studies that they deemed to be at least “good or fair quality.” Almost all were randomized clinical trials, the gold standard for treatment research, in which a treatment is directly compared to a control group condition. About half of the studies focused on pregnant women, and the rest on postpartum women. Some studies targeted women who already had elevated risk for depression, based on risk factors like a personal or family history of depression, low socioeconomic status, and exposure to life stress or intimate partner violence.
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Of these studies, 20 measured the effects of talk therapy. On average, these interventions lasted around eight weeks, with about 12 hours of total time spent in group or individual therapy. Across all 20 studies, counseling interventions reduced the likelihood of perinatal depression by an impressive 39 percent. Based on this statistic and the overall population risk of perinatal depression, the USPSTF estimated that, for every 13 or 14 women from the general population who participates in counseling, we can prevent one case of clinical depression that would have otherwise occurred—a solid return on investment. These effects looked even better when studies zeroed in on women deemed already at risk for perinatal depression.
The counseling interventions that the USPSTF reviewed mostly fell into two camps: cognitive behavior therapy (CBT) approaches, which focus on tracking and modifying thoughts and behaviors, and interpersonal therapy (IPT) treatments, which target social roles and relationships. The USPSTF flagged two treatments that exemplify these approaches. “Mothers and Babies,” a group-based CBT program, offers weekly sessions during pregnancy and several postpartum booster sessions. It includes education about mood, stress, and health, and training in how to rewire problematic thought patterns. “Reach Out, Stay Strong, Essentials for New Mothers” (ROSE) is an IPT group program that includes coaching on how to develop a social support system and anticipate interpersonal conflicts that can arise over the transition to parenthood, including role playing to navigate sticky social situations.
The USPSTF also looked at 30 studies that focused on non-counseling interventions. Some involved health system-level changes such as extra screening and patient navigation tools for perinatal women. Others involved physical exercise, infant sleep education, yoga, expressive writing, and other forms of support such as telephone-based peer support. Many of these interventions helped to reduce perinatal depression, but overall, the findings were inconsistent, suggesting that more research is needed into these alternative treatments.
Among the non-counseling treatments, four studies used pharmacological or dietary treatments for perinatal depression, including sertraline, nortriptyline, and omega-3 fatty acid treatments, but these also yielded mixed and inconclusive results. Moreover, these four studies reported some potential for adverse effects—specifically, side effects and potential risks to the fetus associated with taking medications or supplements—whereas counseling and other psychosocial interventions did not come with any potential downsides.
Although it is great news that psychotherapy can ward off perinatal depression, the on-the-ground reality has not yet caught up to the promise of preventive care. For too many perinatal women, depression during the transition to parenthood is either ignored or, worse, criminalized. As awareness about perinatal depression grows and the stigma begins to lift, policies are changing. For example, a new bill in California mandates that obstetric providers perform regular mental health screenings, making sure that perinatal depression is caught early.
Of course, catching depression is only half the battle: it needs to be treated or, even better, prevented. Can counseling interventions like the ones reviewed by the USPSTF be integrated into routine perinatal care and made easily accessible to the women who need them? Although this may sound like a costly proposition, remember that these interventions comprised, on average, eight sessions, which can be facilitated by a paraprofessional (a licensed clinical social worker, for example). Recently, a new intravenous medication for postpartum depression was debuted to great fanfare. However, this medication costs $34,000 per patient and requires an inpatient stay. Comparatively, the per-patient cost of eight sessions of group therapy looks like a bargain. And compare this to the enormous societal costs of untreated perinatal depression, which can reverberate to affect the long-term health of the whole family. Preventive perinatal counseling may be one of the best deals in health care.