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Psychosocial and psychological interventions for preventing postpartum depression

  1. Cindy-Lee Dennis1,*,
  2. Therese Dowswell2

Editorial Group: Cochrane Pregnancy and Childbirth Group

Published Online: 28 FEB 2013

Assessed as up-to-date: 30 MAY 2012

DOI: 10.1002/14651858.CD001134.pub3

How to Cite

Dennis CL, Dowswell T. Psychosocial and psychological interventions for preventing postpartum depression. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD001134. DOI: 10.1002/14651858.CD001134.pub3.

Author Information

  1. 1

    University of Toronto and Women's College Research Institute, Toronto, Ontario, Canada

  2. 2

    The University of Liverpool, Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, Liverpool, UK

*Cindy-Lee Dennis, University of Toronto and Women's College Research Institute, 155 College Street, Toronto, Ontario, M5T 1P8, Canada. cindylee.dennis@utoronto.ca.

Publication History

  1. Publication Status: New search for studies and content updated (conclusions changed)
  2. Published Online: 28 FEB 2013

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Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
 

Description of the condition

Depression is a major cause of disability for all ages and both sexes worldwide (WHO 2010). The public health significance of depression in women is undeniable, with lifetime rates between 10% and 25% (Kessler 2005; Weissman 1996). According to the World Health Organization, by 2020 depression is projected to carry the highest disease burden of all health conditions in women, accounting for 5.7% of the total disease burden measured in disability-adjusted life years. Depression impairs social and physical functioning, is a major precipitating factor in suicide, and is associated with healthcare costs, morbidity, and mortality from medical illness. For women aged 15 to 44, depression is the leading cause of non-obstetric hospitalisations among women in the United States (O'Hara 2009). Postpartum depression is often defined as depression occurring within the first year following childbirth. In most studies this includes those women for whom the depression may be a continuation of that experienced during pregnancy, as well as those for whom it is a new onset. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) does not recognise postpartum depression as diagnostically distinct from depression at other times, although does allow for the addition of a "postpartum-onset specifier" in women with an onset within four weeks of birth.  Results from a meta-analysis of postpartum depression in 59 studies found an overall prevalence of 13% within the first 12 weeks following childbirth (n = 12,810; 95% confidence interval 12.3% to 13.4%)(O'Hara 1996). A more recent systematic review of postpartum depression found the period prevalence of all depression to be 19.2% in the first 12 weeks postnatally, with a period prevalence for major depression of 7.1% (Gaynes 2005). This review also identified depression to be common during pregnancy with a period prevalence of 18.4% across the nine months of pregnancy, with 12.7% having an episode of major depression during this time. Not surprisingly, antenatal depression is a strong risk factor of postpartum depression. For the majority of women, postpartum depression starts within the first 12 weeks postpartum and common symptoms include dysphoria, emotional lability, insomnia, confusion, guilt, and suicidal ideation. For about 8% of mothers, their depressive symptoms will continue past the first year postpartum (Dennis 2012). If left untreated, postpartum depression can develop into severe clinical depression and, in a small number of cases, lead to suicide, which is one of the leading causes of maternal deaths in the UK (Lewis 2007; Lindahl 2005).

 

How the intervention might work

The cause of postpartum depression suggests a multifactorial aetiology (Beck 2001; O'Hara 1996). Despite considerable research, no single causative factor has been isolated. However, meta-analytic findings consistently highlight the importance of psychosocial variables such as stressful life events, marital conflict, and the lack of social support. To address this issue, a variety of psychosocial and psychological interventions have been developed to treat postpartum depression (Dennis 2007). For example, randomised controlled trials evaluating cognitive-behavioural counselling with antidepressants (Appleby 1997), cognitive-behavioural therapy and non-directive counselling (Cooper 1997; Cooper 2003), health visitor-led non-directive counselling (Holden 1989; Wickberg 1996), peer support (Dennis 2003a), and interpersonal psychotherapy (O'Hara 2000) have all demonstrated the amenability of postpartum depression to treatment. It is theoretically plausible that psychosocial and psychological interventions may also prevent postpartum depression, as many of the known risk factors are present during pregnancy and the immediate postpartum period. As such, these interventions may be provided to women antenatally or initiated early in the postpartum period. They may be individually-based focusing on specific maternal needs or provided in a group setting that could incorporate peer support from other women and social comparisons. Interventions may be intensive and include multiple contacts or be provided during a single session. Interventions may also be provided by a health professional, such as a midwife, nurse, psychologist, or lay individuals such as experienced mothers recruited from the community. The usefulness of any intervention to prevent postpartum depression, at a population level, depends on the proportion of depressed women who would have been identified to be at risk and offered the intervention (sensitivity of risk targeting). The cost-effectiveness will depend crucially on the proportion of women who would have developed postpartum depression amongst those identified to be at risk (positive predictive value of risk targeting). One way to identify those at increased risk of developing postpartum depression is to use a risk screening tool. A simpler approach is to target individual risk groups. Although there are unique circumstances in the perinatal period that might increase risk of depression, such as obstetric and neonatal complications, the risk factors identified by most studies are similar to those for depression at other times such as a past history of psychopathology, antenatal depression or anxiety, a poor relationship with partner, low social support, and stressful life events (Beck 2001; O'Hara 1996). There are also specific subgroups of women who are at high risk, e.g. those with a history of abuse (emotional, physical, sexual) (Ross 2009), young mothers (Brown 2011), and migrant groups (Collins 2011).

It is anticipated that the psychosocial and psychological interventions may reduce the risk for postpartum depression via several mechanisms (Cohen 2000; Dennis 2003b). These interventions can directly influence the development of postpartum depression by: (1) decreasing isolation and feelings of loneliness, (2) swaying health practices and deterring maladaptive behaviours or responses, (3) promoting positive psychological states and individual motivation, and (4) providing information regarding access to medical services or the benefits of behaviours that positively influence health and well-being. They may also buffer the influence of stress by: (1) redefining and reducing the potential for harm posed by the stressor, (2) broadening the number of coping resources, (3) discussing coping strategies, problem-solving techniques, and counter-responses thereby moderating the initial appraisals of the stressor, (4) highlighting norms through social comparison which prescribe adaptive behaviour, (5) inhibiting maladaptive responses, and (6) counteracting the propensity to blame oneself for causing the stressor or adversity thus preventing active coping efforts to be hampered by self-recriminations. Lastly, psychosocial or psychological interventions may mediate the development of postpartum depression by: (1) assisting in the interpretation and positive reinforcement of performance accomplishments, (2) providing vicarious experience and observational learning through role modelling, (3) offering opportunities for social comparisons to promote self-evaluations and motivation, (4) teaching coping strategies and conveying information about ability, (5) positively interpreting emotional arousal, and (6) encouraging cognitive restructuring through anticipatory guidance.

 

Why it is important to do this review

Postpartum depression occurs at a time when the infant is maximally dependent on parental care and is highly sensitive to the quality of the interaction. Concern for infant development is warranted as mood disorders can be incompatible with good parenting interactions and can cause significant stress for children (England 2009; Goodman 1999). There is a substantial body of evidence showing that maternal depression and subsequent poor maternal-infant interactions adversely affect the developing child (Weinberg 1998; Weissman 2006). Observational research shows that children of depressed mothers, compared with those of non-depressed mothers, are more fussy, receive lower scores on measures of intellectual and motor development, have more difficult temperaments and less secure attachments to their mothers, react more negatively to stress, show delayed development of self-regulatory strategies, and exhibit poorer academic performance, fewer social competencies, lower levels of self-esteem, and higher levels of behavioural problems (England 2009; Goodman 1999).  A recent meta-analysis, including 193 studies, reported that maternal depression (not restricted to the postnatal period), was associated with higher levels of internalising behaviour, externalising behaviour, general psychopathology and to lower levels of positive affect in the offspring (Goodman 2011). Of particular relevance is the observation that these effects were stronger if the child was exposed to maternal depression at an early age. Suggested mechanisms by which maternal-interactions transmit risk from depressed mother to the child include maternal modelling of depressed affect, cognitions, and behaviours; reduced positive reinforcement for the child and inconsistent discipline practices; the development of an insecure child attachment, an indirect influence on maternal depression through its detrimental effects on the marital relationship and family functioning. Not surprisingly, international experts have clearly identified maternal depression as a major childhood adversity and that effective interventions to address this condition are one of the most important public health preventive strategies we can implement to reduce the long-term negative developmental outcomes among children (England 2009). This review will assist in the development of effective postpartum depression interventions with the aim of reducing the number of women who develop postpartum depression and thus aid in preventing poor child developmental outcomes.

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

The primary objective of this review was to assess the effects, on mothers and their families, of preventive psychosocial and psychological interventions compared with usual antepartum, intrapartum, or postpartum care to reduce the risk of postpartum depression. Secondary objectives were to examine:

  1. the effectiveness of specific types of psychosocial interventions (e.g., a "talking therapy" which is theoretically based on the social environment such as enhancing supportive interactions or creating supportive relationships);
  2. the effectiveness of specific types of psychological interventions (e.g., a "talking therapy" which is theoretically based in a specific psychological method such as cognitive behavioural therapy, interpersonal psychotherapy, psychological debriefing);
  3. the effects of intervention provider (e.g., professionally-based interventions, lay-based interventions);
  4. the effects of intervention mode (e.g., individually-based interventions, group-based interventions);
  5. the effects of intervention duration (e.g., single-contact interventions, multiple-contact interventions);
  6. the effects of intervention onset (e.g., antenatal only interventions, antenatal and postnatal interventions, and postnatal-only interventions);
  7. the effects of sample selection criteria (e.g., interventions targeting women with specific risk factors, interventions offered to the general population).

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
 

Criteria for considering studies for this review

 

Types of studies

All published, unpublished and ongoing randomised controlled trials of preventive psychosocial or psychological interventions in which the primary or secondary aim was reduction in the risk of developing postpartum depression. Quasi-randomised trials (e.g., those randomised by delivery date, or odd versus even medical record numbers) were excluded from the analysis.

 

Types of participants

Pregnant women and new (less than six weeks postpartum) mothers, including those at no known risk and those identified as at-risk of developing postpartum depression. Trials where more than 20% of participants were depressed at trial entry were excluded.

 

Types of interventions

Any form of standard or usual care compared with a variety of non-pharmaceutical interventions - including psycho educational strategies, cognitive behavioural therapy, interpersonal psychotherapy, non-directive counselling, psychological debriefing, various supportive interactions, and tangible assistance - delivered via telephone, home or clinic visits, or individual or group sessions antenatally and/or within the first month postpartum by a professional (e.g., nurse, midwife, childbirth educator, physician, psychiatrist, psychologist) or lay person (e.g., specially trained woman from the community, student, research assistant).

 

Types of outcome measures

 

Primary outcome

 
Maternal

1. Postpartum depression (as variously defined and measured by trialists).

 

Secondary outcomes

 
Maternal

2. Maternal mortality and serious morbidity including self-harm, suicide attempts.
3. Maternal-infant attachment.
4. Anxiety.
5. Maternal stress.
6. Parental stress (e.g. measured using a tool such as the parenting stress index, Abidin 1995).
7. Maternal perceived social support.
8. Maternal dissatisfaction with care provided.

 
Infant

9. Infant health parameters including no immunisation or having accidental injury or non accidental injury.
10. Infant developmental assessments (variously defined).
11. Child abuse and/or neglect.

 
Family outcomes

12. Marital discord

The outcomes were assessed at four time points across the postpartum period:

  • immediate (zero to eight weeks postpartum);
  • short term (nine to 16 weeks postpartum);
  • intermediate (17 to 24 weeks postpartum);
  • long term (greater than 24 weeks postpartum).

 

Search methods for identification of studies

 

Electronic searches

We searched the Cochrane Pregnancy and Childbirth Group trials register by contacting the Trials Search Co-ordinator (30 November 2011). We updated the search on 31 December 2012 and added the results to Characteristics of studies awaiting classification for consideration at the next update.

The Cochrane Pregnancy and Childbirth Group’s Trials Register is maintained by the Trials Search Co-ordinator and contains trials identified from:

  1. monthly searches of the Cochrane Central Register of Controlled Trials (CENTRAL);
  2. weekly searches of MEDLINE;
  3. weekly searches of EMBASE;
  4. handsearches of 30 journals and the proceedings of major conferences;
  5. weekly current awareness alerts for a further 44 journals plus monthly BioMed Central email alerts.

Details of the search strategies for CENTRAL, MEDLINE and EMBASE, the list of handsearched journals and conference proceedings, and the list of journals reviewed via the current awareness service can be found in the ‘Specialized Register’ section within the editorial information about the Cochrane Pregnancy and Childbirth Group.

Trials identified through the searching activities described above are each assigned to a review topic (or topics). The Trials Search Co-ordinator searches the register for each review using the topic list rather than keywords. 

 

Searching other resources

We examined secondary references and contacted experts in the field.

We did not apply any language restrictions.

 

Data collection and analysis

For the methods used when assessing the trials identified in the previous version of this review, see Appendix 1. For this update we used the following methods when assessing the reports identified by the updated search.

 

Selection of studies

Two review authors independently assessed for inclusion all the potential studies we identified as a result of the search strategy. We resolved any uncertainties regarding the appropriateness for inclusion through discussion or consultation with a third person.

 

Data extraction and management

We designed a form to extract data. For eligible studies, two review authors independently extracted the data using the agreed form. We resolved discrepancies through discussion or, if required, we consulted a third person. We entered data into Review Manager software (RevMan 2011) and checked for accuracy.

When information regarding any of the above was unclear, we attempted to contact authors of the original reports to provide further details.

 

Assessment of risk of bias in included studies

Two review authors independently assessed the risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We resolved any disagreement by discussion or by involving a third person.

 

(1) Sequence generation (checking for possible selection bias)

We described for each included study the method used to generate the allocation sequence in sufficient detail to allow an assessment of whether it should produce comparable groups.

We assessed the method as:

  • low risk of bias (any truly random process, e.g., random number table; computer random number generator);
  • high risk of bias (any non-random process, e.g., odd or even date of birth; hospital or clinic record number);
  • unclear risk of bias.   

 

 (2) Allocation concealment (checking for possible selection bias)

We described for each included study the method used to conceal the allocation sequence and determined whether intervention allocation could have been foreseen in advance of, or during recruitment, or changed after assignment.

We assessed the methods as:

  • low risk of bias (e.g., telephone or central randomisation; consecutively numbered sealed opaque envelopes);
  • high risk of bias (open random allocation; unsealed or non-opaque envelopes, alternation; date of birth);
  • unclear risk of bias.   

 

(3) Blinding (checking for possible performance bias)

We described for each included study the methods used, if any, to blind study participants and personnel from knowledge of which intervention a participant received. Since women and care providers cannot be easily blinded as to whether a psychosocial or psychological intervention was given, we considered blinding adequate if outcomes were recorded by outcome assessors who had no knowledge of the woman's group assignment or if the women self-reported outcome data by mailed questionnaire. We considered studies at low risk of bias if they were blinded, or if we judged that the lack of blinding could not have affected the results. We assessed blinding separately for participants and staff and for outcome assessors.

We assessed the methods as:

  • low, high or unclear risk of bias for participants and personnel;
  • low, high or unclear risk of bias for outcome assessors.

 

(4) Incomplete outcome data (checking for possible attrition bias through withdrawals, dropouts, protocol deviations)

We described for each included study, and for each outcome or class of outcomes, the completeness of data including attrition and exclusions from the analysis. We stated whether attrition and exclusions were reported, the numbers included in the analysis at each stage (compared with the total randomised participants), reasons for attrition or exclusion where reported, and whether missing data were balanced across groups or were related to outcomes. Where sufficient information was reported, or could be supplied by the trial authors, we planned to include missing data in the analyses. We did not exclude any trial or outcome from the analysis based on rate of incomplete data. We performed a sensitivity analysis for those trials where 80% of data on a given outcome was available for those who were originally randomised versus those with < 80%.

We assessed methods as:

  • low risk of bias;
  • high risk of bias;
  • unclear risk of bias.

 

(5) Selective reporting bias

We described for each included study how we investigated the possibility of selective outcome reporting bias and what we found.

We assessed the methods as:

  • low risk of bias (where it is clear that all of the study’s pre-specified outcomes and all expected outcomes of interest to the review have been reported);
  • high risk of bias (where not all the study’s pre-specified outcomes have been reported; one or more reported primary outcomes were not pre-specified; outcomes of interest were reported incompletely and so could not be used; study failed to include results of a key outcome that would have been expected to have been reported);
  • unclear risk of bias.

 

(6) Other sources of bias

We described for each included study any important concerns we had about other possible sources of bias.

We assessed whether each study was free of other problems that could put it at risk of bias:

  • low risk of other sources of bias;
  • high risk of other sources of bias;
  • unclear risk of other sources of bias.

For cluster-randomised trials we described the following (as per the Cochrane Handbook for Systematic Reviews of Interventions 16.3.2 Higgins 2011).

  1. Recruitment bias - whether the individuals participating in the trial were blinded to the type of cluster they were in before agreeing to participate.
  2. Baseline imbalances - whether there were differences in baseline characteristics between the randomised groups.
  3. Loss of clusters - whether any complete clusters were lost to follow-up and the reasons.
  4. Incorrect analysis - whether the proper statistical analysis was carried out for a cluster-randomised design.
  5. Differences in intervention effects - whether the cluster-randomisation method could have resulted in different intervention effects than an individually-randomised trial.

 

(7) Overall risk of bias

We made explicit judgements about whether studies were at high risk of bias, according to the criteria given in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). With reference to (1) to (6) above, we assessed the likely magnitude and direction of the bias and whether we considered it was likely to impact on the findings.  We explored the impact of the level of bias through undertaking sensitivity analyses - see Sensitivity analysis.

 

Measures of treatment effect

 

Dichotomous data

For dichotomous data, we presented results as summary risk ratio with 95% confidence intervals. 

 

Continuous data

For continuous data, we used the mean difference if outcomes were measured in the same way between trials. We used the standardised mean difference to combine trials that examined the same outcome, but used different measures.  

 

Unit of analysis issues

 

Cluster-randomised trials

We included cluster-randomised trials in the analyses along with individually-randomised trials. We adjusted the sample sizes using the methods described in the Cochrane Handbook for Systematic Reviews of Interventions Section 16.3.4 using an estimate of the intracluster correlation co-efficient (ICC) derived from the trial. We synthesised the relevant information from the cluster-randomised trials and individually-randomised trials we identified. We considered it reasonable to combine the results from both as there was little heterogeneity between the study designs and the interaction between the effect of intervention and the choice of randomisation unit was considered to be unlikely.

We also acknowledged heterogeneity in the randomisation unit and performed a sensitivity analysis to investigate the effects of the randomisation unit.

 

Other unit of analysis issues

In Sen 2006, data for the mother-infant attachment outcome were collected for each twin. We took the 'worst' score from the two twins so we did not miss a 'bad outcome'.

 

Dealing with missing data

For included studies, we noted levels of attrition. We explored the impact of including studies with high levels of missing data in the overall assessment of treatment effect by using sensitivity analysis. We compared those trials where 80% of data on a given outcome were available for those who were originally randomised versus those with less than 80%.

For all outcomes, we carried out analyses, as far as possible, on an intention-to-treat basis, i.e., we attempted to include all participants randomised to each group in the analyses, and all participants were analysed in the group to which they were allocated, regardless of whether or not they received the allocated intervention. The denominator for each outcome in each trial was the number randomised minus any participants whose outcomes were known to be missing.

 

Assessment of heterogeneity

We assessed statistical heterogeneity in each meta-analysis using the T², I² and Chi² statistics. We regarded heterogeneity as substantial if T² was greater than zero and either I² was greater than 30% or there was a low P value (less than 0.10) in the Chi² test for heterogeneity.

 

Assessment of reporting biases

For the primary outcome (postpartum depression), if there were 10 or more studies in the meta-analysis we investigated possible reporting biases (such as publication bias) using funnel plots. We assessed funnel plots visually, and if there had been any obvious asymmetry apparent we planned to seek statistical advice on carrying out formal tests for funnel plot asymmetry.

 

Data synthesis

We carried out statistical analysis using the Review Manager software (RevMan 2011). All trials were considered to include some form of 'talking therapy' and thus eligible to be combined in a meta-analysis. We used fixed-effect meta-analysis for combining data where it was reasonable to assume that the studies were estimating the same underlying treatment effect: i.e., where trials examined similar interventions, and the trials’ populations and methods were judged sufficiently similar. If there was clinical heterogeneity sufficient to expect that the underlying treatment effects differed between trials, or if substantial statistical heterogeneity was detected, we used random-effects meta-analysis to produce an overall summary if an average treatment effect across trials was considered clinically meaningful. The random-effects summary was treated as the average range of possible treatment effects and we discussed the clinical implications of treatment effects differing between trials. If the average treatment effect was not clinically meaningful, we did not combine trials. If we used random-effects analyses, the results were presented as the average treatment effect with its 95% confidence interval, and the estimates of  T² and I².

 

Subgroup analysis and investigation of heterogeneity

We planned and completed the following a priori subgroup analyses:

  1. the effect of psychosocial interventions (e.g., antenatal/postnatal classes, professional home visits, lay home visits, lay telephone support, early postpartum follow-up, continuity model of care);
  2. the effect of psychological interventions (e.g., cognitive behavioural therapy, interpersonal psychotherapy, psychological debriefing);
  3. the effect of intervention provider (e.g., professionally-based and lay-based interventions);
  4. the effect of intervention mode (e.g., individual-based and group-based interventions);
  5. the effect of intervention duration (e.g., single-contact and multiple-contact interventions);
  6. the effect of intervention onset (e.g., antenatal-only interventions, antenatal and postnatal interventions and postnatal-only interventions);
  7. the effects of sample selection criteria (e.g., interventions targeting women with specific risk factors and the general population).

Where data were available, the following postpartum depression outcomes were used in subgroup analysis:

  1. depressive symptomatolgy (as defined by trialist, presented as dichotomous outcome;
  2. mean depression scores (as defined by trialist, presented as continuous measure);
  3. diagnosis of depression (as defined by trialist).

All outcomes were assessed at four time points across the postpartum period:

  • immediate (zero to eight weeks postpartum);
  • short term (nine to 16 weeks postpartum);
  • intermediate (17 to 24 weeks postpartum);
  • long term (more than 24 weeks postpartum).

For random-effects and fixed-effect meta-analyses, we assessed differences between subgroups by inspection of the subgroups’ confidence intervals; non-overlapping confidence intervals suggested a statistically significant difference in treatment effect between the subgroups. We also carried out formal sub-group analysis available in RevMan 2011. Where data were available we set up analysis for all of the four time points described above, but in the text we have reported results only for outcomes measured at the final study assessment.

 

Sensitivity analysis

We performed sensitivity analyses, for the primary outcome, in instances in which any of the following occurred:

  1. a high risk of bias associated with the methodological quality of included trials;
  2. incomplete outcome data (more than 20% missing data) for any of the included trials.

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of studies awaiting classification; Characteristics of ongoing studies.

Please see table of Characteristics of included studies. Thirty trials, reported between 1995 and 2011, were identified and met the inclusion criteria. Two trials (Austin 2008; Heinicke 1999) that were otherwise eligible for inclusion in the review did not report usable data for our primary outcome. Further information about these studies can be found in the Characteristics of included studies tables but these trials will not be discussed below. In total, 16,912 women from 28 trials were included in the meta-analyses.The trials were primarily conducted in Australia and the UK; four trials were conducted in the USA (Feinberg 2008; Gjerdingen 2002; Gorman 1997; Zlotnick 2001), two trials were conducted in China (Gao 2010; Tam 2003), and one trial was conducted in each of the following countries: Canada (Dennis 2009), Germany (Weidner 2010) and India (Tripathy 2010). While all trials included the outcome postpartum depression, several studies provided data on other variables including: maternal mortality (Tripathy 2010), maternal-infant attachment (Armstrong 1999; Feinberg 2008; Sen 2006), anxiety (Dennis 2009; Gamble 2005; Gorman 1997; Lavender 1998; Sen 2006; Weidner 2010), maternal stress (Gamble 2005; Ickovics 2011), parental stress (Armstrong 1999; Cupples 2011; Sen 2006), perceived social support (Armstrong 1999; Brugha 2000; Gjerdingen 2002; Ickovics 2011; Lumley 2006; Morrell 2000; Reid 2002; Sen 2006),dissatisfaction with care provided (Armstrong 1999; MacArthur 2002; Sen 2006; Small 2000; Tam 2003; Waldenstrom 2000), infant health parameters such as full immunisation (MacArthur 2002), infant development (Cupples 2011), child abuse (Armstrong 1999), and marital discord (Gjerdingen 2002; Gorman 1997; Sen 2006).

 

Definition of postpartum depression

In all trials but seven (Cupples 2011; Feinberg 2008; Gjerdingen 2002; Ickovics 2011; Weidner 2010; Zlotnick 2001; Zlotnick 2006), postpartum depressive symptomatology was defined as a score above a specified cut-off point on a self-report measure; for the majority of studies (15) an Edinburgh Postnatal Depression Scale (EPDS) score greater than 12 (also reported as a 12/13 cut-off score) indicated postpartum depression. Several studies also reported mean EPDS scores (Armstrong 1999; Dennis 2009; Gao 2010, Gorman 1997; Gunn 1998; Ickovics 2011; Le 2011; Lumley 2006; MacArthur 2002; Morrell 2000; Reid 2002; Sen 2006; Small 2000). Three additional trials used the EPDS to measure postpartum depression but incorporated a different cut-off score; Brugha 2000 used a 10/11 cut-off, while Morrell 2000 and Reid 2002 selected a 11/12 cut-off. It is important to note that the EPDS does not diagnose postpartum depression (as this can only be accomplished through a psychiatric clinical interview) but rather it is the most frequently used instrument to assess for postpartum depressive symptomatology. Created to counter the limitations of other well-established depression scales, the EPDS has been validated by standardised psychiatric interviews with large samples and has well-documented reliability and validity in over 20 languages. Several other trials used a self-report measure other than the EPDS and included the Beck Depression Inventory (BDI) (Le 2011; Zlotnick 2001; Zlotnick 2006), Center for Epidemiologic Studies Depression Scale (CES-D) (Feinberg 2008; Ickovics 2011), Hospital Anxiety and Depression Scale (HADS) (Lavender 1998; Tam 2003; Weidner 2010), Kessler-10 (Tripathy 2010), and the SF36 Mental Health Subscale (Cupples 2011; Gjerdingen 2002). For trials that used two self-report measures of depression, if one was the EPDS then those data were used. Five trials incorporated a semi-structured diagnostic interview to provide a clinical diagnosis of depression (Brugha 2000; Dennis 2009; Gorman 1997; Harris 2006; Zlotnick 2001) with four of these trials using the Structured Clinical Interview for DSM-IV (SCID).

The timing of the outcome assessments varied considerably between studies, ranging from three (Lavender 1998) to more than 24 weeks (Armstrong 1999; Cupples 2011; Ickovics 2011; Le 2011; MacArthur 2002; Priest 2003; Sen 2006). Due to the significant differences in the timing of outcome data, we included an additional outcome assessment point that included data "at final study assessment".

 

Types of psychosocial interventions

The studies were subgrouped into categories to examine specific types of psychosocial interventions such as antenatal and postnatal classes/groups (Brugha 2000; Feinberg 2008; Gjerdingen 2002; Ickovics 2011; Reid 2002; Stamp 1995; Tripathy 2010), professional- (Armstrong 1999; MacArthur 2002) and lay-based (Cupples 2011; Harris 2006; Morrell 2000) home visits, lay-based telephone support (Dennis 2009), early postpartum follow-up (e.g., routine postpartum care initiated earlier than standard practice) (Gunn 1998), continuity/models of care (Lumley 2006; Sen 2006; Waldenstrom 2000). In the majority of studies, the control group was reported to have received usual antenatal/postnatal care, which varied both between and within countries. Wherever there were individual study details on care received by the control group, these are presented in the Characteristics of included studies tables.

 

Types of psychological interventions

The studies were subgrouped into categories to examine specific types of psychological interventions, such as debriefing (Gamble 2005; Lavender 1998; Priest 2003; Small 2000; Tam 2003), cognitive behavioural therapy (Le 2011), interpersonal psychotherapy (Gao 2010, Gorman 1997; Weidner 2010; Zlotnick 2001; Zlotnick 2006).

 

Differences in intervention provider, mode of delivery, duration, and onset

The interventions were provided by a variety of professionals including nurses (Armstrong 1999; Brugha 2000; Lumley 2006; Tam 2003; Zlotnick 2006), physicians (Gunn 1998; Lumley 2006), midwives (Gamble 2005; Gao 2010; Ickovics 2011; Lavender 1998; MacArthur 2002; Priest 2003; Reid 2002; Sen 2006; Small 2000; Stamp 1995; Waldenstrom 2000), mental health specialists (Gorman 1997; Weidner 2010) including psychologists Gjerdingen 2002). In seven trials, the intervention was provided by lay individuals (Cupples 2011; Dennis 2009; Feinberg 2008; Harris 2006; Morrell 2000; Tripathy 2010) including trained research staff (Le 2011). Eleven trials (Brugha 2000; Feinberg 2008; Gao 2010; Gjerdingen 2002; Ickovics 2011; Le 2011; Reid 2002; Stamp 1995; Tripathy 2010; Zlotnick 2001; Zlotnick 2006) provided an intervention that was delivered to groups of women. If parts of the intervention were individualised and other parts were group-based, the subgroup classification was determined by the main focus of the intervention. All trials but four (Gunn 1998; Lavender 1998; Priest 2003; Small 2000) provided multiple contacts as part of the intervention. Four trials (Gjerdingen 2002; Ickovics 2011; Weidner 2010; Zlotnick 2001) evaluated an intervention that was provided solely in the antenatal period. Twelve trials (Brugha 2000; Cupples 2011; Feinberg 2008; Gao 2010; Gorman 1997; Harris 2006; Le 2011; Sen 2006; Stamp 1995; Tripathy 2010; Waldenstrom 2000; Zlotnick 2006) incorporated an intervention that was initiated antenatally and continued into the postpartum period and 12 trials (Armstrong 1999; Dennis 2009; Gamble 2005; Gunn 1998; Lavender 1998; Lumley 2006; MacArthur 2002; Morrell 2000; Priest 2003; Reid 2002; Small 2000; Tam 2003) evaluated a postnatal-only intervention

 

Differences in sample selection criteria

Twelve of the trials targeted at-risk women based on various factors believed to put them at additional likelihood of developing postpartum depression (Armstrong 1999; Brugha 2000; Dennis 2009; Gamble 2005; Gorman 1997; Harris 2006; Le 2011; Stamp 1995; Tam 2003; Weidner 2010; Zlotnick 2001; Zlotnick 2006) while the other 16 trials enrolled women from the general population.

 

Risk of bias in included studies

Randomisation was performed most frequently by consecutively numbered, sealed, opaque envelopes (Gamble 2005; Gorman 1997; Harris 2006; Lavender 1998; Le 2011; Morrell 2000; Priest 2003; Reid 2002; Stamp 1995; Tam 2003; Waldenstrom 2000). Various forms of computer-based randomisation was used by nine trials (Armstrong 1999; Brugha 2000; Cupples 2011; Feinberg 2008; Gao 2010; Gjerdingen 2002; Ickovics 2011; MacArthur 2002; Weidner 2010). Four trials incorporated a central, computerised randomisation service accessed by telephone (Gunn 1998; Small 2000) or the Web (Dennis 2009; Sen 2006) and two trials performed the randomisation of clusters at a public event (Lumley 2006; Tripathy 2010). Allocation concealment was unclear in four trials (Gao 2010; Lumley 2006; Zlotnick 2001; Zlotnick 2006). In all but three trials (Brugha 2000; Harris 2006; Le 2011) outcome data were collected by assessors blinded to group allocation or by mailed questionnaires; for three studies the method of collecting outcomes is unknown (Tam 2003; Zlotnick 2001; Zlotnick 2006). Six trials had a follow-up rate less than 80%: Gunn 1998 (69.7% at 12 weeks); Harris 2006 (55.5% at 12 weeks); MacArthur 2002 (72.8% at 16 weeks); Reid 2002 (73.3% at 12 weeks); Waldenstrom 2000 (68.4% at eight weeks) and Weidner 2010 (47.8% at 52 weeks). It is noteworthy that follow-up in all these trials except Harris 2006 was done by mailed questionnaires. Trials were excluded for sensitivity analyses related to high susceptibility to bias due to methodological quality (Brugha 2000; Harris 2006; Le 2011; Tam 2003; Weidner 2010; Zlotnick 2001; Zlotnick 2006) or follow-up losses greater than 20% (Gunn 1998; Harris 2006; MacArthur 2002; Reid 2002; Waldenstrom 2000; Weidner 2010). A summary of the risk of bias for all included studies can be found in Figure 1 and Figure 2.

 FigureFigure 1. 'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
 FigureFigure 2. 'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

 

Effects of interventions

Twenty-eight trials, involving almost 17,000 women, were included in the meta-analyses. The results are presented in sequential order, starting with maternal outcomes followed by infant and family outcomes. Because of the large number of outcomes in this review, the following summary of results has been restricted at times to present only final study comparisons. Please refer to the meta-analyses graphs for the full results. According to our pre-specified criteria, there was substantial statistical heterogeneity in many of the outcomes. We report results of random-effects analyses for our main comparison (one) and for other comparisons for those outcomes with statistical heterogeneity. Random-effects analyses provide an estimate of the average treatment effect and effects may differ considerably over different settings. Sensitivity analyses, conducted by removing trials with high likelihood of bias due to either methodological quality or follow-up losses greater than 20%, altered some of the conclusions and these have been noted in the text. Sensitivity analyses were not completed for the clinical diagnosis of depression outcome for any comparison due to small trial numbers. Outcomes were categorised and presented in the results as follows:

  1. zero to eight weeks - immediate effects;
  2. nine to 16 weeks - short-term effects;
  3. 17 to 24 weeks - intermediate effects;
  4. more than 24 weeks - long-term effects.

 

Main comparison one: all psychosocial and psychological interventions versus usual care - various study outcomes

We considered eight maternal outcomes, three infant outcomes, and one family outcome. Between one and 20 trials contributed to the analyses of each outcome. In this comparison, we combined trials that have evaluated very different types of interventions and thus there could be substantial clinical heterogeneity. To address this, we used random-effects analysis independent of statistical heterogeneity for all outcomes and, in view of this, we would advise caution in the interpretation of results.

 

A. Maternal outcomes

 
Primary outcome: postpartum depression at last study assessment (variously defined)

The main outcome measure for this review was postpartum depression at final study assessment. There was a beneficial effect on the prevention of depressive symptomatology in the meta-analysis of all types of interventions (20 trials, n = 14,727, average risk ratio (RR) 0.78, 95% confidence interval (CI) 0.66 to 0.93, I² 64%, T² 0.07, I2 64%) ( Analysis 1.1). The standard mean difference (SMD) among trials that provided mean scores was -0.13 (19 trials, n = 12,376, 95% CI -0.28 to 0.01, T2 0.08, I2 = 91%) ( Analysis 1.2). For these outcomes we generated funnel plots to investigate possible reporting biases; visual assessment suggested no obvious plot asymmetry (Figure 3; Figure 4). A significant preventative effect was found among the few studies that included a clinical diagnosis of depression (five trials; n = 939; average RR 0.50, 95% CI 0.32 to 0.78, T2 0.00, I2 = 0%) ( Analysis 1.3). When trials with high susceptibility to bias were temporarily removed (sensitivity analysis related to poor methodological quality or more than 20 loss to follow-up rate), the direction of the effect remained the same for the depressive symptomatology (average RR 0.72, 95% CI 0.57 to 0.91) and also for the SMD in depression scores, although in this case the effect size was reduced when studies at high risk of bias were removed from the analysis (SMD -0.06, 95% CI -0.14 to 0.02) (data not shown).

 FigureFigure 3. Funnel plot of comparison: 1 All interventions versus usual care - various study outcomes, outcome: 1.1 Depressive symptomatology at final study assessment.
 FigureFigure 4. Funnel plot of comparison: 1 All interventions versus usual care - various study outcomes, outcome: 1.2 Mean depression scores at final study assessment.

 
Primary outcome: postpartum depression at eight, 16, 24 and more than 24 weeks (variously defined)

Results suggested an immediate (13 trials; n = 4,907; average RR 0.73, 95% CI 0.56 to 0.95, I² 61%, T² 0.13) and short-term (10 trials; n = 3982; RR 0.73, 95% CI 0.56 to 0.97, I² 65%, T² 0.11) reduction in depressive symptomatology. The preventative effect appeared to weaken at the intermediate postpartum time period between 17 to 24 weeks (nine trials; n = 10,636; average RR 0.93, 95% CI 0.82 to 1.05, I² 15%, T² 0.01) and was again significant when depressive symptomatology was assessed past 24 weeks postpartum (five trials; n = 2936; average RR 0.66, 95% CI 0.54 to 0.82, I² 1%, T² 0.00) ( Analysis 1.4). While no statistically significant preventative effect across the postpartum period was found among trials that examined mean depression scores a short-term beneficial effect was found among trials that included a clinical diagnosis of depression (four trials; n = 902; average RR 0.49, 95% CI 0.31 to 0.77,T2 0.00, I2 = 0%) ( Analysis 1.5;  Analysis 1.6). When sensitivity analyses were performed, the short-term effect in the reduction of depressive symptomatology was strengthened (six trials; n = 1322; RR 0.59, 95% CI 0.46 to 0.75, I² 1%, T² 0) and the difference in means scores became significant (six trials; n = 1061; SMD -0.19, 95% CI -0.31 to -0.07) (data not shown).

 
Secondary outcome: maternal mortality at more than 24 weeks

One cluster trial conducted in India evaluated maternal mortality at one year postpartum and found no beneficial effect (n = 234; RR 0.97, 95% CI 0.06 to 15.27) ( Analysis 1.7).

 
Secondary outcome: maternal-infant attachment at eight, 16, 24 and more than 24 weeks

No significant effect was found across the postpartum period in the one trial that dichotomised maternal-infant attachment or the two trials that examined mean scores on a maternal-infant measure (two trials; n = 268; SMD at final study assessment -0.18, 95% CI -0.42 to 0.06, ) ( Analysis 1.8;  Analysis 1.9).

 
Secondary outcome: anxiety at eight, 16, and more than 24 weeks

While at last study assessment, no significant effect was found when a dichotomous measure of anxiety was used (four trials; n = 959; average RR 0.40, 95% CI 0.14 to 1.14, I² 77%, T² 0.79) ( Analysis 1.10), a significant decrease in mean anxiety scores was found (four trials; n = 815; SMD -0.16, 95% CI -0.30 to -0.03) ( Analysis 1.11).

 
Secondary outcome: maternal stress at 16, 24, and more than 24 weeks

In a single trial (Gamble 2005), the intervention appeared to positively influence stress levels among women at any time in the postpartum period when measured as a dichotomous outcome (one trial; n = 103; RR 0.44, 95% CI 0.20 to 0.96) ( Analysis 1.12). In another trial that measured mean stress scores there was no clear difference between groups for long-term stress scores (one trial; n = 840; MD 0.50, 95% CI -0.51 to 1.51) ( Analysis 1.13).

 
Secondary outcome: parental stress at eight, 24 and more than 24 weeks

At last study assessment, no significant difference in mean scores was found in relation to parental stress as measured using the Parenting Stress Index (PSI) (three trials, n = 465; SMD 0.11, 95% CI -0.25 to 0.48, I² 71%, T² 0.07) ( Analysis 1.14). The PSI is an internationally used questionnaire to measure to identify parent-child problem areas.

 
Secondary outcome: perceived social support at eight, 16, 24 and more than 24 weeks

Seven trials assessed maternal perceptions of support across the postpartum period using different measures; no beneficial effect was demonstrated at final study assessment (n = 8290; SMD 0.01, 95% CI -0.08 to 0.10, I² 45%, T² 0.01) ( Analysis 1.16). Similar results were found when social support was measured as a dichotomous variable at final study assessment (two trials; n = 718; average RR 0.72, 95% CI 0.48 to 1.08) ( Analysis 1.15).

 
Secondary outcome: maternal dissatisfaction with care provided at eight, 16, 24 and more than 24 weeks

At final study assessment, women in the intervention group who received some form of psychosocial or psychological intervention were less likely to be dissatisfied with the care they received than those who were provided with some form of standard care (four trials; n = 3014; average RR 0.67, 95% CI 0.44 to 1.00, I² 83%, T² 0.14) ( Analysis 1.17). For trials that included a mean score of maternal dissatisfaction, no statistically significant difference was found between groups at final study assessment (two trials, n = 676; SMD 0.44, 95% CI -0.44 to 1.32, I² 96%, T² 0.39) ( Analysis 1.18).

 

B. Infant outcomes

 
Secondary outcome: infant health parameters - not fully immunised at more than 24 weeks

Only one trial reported on infant health parameters. There was no beneficial effect of protocol-based midwifery-led postpartum home visits on whether or not infants were fully immunised at one year postpartum (n = 884; RR 1.16, 95% CI 0.39 to 3.43) ( Analysis 1.19).

 
Secondary outcome: infant development more than 24 weeks

One trial reported on infant development using the Bayley (BSID-II). There was no beneficial effect identified of peer mentoring provided via home visits or the telephone on infant development measured at more than 24 weeks postpartum (n = 280; MD -0.90, 95% CI -2.90 to 1.10) ( Analysis 1.20).

 
Secondary outcome: child abuse at eight and more than 24 weeks

One trial that evaluated the effect of a postpartum home visiting program by child health nurses among vulnerable families found a beneficial effect on child abuse potential scores in the immediate postpartum period (n = 176; MD -35.66, 95% CI -62.65 to -8.67) ( Analysis 1.21) but not at one year postpartum (n = 66; MD -41.90, 95% CI -87.48 to 3.68) ( Analysis 1.21).

 

C. Family outcomes

 
Secondary outcome: marital discord at eight, 16, and 24 weeks

There was no significant effect on marital discord scores at last study assessment (three trials, n = 291; SMD -0.14, 95% CI -0.37 to 0.09,) or across the postpartum period ( Analysis 1.22).

 

Main comparison two: all psychosocial interventions versus usual care - variations in intervention type

In total, 17 trials evaluated a psychosocial intervention. Overall, these interventions have a beneficial effect in decreasing the risk of depressive symptomatology at final study assessment (12 trials; n = 11,322; RR 0.83, 95% CI 0.70 to 0.99, I² 57%, T² 0.04) ( Analysis 2.1). There was no obvious funnel plot asymmetry for this outcome at final study assessment (Figure 5;  Analysis 2.4). A beneficial effect was found across the postpartum period from zero to eight weeks (six trials; n = 2138; RR 0.77, 95% CI 0.52 to 1.14, I² 63%, T² 0.14) to more than 24 weeks postpartum (three trials; n = 1385; RR 0.59, 95% CI 0.46 to 0.76, I² 0.0%, T² 0.0), although fewer trials collected longer-term outcome data. A significant preventative effect at final study assessment was also found among the studies that included a clinical diagnosis of depression (three trials; n = 867; RR 0.52, 95% CI 0.33 to 0.83, fixed-effect analysis) ( Analysis 2.3). At final study assessment, the SMD for depression among trials that provided mean scores was -0.14 (12 trials, n = 10,944, 95% CI -0.33 to 0.04, I² 94%, T² 0.10) ( Analysis 2.2); there was no obvious funnel plot asymmetry for this outcome ( Analysis 2.5; Figure 6). Sensitivity analyses strengthened the preventive effect across the postpartum period in relation to depressive symptomatology but did not change any of the mean depression score conclusions.

 FigureFigure 5. Funnel plot of comparison: 2 All psychosocial interventions versus usual care - variations in intervention type, outcome: 2.4 All psychosocial interventions: depressive symptomatology at final study assessment.
 FigureFigure 6. Funnel plot of comparison: 2 All psychosocial interventions versus usual care - variations in intervention type, outcome: 2.5 All psychosocial interventions: mean depression scores.

 

Main comparison three: all psychological interventions versus usual care - variations in intervention type

In total, 11 trials evaluated a psychological intervention. The average RR for depressive symptomatology at final assessment for psychological interventions was 0.61 (eight trials; n = 3405, 95% CI 0.39 to 0.96, I² 75%, T² 0.27) ( Analysis 3.1). Across the postpartum period, the only time a statistically significant beneficial effect was found was at nine to 16 weeks (two trials; n = 277; average RR 0.40, 95% CI 0.18 to 0.89, I² 37%, T² 0.12). The SMD among trials that provided mean scores for depression was -0.10 (seven trials, n = 1432; 95% CI -0.32 to 0.13) ( Analysis 3.2). No significant preventative effect was found among the studies that included a clinical diagnosis of depression (two trials; n = 72; average RR 0.31, 95% CI 0.04 to 2.52, I² 50%, T² 1.25) ( Analysis 3.3). Sensitivity analyses weakened the preventive effect in relation to depressive symptomatology at final assessment but did not change the negative mean depression score conclusion.

 

Subgroup comparisons (comparisons four to 11)

 

Influence of variations in psychosocial interventions (comparison four)

Data were available for all types of psychosocial interventions for depressive symptomatology at final study assessment. While overall 16 trials contributed data to the pooled results, the number of trials examining specific types of interventions was limited (ranging from one to four) and the results of subgroup interaction tests should therefore be interpreted with caution. We identified some evidence of differences between subgroups for depressive symptomatology at final study assessment (X² = 16.37, P = 0.006) ( Analysis 4.1). We found no statistically significant preventive effect on depressive symptomatology at final study assessment when the interventions were antenatal and postnatal classes (four trials, n = 1488; RR 1.01, 95% CI 0.77 to 1.32, I² 0%,T² 0.0), postpartum lay-based home visits (one trial, n = 493; RR 0.88, 95% CI 0.62 to 1.25), early postpartum follow-up (one trial, n = 446; RR 0.90, 95% CI 0.55 to 1.49), or continuity/model of care (three trials, n = 7021; RR 0.99, 95% CI 0.71 to 1.36, I² 60%,T² 0.05) ( Analysis 4.1). However, we found a beneficial effect when the intervention involved postpartum professional-based home visits (two trials, n = 1262; RR 0.56, 95% CI 0.43 to 0.73, I² 0%,T² 0.0) and for postpartum lay-based telephone support (one trial, n = 612; RR 0.54, 95% CI 0.38 to 0.77) ( Analysis 4.1). Due to the small number of trials examining specific types of interventions, sensitivity analyses were not completed.

 

Influence of variations in psychological interventions (comparison five)

We did not have sufficient data from all studies examining different types of psychological interventions to allow us to carry out a complete subgroup analysis for depressive symptomatology at final study assessment: only studies examining psychological debriefing and cognitive behavioural therapy contributed to this analysis. We found no statistically significant preventive effect at final study assessment for psychological debriefing (five trials, n = 3050; RR 0.57, 95% CI 0.31 to 1.03, I² 85%, T² 0.37) and cognitive behavioural therapy (one trial, n = 150; RR 0.74, 95% CI 0.29 to 1.88) ( Analysis 5.1). Mean depression scores at final study assessment were reported in studies examining interpersonal psychotherapy (five trials, n = 366; SMD -0.27, 95% CI -0.52 to -0.01 I² 25%, T² 0.02) and cognitive behavioural therapy (one trial, n = 150; SMD 0.13, 95% CI -0.20 to 0.45) ( Analysis 5.2). The test for subgroup differences was not significant (X² = 3.50, P = 0.06, I² 71.4%) ( Analysis 5.2). Due to the small number of trials examining specific types of interventions, sensitivity analyses were not completed.

 

Influence of variations in intervention provider (comparison six)

 
Outcome: professionally-based and lay-based interventions

In total, 19 trials evaluated an intervention provided by a health professional. The average RR for depressive symptomatology at final assessment for professionally-based interventions was 0.78 (15 trials; n = 6790, 95% CI 0.60 to 1.00, I² 70%, T² 0.15) ( Analysis 6.7). The SMD at final assessment among trials that provided mean scores was -0.15 (12 trials, n = 4509; 95% CI -0.40 to 0.10, I² 93%, T² 0.17) ( Analysis 6.8). Only two studies included a clinical diagnosis of depression (n = 227; RR 0.56, 95% CI 0.22 to 1.47, fixed-effect analysis) ( Analysis 6.9). Seven trials evaluated an intervention provided by a lay individual. The RR for depressive symptomatology at final assessment for lay-based interventions was 0.70 (four trials; n = 1723, 95% CI 0.54 to 0.90) ( Analysis 6.7). The SMD at final assessment among trials that provided mean scores was -0.10 (five trials, n = 1682; 95% CI -0.20 to 0.01, I² 8%, T² 0.0) ( Analysis 6.8). Among the two studies that included a clinical diagnosis of depression between nine to 16 weeks postpartum (final study assessment for both trials) the RR was 0.52 (n = 677; 95% CI 0.32 to 0.86, fixed-effect analysis) ( Analysis 6.9). The test for subgroup differences between professionally-based and lay-based interventions was not significant for depressive symptomatology, mean depression scores, or clinical diagnosis of depression. Sensitivity analyses did not change any of the final conclusions.

 

Influence of variations in professionally-based intervention provider (comparison seven)

Data were available for all types of professionally-based interventions for depressive symptomatology at final study assessment. While overall 19 trials contributed data to the meta-analyses, the number of trials examining a specific type of intervention provider was limited, ranging from one to 10. In relation to depressive symptomatology at final study assessment, we found no evidence that a specific health professional providing an intervention increased the likelihood of a preventative effect. The RR for the specific health professionals were as follows: nurses (three trials, n = 837; RR 0.73, 95% CI 0.51 to 1.04, I² 0%, T² 0.0), physicians (one trial, n = 446; RR 0.90, 95% CI 0.55 to 1.49), midwives (10 trials, n = 5477; RR 0.76, 95% CI 0.54 to 1.07, I² 80%, T² 0.22), mental health professional (one trial, n = 30; RR 1.00, 95% CI 0.24 to 4.18) ( Analysis 7.1). Similar non-significant results were found in relation to mean depression scores at final study assessment. Due to multiple health professionals providing the community-based intervention with no clear primary provider, the trial by Lumley 2006 could not be included in this comparison. There were insufficient trials to complete an analysis in relation to a clinical diagnosis of depression. The test for subgroup differences was not significant for depressive symptomatology or mean depression scores ( Analysis 7.1;  Analysis 7.2).

 

Influence of variations in intervention mode (comparison eight)

 
Outcome: individually-based and group-based interventions

Analysis of 14 trials of interventions provided to individual women suggested a reduction in depressive symptomatology at the last study assessment (n = 12,914; RR 0.75, 95% CI 0.61 to 0.92, I² 72%, T² 0.09) ( Analysis 8.7). When trials susceptible to bias (more than 20% loss to follow-up) were removed, the direction of the effect strengthened (11 trials, n = 10,653; RR 0.71, 95% CI 0.56 to 0.91, I² 70%, T² 0.09) (data not shown). At final study assessment, the SMD among trials that provided mean scores was -0.15 (11 trials, n = 10,092; 95% CI -0.37 to 0.07, I² 94%, T² 0.11) ( Analysis 8.8) and the RR for a clinical diagnosis of depression was significant (three trials; n = 714; RR 0.53, 95% CI 0.33 to 0.84) ( Analysis 8.9). Sensitivity analyses did not change any of the final conclusions.

Of the six trials evaluating interventions delivered to groups of women, there was no clear reduction in depressive symptomatology at final study assessment (n = 1813; RR 0.92, 95% CI 0.71 to 1.19, I² 7%, T² 0.09) ( Analysis 8.7). When sensitivity analysis was performed and trials with more than 20% loss to follow-up were removed, there continued to be no clear beneficial effect (three trials; n = 779; RR 0.87, 95% CI 0.60 to 1.28) (data not shown). No beneficial effect was found in relation to mean depression scores at final study assessment (eight trials, n = 2284; SMD -0.08, 95% CI -0.23 to 0.06) ( Analysis 8.8). Similary, no clear beneficial effect was found in relation to a clinical diagnosis of depression at final study assessment between nine to 16 weeks (two trials, n = 225; RR 0.30, 95% CI 0.05 to 1.66, I² 32%,T² 0.59) ( Analysis 8.9). The test for subgroup differences between individually-based and group-based interventions was not significant for depressive symptomatology, mean depression scores, or clinical diagnosis of depression ( Analysis 8.7;  Analysis 8.8;  Analysis 8.9). Sensitivity analyses did not change any of the final conclusions.

 

Influence of variations in intervention duration (comparison nine)

 
Outcome: single-contact and multiple-contact interventions

Only four trials evaluated a single-contact intervention (e.g. psychological debriefing, early postpartum follow-up). The RR related to depressive symptomatology at final assessment was 0.70 (four trials, n = 2877; 95% CI 0.38 to 1.28, I² 84%, T² 0.30) ( Analysis 9.6) and the mean depression scores at final study assessment was 0.04 (two trials, n = 1362; 95% CI -0.07 to 0.15, I² 5%) ( Analysis 9.7). Sensitivity analyses did not change any of the final conclusions.

Of the 24 trials evaluating a multiple-contact intervention, there was a reduction in depressive symptomatology at final study assessment (16 trials, n = 11,850; average RR 0.78, 95% CI 0.66 to 0.93, I² 53%, T² 0.05) ( Analysis 9.6). Similarly, the average RR for a clinical diagnosis of depression at final study assessment was significant (five trials, n = 939; RR 0.48, 95% CI 0.31 to 0.74, I² 0%) ( Analysis 9.5). The SMD in the 17 trials that provided mean depression scores was -0.15 (n = 11,014; 95% CI -0.32 to 0.02, I² 92%, T² 0.10) ( Analysis 9.7). Sensitivity analyses did not change any of the final conclusions.

There appears to be no strong evidence of subgroup differences for interventions involving a single contact as opposed to more intensive interventions involving multiple contacts for depressive symptomatology at final study assessment (I² = 0%, P = 0.73) ( Analysis 9.6). There was a trend that mean depression scores were lower at final study assessment where interventions involved multiple rather that single contacts (test for subgroup differences I² = 71.4%, P = 0.06) ( Analysis 9.7). However, this result should be interpreted with caution, as while results for this outcome were derived from 17 studies involving multiple contacts, it was measured in only two with single contacts.

 

Influence of variations in intervention onset (comparison 10)

 
Outcome: interventions with antenatal-only component, antenatal and postnatal components, and postnatal-only component

Four trials evaluated an intervention that was conducted only in the antenatal period and the SMD at final study assessment was 0.03 (n = 1050; 95% CI -0.09 to 0.16) ( Analysis 10.10). Eight trials evaluated interventions that were initiated antenatally and continued postnatally. The average RR in relation to depressive symptomatology at final assessment was 0.96 (eight trials, n = 1941; 95% CI 0.75 to 1.22, I² 6%, T² 0.01) ( Analysis 10.9) and the SMD was -0.14 (seven trials, n = 1000; 95% CI -0.31 to 0.02, I² 37%, T² 0.02) ( Analysis 10.10). While a significant effect was found related to a clinical diagnosis of depression (three trials, n = 292; RR 0.44, 95% CI 0.24 to 0.80, fixed-effect analysis), it is noteworthy that two out of the three trials (Brugha 2000; Harris 2006) included in this analysis were identified as high risk for bias. Of the 12 trials that evaluated an Intervention that was initiated postnatally, a significant reduction in depressive symptomatology at final study assessment was found (n = 12,786; average RR 0.73, 95% CI 0.59 to 0.90, I² 75%, T² 0.09) ( Analysis 10.9). However, no preventative effects were found in relation to mean depression scores (eight trials, n = 10,326; SMD -0.16, 95% CI -0.40 to 0.08, I² 96%, T² 0.11) ( Analysis 10.10) or a clinical diagnosis of depression (one trial, n = 612; RR 0.65, 95% CI 0.34 to 1.23) ( Analysis 10.11) at final study assessment. There was no strong evidence of differences between subgroups for outcomes at the final study assessment. For depressive symptomatology, mean depression scores, and diagnosis of depression there was heterogeneity between subgroups, however, there was also considerable heterogeneity within some subgroups; tests for subgroup differences for these outcomes were not statistically significant. Sensitivity analyses did not change any of the final conclusions.

 

Influence of variations in sample selection criteria (comparison 11)

 
Outcome: interventions for at-risk women and women drawn from the general population

In the eight trials that selected participants based on 'at-risk' criteria, a reduction in postpartum depressive symptomatology at final study assessment was found (eight trials, n = 1853; average RR 0.66, 95% CI 0.50 to 0.88, I² 23%, T² 0.04) ( Analysis 11.6). Participants in the intervention groups in these trials also had lower mean depression scores (seven trials, n = 1087; SMD -0.13, 95% CI -0.25 to -0.01, I² 0%, T² 0.00) ( Analysis 11.7) and were less likely to be diagnosed with clinical depression (five trials, n = 939; RR 0.48, 95% CI 0.31 to 0.74, fixed-effect analysis). When sensitivity analyses were performed, the direction of the effect at final study assessment in relation to depressive symptomatology remained the same but the CI widened (five trials, n = 997; RR 0.60, 95% CI 0.35 to 1.02, I² 45%, T² 0.16) (data not shown). The beneficial effect related to a diagnosis with clinical depression disappeared when three out of the five trials (Brugha 2000; Harris 2006; Zlotnick 2001) were deemed high risk for bias and were removed from the analysis (two trials, n = 649; RR 0.64, 95% CI 0.36 to 1.15, I² 0%, T² 0.0) (data not shown). Twelve trials enrolled women from the general population. The average RR related to depressive symptomatology at final study assessment was 0.83 (12 trials, n = 12,874; 95% CI 0.68 to 1.02, I² 71%, T² 0.07) ( Analysis 11.6) and the SMD was -0.15 (12 trials, n = 11,289; 95% CI -0.33 to 0.04, I² 94%, T² 0.10) ( Analysis 11.7). There was no strong evidence of differences between these subgroups at final study assessment for depressive symptomatology or mean scores, although there was much greater heterogeneity in the results of studies including women from the general population (I² = 94%) compared with those recruiting women at high-risk only (I² = 0%). Sensitivity analyses did not change any of the final conclusions.

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

This review summarises the results of 28 trials involving almost 17,000 women, that were conducted in seven countries under a wide variety of circumstances. The methodological quality of the included trials was good to excellent with the most frequently identified weakness being follow-up attrition. In particular, six trials had losses to follow-up greater than 20% with five of these trials collecting outcome data from mailed questionnaires. The removal of trials at risk of bias resulted in minimal changes to any of the conclusions. While intent-to-treat data analyses were performed, several trials involving group sessions had high (Brugha 2000; Reid 2002; Stamp 1995) or unknown (Tripathy 2010) levels of non-compliance with group attendance. Further, the reporting of the trials was often not comprehensive, lacking in terms of details in the training and qualifications of the intervention providers and in the description of adherence to the intervention protocol. There was also a failure to present details of the informational element of the interventions and on the background features of the care received by the control groups.

In the primary comparison, the diversity of preventative interventions and the widely differing study end-points should urge some caution in the interpretation of the pooled data. To partially address this issue, the meta-analyses included immediate, short, intermediate, and longer-term effects where appropriate. Despite this caution and the subgrouping of end-points, this review has demonstrated that women who received a psychosocial or psychological intervention were significantly less likely to experience postpartum depression than those who received standard care (average risk ratio (RR) 0.78, 95% confidence interval (CI) 0.66 to 0.93). Psychosocial (average RR 0.83, 95% CI 0.70 to 0.99) and psychological (average RR 0.61, 95% CI 0.39 to 0.96) interventions were both effective in reducing the risk to develop depressive symptomatology at final study assessment.

Importantly, the review has assisted in specifying what interventions may be effective or not and require further investigation. Although there was no clear evidence of differences between subgroups in trials focusing on different types of psychosocial interventions, antenatal classes addressing postpartum depression have been shown in four trials to have no preventative effect (average RR 1.01, 95% CI 0.77 to 1.32) and cannot be recommended at this time. In four of five trials evaluating in-hospital psychological debriefing there was some evidence of positive effect, but overall, pooled results showed that differences between groups were not statistically significant and more evidence is needed before this intervention is implemented into practice (RR 0.57, 95% CI 0.31 to 1.03).The effectiveness of postpartum lay-based home visits remains uncertain. Morrell 2000 demonstrated that the addition of home visits by a community support worker had no protective effect on postpartum depression (RR 0.88, 95% CI 0.62 to 1.25). However, a review of the intervention activities revealed that the lay women spent a significant amount of their time providing instrumental support, such as housework and infant care, and limited time providing emotional and appraisal (feedback) support to the mother. The potential to positively influence health outcomes depends on predicting which supportive functions will be the most effective for a particular type of stressor (Will 2000). In qualitative studies, women from diverse cultures who have suffered from postpartum depression consistently describe their feelings of loneliness, worries about maternal competence, role conflicts, and inability to cope (Chen 1999; Nahas 1999; Ritter 2000; Small 1994); the presence or absence of instrumental support was not a highlighted factor. The preventative effect of cognitive behavioural therapy also remains uncertain, primarily due to the fact that only one study contributing data to the review (Le 2011) evaluated this type of intervention. Another trial (Austin 2008) also evaluated cognitive behaviour therapy and was included in the review but not the meta-analysis due to the lack of usable data; this study reported no clear differences between intervention and control groups for depression outcomes. Improving the quality of perinatal care provided to women has been another postpartum depression preventative approach. Two trials have evaluated the effect of early postpartum follow-up. Although one quasi-experimental study was not included in this review (Serwint 1991), another well-designed trial demonstrated no beneficial effect on maternal mental health outcomes (Gunn 1998). However, the intervention in this trial did not included a formal assessment of maternal mood during the early postpartum contact. It is well documental that without a formal assessment, most depressive symptomatology remain undetected by primary care health professionals. Three trials evaluated continuity/models of care interventions (Lumley 2006; Sen 2006; Waldenstrom 2000) without demonstrating a preventative effect. The impressive community-based cluster trial by Lumley 2006 was particularly comprehensive where the intervention incorporated strategies at both the primary care and community levels. However, the significant changes to the local government implemented by the State government was not the ideal context for a community-based intervention. Replicating multi-component trials like this are warranted.

There is growing evidence to suggest the importance of additional professional-based home visits provided postnatally (RR 0.56, 95% CI 0.43 to 0.73). While one well-designed trial (Armstrong 1999) suggested intensive nursing home visits with at-risk mothers was protective during the first six weeks postpartum, the beneficial effect was not maintained to 16 weeks. It is noteworthy that the 16-week assessment coincided with a decrease in intervention intensity from weekly to monthly nursing visits. Results from a cluster-randomised controlled trial (MacArthur 2002) demonstrated that flexible, individualised midwifery-based postpartum care that incorporated postpartum depression screening tools also had a preventive effect. Individualised, telephone-based lay support provided by peers postnatally (Dennis 2009) is another promising intervention (RR 0.54, 95% CI 0.38 to 0.77). Combined, these three trials decreased the risk to develop postpartum depression by almost 50% and provide accumulating evidence that additional individualised support early in the postpartum period is an effective preventative intervention. Another strategy that may assist in preventing postpartum depression is interpersonal psychotherapy (standardised mean difference (SMD) -0.27, 95% CI -0.52 to -0.01). Interpersonal psychotherapy is a manual-based, time-limited psychotherapeutic approach with a basic premise that depression, regardless of aetiology, is initiated and maintained within an interpersonal context. The goal of interpersonal psychotherapy is to achieve symptomatic relief for depression by addressing current interpersonal issues associated with its onset or perpetuation; it does not seek to attribute interpersonal problems to underlying personality characteristics or unconscious motivations. Interpersonal psychotherapy is primarily concerned with symptom functioning, presumed to have biological and psychological precipitants, and social functioning. There is a specific focus on social interactions. Given that a lack of support and marital conflict are two strong risk factors for postpartum depression (Beck 2001; O'Hara 1996), this intervention is theoretically congruent with preventing postpartum depression.

While there was diversity in the types of intervention provided, most of the trials included in this review incorporated a primary preventative intervention; only one trial (Dennis 2009) selected participants within the first two weeks postpartum based on evidence of beginning depressive symptomatology. According to Shah 1998, preventative interventions incorporate any strategy that (1) reduces the likelihood of a disease/condition affecting an individual (primary prevention); (2) interrupts or slows the progress of a disease/condition through early detection and treatment (secondary prevention); or (3) slows the progress of a disease/condition and reduces resultant disability through treatment of established disease (tertiary prevention). These preventative interventions can be further classified into different categories depending on the target population: (1) universal interventions are designed to be offered to all women; (2) selective interventions are designed to be offered to women at increased risk of developing depression; and (3) indicated interventions are designed to be offered to women who have been identified as depressed or probably depressed (Mrazek 1994). To examine the effects of universal and selective interventions, subgroup analyses were conducted. The results suggest identifying mothers 'at-risk' may assist in the prevention of postpartum depression (average RR 0.66, 95% CI 0.50 to 0.88). However, currently there is no consistency in the identification of women 'at-risk' and a review of 16 antenatal screening tools suggests that there are no measures with acceptable predictive validity to accurately identify asymptomatic women who will later develop postpartum depression (Austin 2003). This may partially explain why interventions initiated in the postpartum period had a beneficial effect on reducing depressive symptomatology (average RR 0.73, 95% CI 0.59 to 0.90). Other differences in intervention delivery were also examined. Women who received a multiple-contact intervention were less likely to develop postpartum depression (RR average 0.78, 95% CI 0.66 to 0.93). It is noteworthy that all but five trials provided a multi-contact intervention. Individually-based interventions were effective in significantly reducing the number of women with depressive symptomatology at last study assessment and across the various assessment time periods. The decreased effect related to groups could be due to high group attrition and thus insufficient intervention dosage. It may also underpin the fact that there are many unique barriers for pregnant women and new mothers to attend sessions outside of their homes. It is noteworthy that five out of the 11 trials evaluating group-based interventions were classified as high risk of bias. Lastly, both professionally-based (average RR 0.78, 95% CI 0.60 to 1.00) and lay-based (average RR 0.70, 95% CI 0.54 to 0.90) interventions appeared beneficial in reducing the risk to develop depressive symptomatology at last assessment. The majority of the interventions included in this review were professionally-based.

There was insufficient evidence to show that the preventative interventions had an effect on other maternal outcomes including mortality, maternal-infant attachment, stress, perceived support, and marital discord. Most of these outcomes were measured in a relatively small number of trials. It is unclear if there was an effect on anxiety. However, women who received a preventative intervention were less likely to be dissatisfied with the care they received (average RR 0.67, 95% CI 0.44 to 1.00) than those who where provided with standard care. One study (MacArthur 2002) examined infant immunisations and found no beneficial effect; similar results were found with the one study (Cupples 2011) that evaluated infant development. Another study (Armstrong 1999) examined child abuse and while there was a short-term gain when the nursing home visits were being offered, the beneficial effect was not maintained once the intervention discontinued. Very few trials evaluated these secondary outcomes and thus additional research in this area is warranted.

The long-term consequences of postpartum depression suggest preventive approaches are warranted. Manipulation of a risk factor may improve the associated likelihood of developing postpartum depression through many different ways. The most obvious is to decrease the amount of exposure to a given risk factor or, alternatively, reduce the strength or mechanism of the relationship between the risk factor and postpartum depression (McLennan 2002). However, translating risk factor research into predictive screening protocols and preventative interventions is challenging, as complex interactions of biopsychosocial risk factors with individual variations need to be considered. Theoretical justifications for a couple of these preventative approaches were presented by the individual researchers and there is accumulating evidence available to guide practice and policy recommendations. Details of research currently in progress are provided in the Characteristics of ongoing studies table.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

 

Implications for practice

Currently, there is no strong evidence to recommend the following interventions be implemented into practice in order to prevent postpartum depression: antenatal and postnatal classes, postpartum lay-based home visits, early postpartum follow-up, continuity of care models, in-hospital psychological debriefing, and cognitive behavioural therapy. However, professionally-based home visits such as intensive nursing home visits and flexible postpartum care provided by midwives, postpartum lay (peer)-based telephone support, and interpersonal psychotherapy appear to show promise in the prevention of postpartum depression. It is noteworthy that the midwifery-based flexible postpartum care and lay telephone support interventions incorporated screening with the Edinburgh Postnatal Depression Scale (EPDS) for the early identification of depressive symptomatology. Interventions that are individually-based and initiated postnatally may be beneficial. Finally, interventions targeting 'at-risk' mothers may be more beneficial and feasible than those including a general maternal population.

 
Implications for research

There has been great interest in the prevention of postpartum depression. In total, over 40 experimental studies have evaluated an intervention that may be useful in the prevention of postpartum depression. Of these studies, 12 were quasi-experimental and excluded from this review resulting in 30 included randomised controlled trials of which 28 were included in the meta-analyses. Despite the recent upsurge of interest in this area, many questions remain unanswered.

Specific research implications

  • Further research is warranted to examine the effectiveness of psychosocial interventions with a specific focus on intervention content to determine the specific preventative mechanisms. Randomised controlled trials inform whether an intervention is effective or not but they do not specify 'why' the intervention was effective. Did the intervention directly influence the development of postpartum depression by: (1) decreasing isolation and feelings of loneliness, (2) swaying health practices and deterring maladaptive behaviours or responses, (3) promoting positive psychological states and individual motivation, and (4) providing information regarding access to health services or the benefits of behaviours that positively influence health and well-being? Alternatively, did the intervention buffer the influence of stress or mediate the development of postpartum depression by: (1) assisting in the interpretation and positive reinforcement of performance accomplishments, (2) providing vicarious experience and observational learning through role modelling, (3) offering opportunities for social comparisons to promote self-evaluations and motivation, (4) teaching coping strategies and conveying information about ability, (5) positively interpreting emotional arousal, and (6) encouraging cognitive restructuring through anticipatory guidance? This information would assist with the theoretical development of preventative interventions and assist in matching risk factors with appropriate interventions.
  • Flexible, individualised postnatal care provided by a professional that incorporates postpartum depression screening tools appears to be promising. A well-designed trial conducted outside a UK-midwifery context is needed to replicate the results.
  • Telephone-based support provided by a peer among new mothers with beginning depressive symptomatology early in the postpartum period appears to be a promising secondary preventative intervention. Replication of this trial is needed.
  • Interpersonal psychotherapy is another promising intervention. All five trials that evaluated this intervention provided it face-to-face. Additional research in relation to diverse intervention providers and delivery mode (e.g., face-to-face, via telephone, or web-based) is warranted.
  • Further research is warranted to examine the effectiveness of cognitive-behavioural therapy.
  • Both professional and lay interventions appear to be beneficial. However, only seven out of the 28 trials evaluated a lay-based intervention. Trials examining individually-based lay interventions specifically targeting maternal mood are required. Characteristics of the lay individuals (peers versus general community-based workers) and the nature of the relationships developed should be explored.
  • Pregnant women and women in the postpartum period face unique health service barriers. Innovative and creative ways to deliver preventative interventions to these women are required including those that incorporate technology.
  • There is increasing evidence to suggest migrant women (refuge, asylum-seeking, immigrant) are at higher risk to develop postpartum depression. Interventions targeting this vulnerable maternal population are needed.
  • No preventative interventions specifically targeted the mother's partner. This is a significant limitation since a lack of social support and marital conflict are strong risk factors for the development of postpartum depression.

General research implications

Most women receive postpartum services at the primary care level. Hence, the quality of the postpartum depression care in the primary care systems needs to be improved. Various approaches have been employed to improve the quality of care for depression in general. Notable among these is the development of a collaborative care model, a multi-component, healthcare system-level intervention that uses case managers to link primary care providers, patients, and mental health specialists. Collaborative care models typically include case managers, who support primary care providers with functions such as patient education, patient follow-up to track depression outcomes and adherence to treatment, and adjustment of treatment plans for patients who do not improve. In studies of non-postpartum depression, collaborative treatment of depression has been acclaimed as superior to traditional treatment methods (e.g. antidepressants and/or psychotherapy). A special type of collaborative care—stepped care treatment—delivers care in a step-wise manner, beginning with screening, diagnosis, and initial treatment in a primary care setting and adding follow-up and support, decision support, mental health consultation, or referral by a care manager as needed for patients with persistent depressive symptoms. Although it would seem that collaborative care would also improve postpartum depression outcomes, neither collaborative or stepped care have been rigorously evaluated in a postpartum population. Such evaluation would be important given that postpartum women often possess unique help-seeking and treatment barriers, such as the need for childcare, concerns about medication effects on breastfeeding infants, and fear of judgment or referral to child protection. Postpartum depression collaborative, stepped care models should include interventions to prevent postpartum depression. To be most efficient in conducting this research there continues to be a need for further interdisciplinary networking among investigators with complementary research interests. For example, psychosocial intervention researchers could collaborate with health services researchers to develop and test multi-level intervention approaches embedded in service systems. To further address postpartum depression as a public health problem, the inclusion of ethnically and socio-economically diverse women in these research efforts is critical to examining the differences in depression symptoms, response rate to interventions, and health service use. In addition, all trials should include an economic analysis of the relative costs and benefits. It is also necessary to present a few general comments regarding the development of preventive programs. Similar to screening initiatives, preventive interventions should be relatively simple and inexpensive. This is critical if the intervention is to be applied to a relatively large population; unless a project is feasible on a large scale, there is little utility in pursuing smaller demonstration projects.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

The review authors gratefully acknowledge Dr Debra Creedy who assisted Dr Dennis with the first version of this review in 2004. The review authors also wish to thank: (1) Julie Weston for her data extraction, independent evaluation of trial quality, contacting trial authors as necessary, and data entry; (2) Danni Li for translating Sun 2004; Tang 2009; Xu 2003. Edward Plaisance Jr for translating Ajh 2006. Alison Balmfirth, Laura Wills, Ed Doragh and Nivene Raafat for translating Bittner 2009. Aoife Fogarty for translating Kleeb 2005. Francesca Gatenby, Nick Jones, Juliet Sheath for translating Urech 2009; and (3) the many study authors who were very helpful in responding to queries and providing additional data.

As part of the pre-publication editorial process, this review has been commented on by four peers (an editor and three referees who are external to the editorial team), a member of the Pregnancy and Childbirth Group's international panel of consumers and the Group's Statistical Adviser.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
Download statistical data

 
Comparison 1. All psychosocial and psychological interventions versus usual care - various study outcomes

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Depressive symptomatology at final study assessment2014727Risk Ratio (M-H, Random, 95% CI)0.78 [0.66, 0.93]

 2 Mean depression scores at final study assessment1912376Std. Mean Difference (IV, Random, 95% CI)-0.13 [-0.28, 0.01]

 3 Diagnosis of depression at final study assessment5939Risk Ratio (M-H, Random, 95% CI)0.50 [0.32, 0.78]

 4 Depressive symptomatology at 8, 16, 24, and > 24 weeks20Risk Ratio (M-H, Random, 95% CI)Subtotals only

    4.1 Immediate outcomes 0-8 weeks
134907Risk Ratio (M-H, Random, 95% CI)0.73 [0.56, 0.95]

    4.2 Short-term outcome 9-16 weeks
103982Risk Ratio (M-H, Random, 95% CI)0.73 [0.56, 0.97]

    4.3 Intermediate outcome 17-24 weeks
910636Risk Ratio (M-H, Random, 95% CI)0.93 [0.82, 1.05]

    4.4 Long-term outcome > 24 weeks
52936Risk Ratio (M-H, Random, 95% CI)0.66 [0.54, 0.82]

 5 Mean depression scores at 8, 16, 24, and > 24 weeks19Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    5.1 Immediate outcomes: 0-8 weeks
61234Std. Mean Difference (IV, Random, 95% CI)-0.16 [-0.41, 0.09]

    5.2 Short-term outcome 9-16 weeks
93628Std. Mean Difference (IV, Random, 95% CI)-0.26 [-0.72, 0.20]

    5.3 Intermediate outcome 17-24 weeks
109944Std. Mean Difference (IV, Random, 95% CI)0.01 [-0.03, 0.05]

    5.4 Long-term outcome > 24 weeks
72447Std. Mean Difference (IV, Random, 95% CI)-0.17 [-0.58, 0.25]

 6 Diagnosis of depression at 8, 16, 24, and > 24 weeks5Risk Ratio (M-H, Random, 95% CI)Subtotals only

    6.1 Immediate outcomes 0-8 weeks
139Risk Ratio (M-H, Random, 95% CI)0.09 [0.01, 1.47]

    6.2 Short-term outcomes 9-16 weeks postpartum
4902Risk Ratio (M-H, Random, 95% CI)0.49 [0.31, 0.77]

    6.3 Intermediate outcome: 17-24 weeks
137Risk Ratio (M-H, Random, 95% CI)0.64 [0.17, 2.46]

 7 Maternal mortality at > 24 weeks1234Risk Ratio (M-H, Random, 95% CI)0.97 [0.06, 15.27]

 8 Maternal-infant attachment at 8, 16, and 24 weeks1Risk Ratio (M-H, Random, 95% CI)Subtotals only

    8.1 Immediate outcomes 0-8 weeks
1133Risk Ratio (M-H, Random, 95% CI)1.01 [0.64, 1.59]

    8.2 Short-term outcome 9-16 weeks
1126Risk Ratio (M-H, Random, 95% CI)1.29 [0.78, 2.13]

    8.3 Intermediate outcome 17-24 weeks
1127Risk Ratio (M-H, Random, 95% CI)0.89 [0.59, 1.34]

 9 Mean maternal-infant attachment scores at 8, 16, 24, and > 24 weeks2Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    9.1 Immediate outcomes 0-8 weeks
1176Std. Mean Difference (IV, Random, 95% CI)-0.11 [-0.40, 0.19]

    9.2 Short-term outcome 9-16 weeks
1160Std. Mean Difference (IV, Random, 95% CI)-0.20 [-0.51, 0.11]

    9.3 Intermediate outcome 17-24 weeks
1152Std. Mean Difference (IV, Random, 95% CI)-0.22 [-0.54, 0.10]

    9.4 Long-term outcome > 24 weeks
1116Std. Mean Difference (IV, Random, 95% CI)-0.12 [-0.49, 0.24]

    9.5 At final study assessment
2268Std. Mean Difference (IV, Random, 95% CI)-0.18 [-0.42, 0.06]

 10 Anxiety at 8, 16, and 24 weeks4Risk Ratio (M-H, Random, 95% CI)Subtotals only

    10.1 Immediate outcomes 0-8 weeks
2245Risk Ratio (M-H, Random, 95% CI)0.35 [0.05, 2.34]

    10.2 Short-term outcome 9-16 weeks
3843Risk Ratio (M-H, Random, 95% CI)0.41 [0.12, 1.41]

    10.3 Intermediate outcome 17-24 weeks
1130Risk Ratio (M-H, Random, 95% CI)0.94 [0.25, 3.60]

    10.4 At final study assessment
4959Risk Ratio (M-H, Random, 95% CI)0.40 [0.14, 1.14]

 11 Mean anxiety scores at 8, 16, 24, and > 24 weeks4Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    11.1 Immediate outcomes 0-8 weeks
2163Std. Mean Difference (IV, Random, 95% CI)-0.09 [-0.39, 0.22]

    11.2 Short-term outcome 9-16 weeks
2740Std. Mean Difference (IV, Random, 95% CI)-0.15 [-0.30, -0.01]

    11.3 Intermediate outcome 17-24 weeks
2160Std. Mean Difference (IV, Random, 95% CI)-0.24 [-0.55, 0.07]

    11.4 Long-term outcome > 24 weeks
143Std. Mean Difference (IV, Random, 95% CI)-0.17 [-0.77, 0.43]

    11.5 At final study assessment
4815Std. Mean Difference (IV, Random, 95% CI)-0.16 [-0.30, -0.03]

 12 Maternal stress at 16 weeks1Risk Ratio (M-H, Random, 95% CI)Subtotals only

    12.1 Short-term outcome 9-16 weeks
1103Risk Ratio (M-H, Random, 95% CI)0.44 [0.20, 0.96]

 13 Mean maternal stress scores at 24 and > 24 weeks1Mean Difference (IV, Random, 95% CI)Subtotals only

    13.1 Intermediate outcome 17-24 weeks
1787Mean Difference (IV, Random, 95% CI)0.0 [-1.02, 1.02]

    13.2 Long-term outcome > 24 weeks
1840Mean Difference (IV, Random, 95% CI)0.5 [-0.51, 1.51]

 14 Mean parental stress scores at 8, 24, and > 24 weeks3Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    14.1 Immediate outcomes 0-8 weeks
1176Std. Mean Difference (IV, Random, 95% CI)-0.08 [-0.37, 0.22]

    14.2 Intermediate outcome 17-24 weeks
1124Std. Mean Difference (IV, Random, 95% CI)-0.27 [-0.62, 0.09]

    14.3 Long-term outcome > 24 weeks
2341Std. Mean Difference (IV, Random, 95% CI)0.27 [0.05, 0.48]

    14.4 At final study assessment
3465Std. Mean Difference (IV, Random, 95% CI)0.11 [-0.25, 0.48]

 15 Perceived social support at 8 and 16 weeks2Risk Ratio (M-H, Random, 95% CI)Subtotals only

    15.1 Immediate outcomes 0-8 weeks
1528Risk Ratio (M-H, Random, 95% CI)0.68 [0.45, 1.05]

    15.2 Short-term outcome 9-16 weeks
1190Risk Ratio (M-H, Random, 95% CI)1.02 [0.34, 3.05]

    15.3 At final study assessment
2718Risk Ratio (M-H, Random, 95% CI)0.72 [0.48, 1.08]

 16 Mean perceived social support scores at 8, 16, 24, and > 24 weeks7Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    16.1 Immediate outcomes 0-8 weeks
3822Std. Mean Difference (IV, Random, 95% CI)0.02 [-0.13, 0.17]

    16.2 Short-term outcome 9-16 weeks
2863Std. Mean Difference (IV, Random, 95% CI)0.16 [-0.21, 0.53]

    16.3 Intermediate outcome 17-24 weeks
68122Std. Mean Difference (IV, Random, 95% CI)0.03 [-0.06, 0.12]

    16.4 Long-term outcome > 24 weeks
2955Std. Mean Difference (IV, Random, 95% CI)-0.07 [-0.20, 0.06]

    16.5 At final study assessment
78290Std. Mean Difference (IV, Random, 95% CI)0.01 [-0.08, 0.10]

 17 Maternal dissatisfaction with care provided at 8, 16, and 24 weeks4Risk Ratio (M-H, Random, 95% CI)Subtotals only

    17.1 Immediate outcomes 0-8 weeks
2825Risk Ratio (M-H, Random, 95% CI)0.56 [0.29, 1.09]

    17.2 Short-term outcome 9-16 weeks
11278Risk Ratio (M-H, Random, 95% CI)0.88 [0.65, 1.19]

    17.3 Intermediate outcome 17-24 weeks
1911Risk Ratio (M-H, Random, 95% CI)0.75 [0.44, 1.25]

    17.4 At final study assessment
43014Risk Ratio (M-H, Random, 95% CI)0.67 [0.44, 1.00]

 18 Mean maternal dissatisfaction scores at 8 and 16 weeks2Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    18.1 Immediate outcomes 0-8 weeks
1516Std. Mean Difference (IV, Random, 95% CI)0.0 [-0.17, 0.17]

    18.2 Short-term outcome 9-16 weeks
1160Std. Mean Difference (IV, Random, 95% CI)0.90 [0.58, 1.23]

    18.3 At final study assessment
2676Std. Mean Difference (IV, Random, 95% CI)0.44 [-0.44, 1.32]

 19 Infant health parameters - not fully immunized at > 24 weeks1884Risk Ratio (M-H, Random, 95% CI)1.16 [0.39, 3.43]

 20 Infant development > 24 weeks1280Mean Difference (IV, Random, 95% CI)-0.90 [-2.90, 1.10]

    20.1 Bayley (BSID-II)
1280Mean Difference (IV, Random, 95% CI)-0.90 [-2.90, 1.10]

 21 Child abuse at 8 and > 24 weeks1Mean Difference (IV, Random, 95% CI)Subtotals only

    21.1 Immediate outcomes 0-8 weeks
1176Mean Difference (IV, Random, 95% CI)-35.66 [-62.65, -8.67]

    21.2 Long-term outcome > 24 weeks
166Mean Difference (IV, Random, 95% CI)-41.90 [-87.48, 3.68]

 22 Mean marital discord scores at 8, 16, and 24 weeks3Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    22.1 Immediate outcomes 0-8 weeks
2163Std. Mean Difference (IV, Random, 95% CI)-0.03 [-0.34, 0.28]

    22.2 Short-term outcome 9-16 weeks
1127Std. Mean Difference (IV, Random, 95% CI)-0.28 [-0.63, 0.07]

    22.3 Intermediate outcome 17-24 weeks
3291Std. Mean Difference (IV, Random, 95% CI)-0.14 [-0.37, 0.09]

    22.4 At final study assessment
3291Std. Mean Difference (IV, Random, 95% CI)-0.14 [-0.37, 0.09]

 
Comparison 2. All psychosocial interventions versus usual care - variations in intervention type

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 All psychosocial interventions - depressive symptomatology12Risk Ratio (M-H, Random, 95% CI)Subtotals only

    1.1 Immediate outcome - 0-8 weeks
62138Risk Ratio (M-H, Random, 95% CI)0.77 [0.52, 1.14]

    1.2 Short-term outcomes 9-16 weeks
83705Risk Ratio (M-H, Random, 95% CI)0.80 [0.61, 1.06]

    1.3 Intermediate outcomes 17-24 weeks
68116Risk Ratio (M-H, Random, 95% CI)0.88 [0.78, 1.00]

    1.4 Long-term outcomes >24 weeks
31385Risk Ratio (M-H, Random, 95% CI)0.59 [0.46, 0.76]

    1.5 At final study assessment
1211322Risk Ratio (M-H, Random, 95% CI)0.83 [0.70, 0.99]

 2 All psychosocial interventions - mean depression scores12Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 Immediate outcomes 0-8 weeks
3849Std. Mean Difference (IV, Random, 95% CI)-0.12 [-0.47, 0.23]

    2.2 Short-term outcomes 9-16 weeks
63333Std. Mean Difference (IV, Random, 95% CI)-0.32 [-0.90, 0.25]

    2.3 Intermediate outcomes 17-24 weeks
88998Std. Mean Difference (IV, Random, 95% CI)0.00 [-0.04, 0.05]

    2.4 Long-term outcomes > 24 weeks
52254Std. Mean Difference (IV, Random, 95% CI)-0.26 [-0.76, 0.24]

    2.5 At final study assessment
1210944Std. Mean Difference (IV, Random, 95% CI)-0.14 [-0.33, 0.04]

 3 All psychosocial interventions - diagnosis of depression3Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    3.1 Short-term outcomes 9-16 weeks
3867Risk Ratio (M-H, Fixed, 95% CI)0.52 [0.33, 0.83]

 4 All psychosocial interventions: depressive symptomatology at final study assessment1211322Risk Ratio (M-H, Random, 95% CI)0.83 [0.70, 0.99]

 5 All psychosocial interventions: mean depression scores1210944Std. Mean Difference (IV, Random, 95% CI)-0.14 [-0.33, 0.04]

 
Comparison 3. All psychological interventions versus usual care - variations in intervention type

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 All psychological interventions - depressive symptomatology8Risk Ratio (M-H, Random, 95% CI)Subtotals only

    1.1 Immediate outcomes 0-8 weeks
72760Risk Ratio (M-H, Random, 95% CI)0.69 [0.47, 1.02]

    1.2 Short-term outcomes 9-16 weeks
2277Risk Ratio (M-H, Random, 95% CI)0.40 [0.18, 0.89]

    1.3 Intermediate outcomes 17-24 weeks
32520Risk Ratio (M-H, Random, 95% CI)1.04 [0.83, 1.30]

    1.4 Long-term outcomes >24 weeks
21551Risk Ratio (M-H, Random, 95% CI)0.86 [0.58, 1.28]

    1.5 At final study assessment
83405Risk Ratio (M-H, Random, 95% CI)0.61 [0.39, 0.96]

 2 All psychological interventions - mean depression scores7Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 immediate outcome 0-8 weeks
3385Std. Mean Difference (IV, Random, 95% CI)-0.20 [-0.63, 0.22]

    2.2 Short-term outcomes 9-16 weeks
3295Std. Mean Difference (IV, Random, 95% CI)-0.03 [-0.27, 0.21]

    2.3 Intermediate outcomes 17-24 weeks
2946Std. Mean Difference (IV, Random, 95% CI)0.08 [-0.05, 0.20]

    2.4 Long-term outcomes > 24 weeks
2193Std. Mean Difference (IV, Random, 95% CI)0.11 [-0.17, 0.39]

    2.5 At final study assessment
71432Std. Mean Difference (IV, Random, 95% CI)-0.10 [-0.32, 0.13]

 3 All psychological interventions - diagnosis of depression2Risk Ratio (M-H, Random, 95% CI)Subtotals only

    3.1 Diagnosis of depression - 0-8 weeks
139Risk Ratio (M-H, Random, 95% CI)0.09 [0.01, 1.47]

    3.2 Short-term outcomes 9-16 weeks
135Risk Ratio (M-H, Random, 95% CI)0.08 [0.00, 1.34]

    3.3 Intermediate outcomes 17-24 weeks
137Risk Ratio (M-H, Random, 95% CI)0.64 [0.17, 2.46]

    3.4 At final study assessment
272Risk Ratio (M-H, Random, 95% CI)0.31 [0.04, 2.52]

 
Comparison 4. Subgroup analysis: variations in psychosocial interventions

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 TEST FOR SUBGROUP DIFFERENCES: depressive symptomatology at final study assessment1211322Risk Ratio (M-H, Random, 95% CI)0.83 [0.70, 0.99]

    1.1 Antenatal and postnatal classes
41488Risk Ratio (M-H, Random, 95% CI)1.01 [0.77, 1.32]

    1.2 Postpartum professional-based home visits
21262Risk Ratio (M-H, Random, 95% CI)0.56 [0.43, 0.73]

    1.3 Postpartum lay-based home visits
1493Risk Ratio (M-H, Random, 95% CI)0.88 [0.62, 1.25]

    1.4 Postpartum lay-based telephone support
1612Risk Ratio (M-H, Random, 95% CI)0.54 [0.38, 0.77]

    1.5 Early postpartum follow-up
1446Risk Ratio (M-H, Random, 95% CI)0.90 [0.55, 1.49]

    1.6 Continuity model of care
37021Risk Ratio (M-H, Random, 95% CI)0.99 [0.71, 1.36]

 2 TEST FOR SUBGROUP DIFFERENCES: mean depression score at final study assessment41411Std. Mean Difference (IV, Fixed, 95% CI)-0.01 [-0.12, 0.10]

    2.1 Antenatal and postnatal classes
31124Std. Mean Difference (IV, Fixed, 95% CI)0.01 [-0.11, 0.13]

    2.2 Antenatal and postnatal lay-based home visits and telephone support
1287Std. Mean Difference (IV, Fixed, 95% CI)-0.10 [-0.33, 0.14]

 
Comparison 5. Subgroup analysis: variations in psychological interventions

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 TEST FOR SUBGROUP DIFFERENCES: depressive symptomatology at final study assessment63200Risk Ratio (M-H, Random, 95% CI)0.59 [0.35, 1.01]

    1.1 Psychological debriefing
53050Risk Ratio (M-H, Random, 95% CI)0.57 [0.31, 1.03]

    1.2 Cognitive behavioural therapy
1150Risk Ratio (M-H, Random, 95% CI)0.74 [0.29, 1.88]

 2 TEST FOR SUBGROUP DIFFERENCES: mean depression score at final study assessment6516Std. Mean Difference (IV, Random, 95% CI)-0.16 [-0.43, 0.11]

    2.1 Interpersonal psychotherapy
5366Std. Mean Difference (IV, Random, 95% CI)-0.27 [-0.52, -0.01]

    2.2 Cognitive behavioural therapy
1150Std. Mean Difference (IV, Random, 95% CI)0.13 [-0.20, 0.45]

 
Comparison 6. Subgroup analysis: variations in intervention provider

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Professionally-based interventions - depressive symptomatology15Risk Ratio (M-H, Random, 95% CI)Subtotals only

    1.1 Immediate outcomes 0-8 weeks
103699Risk Ratio (M-H, Random, 95% CI)0.65 [0.45, 0.93]

    1.2 Short-term outcome 9-16 weeks
83196Risk Ratio (M-H, Random, 95% CI)0.79 [0.57, 1.09]

    1.3 Intermediate outcome 17-24 weeks
73929Risk Ratio (M-H, Random, 95% CI)1.03 [0.87, 1.23]

    1.4 Long-term outcome > 24 weeks
42786Risk Ratio (M-H, Random, 95% CI)0.68 [0.51, 0.90]

 2 Professionally-based interventions - mean depression scores12Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 Immediate outcomes: 0-8 weeks
4512Std. Mean Difference (IV, Random, 95% CI)-0.34 [-0.56, -0.12]

    2.2 Short-term outcome 9-16 weeks
62807Std. Mean Difference (IV, Random, 95% CI)-0.31 [-0.95, 0.34]

    2.3 Intermediate outcome 17-24 weeks
73161Std. Mean Difference (IV, Random, 95% CI)0.02 [-0.05, 0.09]

    2.4 Long-term outcome >24 weeks
52010Std. Mean Difference (IV, Random, 95% CI)-0.24 [-0.79, 0.31]

 3 Professionally-based interventions - diagnosis of depression2Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    3.1 Immediate outcomes 0-8 weeks
139Risk Ratio (M-H, Fixed, 95% CI)0.09 [0.01, 1.47]

    3.2 Short-term outcomes 9-16 weeks postpartum
1190Risk Ratio (M-H, Fixed, 95% CI)0.51 [0.13, 1.98]

    3.3 Intermediate outcome: 17-24 weeks
137Risk Ratio (M-H, Fixed, 95% CI)0.64 [0.17, 2.46]

 4 Lay-based interventions - depressive symptomatology4Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    4.1 Immediate outcomes 0-8 weeks
31208Risk Ratio (M-H, Fixed, 95% CI)0.91 [0.70, 1.18]

    4.2 Short-term outcome 9-16 weeks
2786Risk Ratio (M-H, Fixed, 95% CI)0.55 [0.40, 0.75]

    4.3 Intermediate outcome 17-24 weeks
1493Risk Ratio (M-H, Fixed, 95% CI)0.88 [0.62, 1.25]

    4.4 Long-term outcome > 24 weeks
1150Risk Ratio (M-H, Fixed, 95% CI)0.74 [0.29, 1.88]

 5 Lay-based interventions - mean depression scores5Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    5.1 Immediate outcomes: 0-8 weeks
2722Std. Mean Difference (IV, Random, 95% CI)0.11 [-0.04, 0.25]

    5.2 Short-term outcome 9-16 weeks
2786Std. Mean Difference (IV, Random, 95% CI)-0.08 [-0.35, 0.19]

    5.3 Intermediate outcome 17-24 weeks
2633Std. Mean Difference (IV, Random, 95% CI)-0.06 [-0.22, 0.09]

    5.4 Long-term outcome > 24 weeks
2437Std. Mean Difference (IV, Random, 95% CI)-0.01 [-0.22, 0.20]

 6 Lay-based interventions - diagnosis of depression2Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    6.1 Short-term outcomes 9-16 weeks postpartum
2677Risk Ratio (M-H, Fixed, 95% CI)0.52 [0.32, 0.86]

 7 TEST FOR SUBGROUP DIFFERENCES: depressive symptomatology: at final study assessment19Risk Ratio (M-H, Random, 95% CI)Subtotals only

    7.1 Professionally-based interventions
156790Risk Ratio (M-H, Random, 95% CI)0.78 [0.60, 1.00]

    7.2 Lay-based interventions
41723Risk Ratio (M-H, Random, 95% CI)0.70 [0.54, 0.90]

 8 TEST FOR SUBGROUP DIFFERENCES: mean depression scores: at final study assessment17Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    8.1 Professionally-based interventions
124509Std. Mean Difference (IV, Random, 95% CI)-0.15 [-0.40, 0.10]

    8.2 Lay-based interventions
51682Std. Mean Difference (IV, Random, 95% CI)-0.10 [-0.20, 0.01]

 9 TEST FOR SUBGROUP DIFFERENCES: diagnosis of depression: at final study assessment4Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    9.1 Professionally-based interventions
2227Risk Ratio (M-H, Fixed, 95% CI)0.56 [0.22, 1.47]

    9.2 Lay-based interventions
2677Risk Ratio (M-H, Fixed, 95% CI)0.52 [0.32, 0.86]

 
Comparison 7. Subgroup analysis: variations in professionally-based intervention provider

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 TEST FOR SUBGROUP DIFFERENCES: depressive symptomatology at final study assessment15Risk Ratio (M-H, Random, 95% CI)Subtotals only

    1.1 Intervention provided by nurses
3837Risk Ratio (M-H, Random, 95% CI)0.73 [0.51, 1.04]

    1.2 Intervention provided by physicians
1446Risk Ratio (M-H, Random, 95% CI)0.90 [0.55, 1.49]

    1.3 Intervention provided by midwives
105477Risk Ratio (M-H, Random, 95% CI)0.76 [0.54, 1.07]

    1.4 Intervention provided by mental health specialists
130Risk Ratio (M-H, Random, 95% CI)1.0 [0.24, 4.18]

 2 TEST FOR SUBGROUP DIFFERENCES: mean depression score at final study assessment4Std. Mean Difference (IV, Fixed, 95% CI)Subtotals only

    2.1 Intervention provided by nurses
186Std. Mean Difference (IV, Fixed, 95% CI)-0.08 [-0.51, 0.34]

    2.2 Intervention provided by midwives
1840Std. Mean Difference (IV, Fixed, 95% CI)0.05 [-0.09, 0.19]

    2.3 Intervention provided by mental health specialists
2175Std. Mean Difference (IV, Fixed, 95% CI)0.04 [-0.26, 0.34]

 
Comparison 8. Subgroup analysis: variations in intervention mode

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Individually-based interventions - depressive symptomatology14Risk Ratio (M-H, Random, 95% CI)Subtotals only

    1.1 Immediate outcomes 0-8 weeks
93947Risk Ratio (M-H, Random, 95% CI)0.70 [0.49, 1.00]

    1.2 Short-term outcomes 9-16 weeks
62757Risk Ratio (M-H, Random, 95% CI)0.66 [0.47, 0.91]

    1.3 Intermediate outcomes 17-24 weeks
79806Risk Ratio (M-H, Random, 95% CI)0.88 [0.80, 0.98]

    1.4 Long-term outcomes > 24 weeks
42786Risk Ratio (M-H, Random, 95% CI)0.68 [0.51, 0.90]

 2 Individually-based interventions - mean depression scores11Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 Immediate outcomes 0-8 weeks
4882Std. Mean Difference (IV, Random, 95% CI)-0.11 [-0.41, 0.19]

    2.2 Short-term outcomes 9-16 weeks
52601Std. Mean Difference (IV, Random, 95% CI)-0.40 [-1.07, 0.26]

    2.3 Intermediate outcomes 17-24 weeks
68156Std. Mean Difference (IV, Random, 95% CI)0.01 [-0.03, 0.05]

    2.4 Long-term outcomes > 24 weeks
51457Std. Mean Difference (IV, Random, 95% CI)-0.28 [-0.78, 0.23]

 3 Individually-based interventions - diagnosis of depression3Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    3.1 Immediate outcomes 0-8 weeks
139Risk Ratio (M-H, Fixed, 95% CI)0.09 [0.01, 1.47]

    3.2 Short-term outcomes 9-16 weeks
2677Risk Ratio (M-H, Fixed, 95% CI)0.52 [0.32, 0.86]

    3.3 Intermediate outcomes 17-24 weeks
137Risk Ratio (M-H, Fixed, 95% CI)0.64 [0.17, 2.46]

 4 Group-based interventions - depressive symptomatology6Risk Ratio (M-H, Random, 95% CI)Subtotals only

    4.1 Immediate outcomes 0-8 weeks
4946Risk Ratio (M-H, Random, 95% CI)0.64 [0.45, 0.91]

    4.2 Short-term outcomes 9-16 weeks
41225Risk Ratio (M-H, Random, 95% CI)0.91 [0.60, 1.39]

    4.3 Intermediate outcomes 17-24 weeks
2830Risk Ratio (M-H, Random, 95% CI)1.20 [0.85, 1.71]

    4.4 Long-term outcomes > 24 weeks
1150Risk Ratio (M-H, Random, 95% CI)0.74 [0.29, 1.88]

 5 Group-based interventions - mean depression scores8Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    5.1 Immediate outcomes 0-8 weeks
2352Std. Mean Difference (IV, Random, 95% CI)-0.24 [-0.80, 0.31]

    5.2 Short-term outcomes 9-16 weeks
41027Std. Mean Difference (IV, Random, 95% CI)0.04 [-0.09, 0.16]

    5.3 Intermediate outcomes 17-24 weeks
41788Std. Mean Difference (IV, Random, 95% CI)0.01 [-0.08, 0.11]

    5.4 Long-term outcomes > 24 weeks
2990Std. Mean Difference (IV, Random, 95% CI)0.06 [-0.07, 0.19]

 6 Group-based interventions - diagnosis of depression2Risk Ratio (M-H, Random, 95% CI)Subtotals only

    6.1 Short-term outcomes 9-16 weeks
2225Risk Ratio (M-H, Random, 95% CI)0.30 [0.05, 1.66]

 7 TEST FOR SUBGROUP DIFFERENCES: depressive symptomatology: at final study assessment2014727Risk Ratio (M-H, Random, 95% CI)0.78 [0.66, 0.93]

    7.1 Individually-based interventions
1412914Risk Ratio (M-H, Random, 95% CI)0.75 [0.61, 0.92]

    7.2 Group-based interventions
61813Risk Ratio (M-H, Random, 95% CI)0.92 [0.71, 1.19]

 8 TEST FOR SUBGROUP DIFFERENCES: mean depression scores: at final study assessment1912376Std. Mean Difference (IV, Random, 95% CI)-0.13 [-0.28, 0.01]

    8.1 Individually-based interventions
1110092Std. Mean Difference (IV, Random, 95% CI)-0.15 [-0.37, 0.07]

    8.2 Group-based interventions
82284Std. Mean Difference (IV, Random, 95% CI)-0.08 [-0.23, 0.06]

 9 TEST FOR SUBGROUP DIFFERENCES: diagnosis of depression: at final study assessment5939Risk Ratio (M-H, Random, 95% CI)0.50 [0.32, 0.78]

    9.1 Individually-based interventions
3714Risk Ratio (M-H, Random, 95% CI)0.53 [0.33, 0.84]

    9.2 Group-based interventions
2225Risk Ratio (M-H, Random, 95% CI)0.30 [0.05, 1.66]

 
Comparison 9. Subgroup analysis: variations in intervention duration

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Single-contact interventions - depressive symptomatology4Risk Ratio (M-H, Random, 95% CI)Subtotals only

    1.1 Immediate outcomes 0-8 weeks
21756Risk Ratio (M-H, Random, 95% CI)0.39 [0.07, 2.16]

    1.2 Short-term outcomes 9-16 weeks
1476Risk Ratio (M-H, Random, 95% CI)1.24 [0.81, 1.91]

    1.3 Intermediate outcomes 17-24 weeks
32936Risk Ratio (M-H, Random, 95% CI)1.01 [0.82, 1.26]

    1.4 Long-term outcomes > 24 weeks
11401Risk Ratio (M-H, Random, 95% CI)0.89 [0.58, 1.37]

 2 Single-contact interventions - mean depression scores2Mean Difference (IV, Fixed, 95% CI)Subtotals only

    2.1 Short-term outcomes 9-16 weeks
1476Mean Difference (IV, Fixed, 95% CI)-0.10 [-1.06, 0.86]

    2.2 Intermediate outcomes 17-24 weeks
21362Mean Difference (IV, Fixed, 95% CI)0.21 [-0.37, 0.79]

 3 Multiple-contact interventions - depressive symptomatology16Risk Ratio (M-H, Random, 95% CI)Subtotals only

    3.1 Immediate outcomes 0-8 weeks
113137Risk Ratio (M-H, Random, 95% CI)0.77 [0.60, 0.99]

    3.2 Short-term outcomes 9-16 weeks
93506Risk Ratio (M-H, Random, 95% CI)0.69 [0.52, 0.91]

    3.3 Intermediate outcomes 17-24 weeks
67700Risk Ratio (M-H, Random, 95% CI)0.89 [0.77, 1.01]

    3.4 Long-term outcomes > 24 weeks
41535Risk Ratio (M-H, Random, 95% CI)0.60 [0.47, 0.76]

 4 Multiple-contact interventions - mean depression scores17Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    4.1 Immediate outcomes 0-8 weeks
61234Std. Mean Difference (IV, Random, 95% CI)-0.16 [-0.41, 0.09]

    4.2 Short-term outcomes 9-16 weeks
83152Std. Mean Difference (IV, Random, 95% CI)-0.30 [-0.81, 0.22]

    4.3 Intermediate outcomes 17-24 weeks
88582Std. Mean Difference (IV, Random, 95% CI)0.01 [-0.04, 0.05]

    4.4 Long-term outcomes > 24 weeks
72447Std. Mean Difference (IV, Random, 95% CI)-0.17 [-0.58, 0.25]

 5 Multiple-contact interventions - diagnosis of depression5Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    5.1 Immediate outcomes 0-8 weeks
139Risk Ratio (M-H, Fixed, 95% CI)0.09 [0.01, 1.47]

    5.2 Short-term outcomes 9-16 weeks
4902Risk Ratio (M-H, Fixed, 95% CI)0.47 [0.30, 0.74]

    5.3 Intermediate outcomes 17-24 weeks
137Risk Ratio (M-H, Fixed, 95% CI)0.64 [0.17, 2.46]

    5.4 At final study assessment
5939Risk Ratio (M-H, Fixed, 95% CI)0.48 [0.31, 0.74]

 6 TEST FOR SUBGROUP DIFFERENCES: depressive symptomatology: at final study assessment2014727Risk Ratio (M-H, Random, 95% CI)0.78 [0.66, 0.93]

    6.1 Single contact intervention
42877Risk Ratio (M-H, Random, 95% CI)0.70 [0.38, 1.28]

    6.2 Multiple contact intervention
1611850Risk Ratio (M-H, Random, 95% CI)0.78 [0.66, 0.93]

 7 TEST FOR SUBGROUP DIFFERENCES: mean depression scores: at final study assessment1912376Std. Mean Difference (IV, Random, 95% CI)-0.13 [-0.28, 0.01]

    7.1 Single contact intervention
21362Std. Mean Difference (IV, Random, 95% CI)0.04 [-0.07, 0.15]

    7.2 Multiple contact intervention
1711014Std. Mean Difference (IV, Random, 95% CI)-0.15 [-0.32, 0.02]

 
Comparison 10. Subgroup analysis: variations in intervention onset

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Interventions with antenatal only component - mean depression scores4Std. Mean Difference (IV, Fixed, 95% CI)Subtotals only

    1.1 Short-term outcomes 9-16 weeks
135Std. Mean Difference (IV, Fixed, 95% CI)-0.44 [-1.11, 0.23]

    1.2 Intermediate outcomes 17-24 weeks
2919Std. Mean Difference (IV, Fixed, 95% CI)0.06 [-0.07, 0.19]

    1.3 Long-term outcomes > 24 weeks
2883Std. Mean Difference (IV, Fixed, 95% CI)0.05 [-0.09, 0.19]

 2 Interventions with antenatal only component - diagnosis of depression1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    2.1 Short-term outcomes 9-16 weeks
135Risk Ratio (M-H, Fixed, 95% CI)0.08 [0.00, 1.34]

 3 Interventions with antenatal and postnatal components - depressive symptomatology8Risk Ratio (M-H, Random, 95% CI)Subtotals only

    3.1 Immediate outcomes 0-8 weeks
71794Risk Ratio (M-H, Random, 95% CI)0.75 [0.52, 1.08]

    3.2 Short-term outcomes 9-16 weeks
4621Risk Ratio (M-H, Random, 95% CI)0.66 [0.45, 0.97]

    3.3 Intermediate outcomes 17-24 weeks
3284Risk Ratio (M-H, Random, 95% CI)0.87 [0.41, 1.85]

    3.4 Long-term outcomes > 24 weeks
2273Risk Ratio (M-H, Random, 95% CI)0.82 [0.46, 1.46]

 4 Interventions with antenatal and postnatal components - mean depression scores7Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    4.1 Immediate outcomes 0-8 weeks
4518Std. Mean Difference (IV, Random, 95% CI)-0.18 [-0.47, 0.11]

    4.2 Short-term outcomes 9-16 weeks
3388Std. Mean Difference (IV, Random, 95% CI)-0.05 [-0.25, 0.15]

    4.3 Intermediate outcomes 17-24 weeks
3315Std. Mean Difference (IV, Random, 95% CI)-0.22 [-0.45, -0.00]

    4.4 Long-term outcomes > 24 weeks
3560Std. Mean Difference (IV, Random, 95% CI)-0.03 [-0.20, 0.13]

 5 Interventions with antenatal and postnatal components - diagnosis of depression3Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    5.1 Immediate outcomes 0-8 weeks
139Risk Ratio (M-H, Fixed, 95% CI)0.09 [0.01, 1.47]

    5.2 Short-term outcomes 9-16 weeks
2255Risk Ratio (M-H, Fixed, 95% CI)0.40 [0.21, 0.79]

    5.3 Intermediate outcomes 17-24 weeks
137Risk Ratio (M-H, Fixed, 95% CI)0.64 [0.17, 2.46]

 6 Interventions with postnatal only component - depressive symptomatology12Risk Ratio (M-H, Random, 95% CI)Subtotals only

    6.1 Immediate outcomes 0-8 weeks
63099Risk Ratio (M-H, Random, 95% CI)0.63 [0.41, 0.98]

    6.2 Short-term outcomes 9-16 weeks
63361Risk Ratio (M-H, Random, 95% CI)0.76 [0.53, 1.11]

    6.3 Intermediate outcomes 17-24 weeks
610352Risk Ratio (M-H, Random, 95% CI)0.93 [0.82, 1.06]

    6.4 Long-term outcomes >24 weeks
32663Risk Ratio (M-H, Random, 95% CI)0.66 [0.46, 0.93]

 7 Interventions with postnatal only component - mean depression scores8Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    7.1 Immediate outcomes 0-8 weeks
2716Std. Mean Difference (IV, Random, 95% CI)-0.14 [-0.69, 0.42]

    7.2 Short-term outcomes 9-16 weeks
53205Std. Mean Difference (IV, Random, 95% CI)-0.35 [1.00, 0.31]

    7.3 Intermediate outcomes 17-24 weeks
58710Std. Mean Difference (IV, Random, 95% CI)0.01 [-0.03, 0.06]

    7.4 Long-term outcomes > 24 weeks
21004Std. Mean Difference (IV, Random, 95% CI)-0.59 [-1.39, 0.21]

 8 Interventions with postnatal only component - diagnosis of depression1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    8.1 Short-term outcomes 9-16 weeks
1612Risk Ratio (M-H, Fixed, 95% CI)0.65 [0.34, 1.23]

 9 TEST FOR SUBGROUP DIFFERENCES: depressive symptomatology: at final study assessment2014727Risk Ratio (M-H, Random, 95% CI)0.78 [0.66, 0.93]

    9.1 Antenatal and postnatal intervention
81941Risk Ratio (M-H, Random, 95% CI)0.96 [0.75, 1.22]

    9.2 Postnatal intervention only
1212786Risk Ratio (M-H, Random, 95% CI)0.73 [0.59, 0.90]

 10 TEST FOR SUBGROUP DIFFERENCES: mean depression scores: at final study assessment1912376Std. Mean Difference (IV, Random, 95% CI)-0.13 [-0.28, 0.01]

    10.1 Antenatal intervention only
41050Std. Mean Difference (IV, Random, 95% CI)0.03 [-0.09, 0.16]

    10.2 Antenatal and postnatal intervention
71000Std. Mean Difference (IV, Random, 95% CI)-0.14 [-0.31, 0.02]

    10.3 Postnatal intervention only
810326Std. Mean Difference (IV, Random, 95% CI)-0.16 [-0.40, 0.08]

 11 TEST FOR SUBGROUP DIFFERENCES: diagnosis of depression: at final study assessment5939Risk Ratio (M-H, Fixed, 95% CI)0.48 [0.31, 0.74]

    11.1 Antenatal intervention only
135Risk Ratio (M-H, Fixed, 95% CI)0.08 [0.00, 1.34]

    11.2 Antenatal and postnatal intervention
3292Risk Ratio (M-H, Fixed, 95% CI)0.44 [0.24, 0.80]

    11.3 Postnatal intervention only
1612Risk Ratio (M-H, Fixed, 95% CI)0.65 [0.34, 1.23]

 
Comparison 11. Subgroup analysis: variations in sample selection criteria

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Interventions for at-risk women - depressive symptomatology9Risk Ratio (M-H, Random, 95% CI)Subtotals only

    1.1 Immediate outcomes 0-8 weeks
71301Risk Ratio (M-H, Random, 95% CI)0.67 [0.51, 0.88]

    1.2 Short-term outcomes 9-16 weeks
61368Risk Ratio (M-H, Random, 95% CI)0.59 [0.47, 0.75]

    1.3 Intermediate outcomes 17-24 weeks
2151Risk Ratio (M-H, Random, 95% CI)1.34 [0.60, 2.98]

    1.4 Long-term outcomes > 24 weeks
2281Risk Ratio (M-H, Random, 95% CI)0.60 [0.29, 1.24]

 2 Interventions for at-risk women - mean depression scores7Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 Immediate outcomes 0-8 weeks
3387Std. Mean Difference (IV, Random, 95% CI)-0.17 [-0.52, 0.18]

    2.2 Short-term outcomes 9-16 weeks
51067Std. Mean Difference (IV, Random, 95% CI)-0.14 [-0.26, -0.02]

    2.3 Intermediate outcomes 17-24 weeks
130Std. Mean Difference (IV, Random, 95% CI)-0.02 [-0.74, 0.70]

    2.4 Long-term outcomes >24 weeks
3324Std. Mean Difference (IV, Random, 95% CI)-0.00 [-0.22, 0.22]

 3 Interventions for at-risk women - diagnosis of depression5Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    3.1 Immediate outcomes 0-8 weeks
139Risk Ratio (M-H, Fixed, 95% CI)0.09 [0.01, 1.47]

    3.2 Short-term outcomes 9-16 weeks
4902Risk Ratio (M-H, Fixed, 95% CI)0.47 [0.30, 0.74]

    3.3 Intermediate outcomes 17-24 weeks
137Risk Ratio (M-H, Fixed, 95% CI)0.64 [0.17, 2.46]

    3.4 At final study assessment
5939Risk Ratio (M-H, Fixed, 95% CI)0.48 [0.31, 0.74]

 4 Interventions for general population - depressive symptomatology12Risk Ratio (M-H, Random, 95% CI)Subtotals only

    4.1 Immediate outcomes 0-8 weeks
73767Risk Ratio (M-H, Random, 95% CI)0.69 [0.46, 1.03]

    4.2 Short-term outcomes 9-16 weeks
42614Risk Ratio (M-H, Random, 95% CI)0.91 [0.58, 1.42]

    4.3 Intermediate outcomes 17-24 weeks
710485Risk Ratio (M-H, Random, 95% CI)0.92 [0.81, 1.06]

    4.4 Long-term outcomes > 24 weeks
32655Risk Ratio (M-H, Random, 95% CI)0.71 [0.51, 0.99]

 5 Interventions for general population - mean depression scores12Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    5.1 Immediate outcomes 0-8 weeks
3847Std. Mean Difference (IV, Random, 95% CI)-0.15 [-0.56, 0.25]

    5.2 Short-term outcomes 9-16 weeks
42561Std. Mean Difference (IV, Random, 95% CI)-0.40 [-1.24, 0.44]

    5.3 Intermediate outcomes 17-24 weeks
99914Std. Mean Difference (IV, Random, 95% CI)0.01 [-0.03, 0.05]

    5.4 Long-term outcomes > 24 weeks
42123Std. Mean Difference (IV, Random, 95% CI)-0.28 [-0.87, 0.30]

 6 TEST FOR SUBGROUP DIFFERENCES: depressive symptomatology: at final study assessment2014727Risk Ratio (M-H, Random, 95% CI)0.78 [0.66, 0.93]

    6.1 Interventions for at-risk women
81853Risk Ratio (M-H, Random, 95% CI)0.66 [0.50, 0.88]

    6.2 General population
1212874Risk Ratio (M-H, Random, 95% CI)0.83 [0.68, 1.02]

 7 TEST FOR SUBGROUP DIFFERENCES: mean depression scores: at final study assessment1912376Std. Mean Difference (IV, Random, 95% CI)-0.13 [-0.28, 0.01]

    7.1 Interventions for at risk women
71087Std. Mean Difference (IV, Random, 95% CI)-0.13 [-0.25, -0.01]

    7.2 General population
1211289Std. Mean Difference (IV, Random, 95% CI)-0.15 [-0.33, 0.04]

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
 

Appendix 1. Methods used to assess trials included in previous versions of this review

 

Selection of trials

Titles and abstracts of the electronic searches were reviewed by the primary reviewer. We independently evaluated trials under consideration for methodological quality and appropriateness for inclusion, without consideration of their results. We resolved uncertainties regarding the appropriateness for inclusion through discussion and consensus.

 

Methodological quality assessment

We assessed the quality of the trials that met the eligibility criteria using the following criteria:

  1. generation of random allocation sequence: adequate, inadequate, unclear;
  2. allocation concealment: A = adequate, B = unclear, C = inadequate;
  3. blinding of participants: yes, no, inadequate, no information;
  4. blinding of caregivers: yes, no, inadequate, no information;
  5. blinding of outcome assessment: yes, no, inadequate or no information;
  6. completeness of follow-up data (including any differential loss of participants from each group): A = less than 3% of participants excluded, B = 3% to 9.9% of participants excluded, C = 10% to 19.9% excluded, D = 20% or more excluded, E = unclear;
  7. analysis of participants in randomised groups.

We assigned a rating to each trial, compared results and discussed differences until we reached agreement. We have clearly described reasons for exclusion of any apparently eligible trial (see 'Characteristics of excluded studies' table).

 

Data extraction

We independently extracted data from trial reports using a pilot-tested data extraction form developed by the primary reviewer. Wherever necessary, we requested unpublished or missing data from the trial contact author. In addition, we sought data to allow an 'intention-to-treat' analysis. Data were entered into RevMan 2000 by one reviewer and double data entry was completed by the other reviewer or a research assistant.

 

Data synthesis

Trials using different preventive strategies were analysed separately and the results combined only if there was no reason to think that they differed in relevant ways. While the primary meta-analysis was based on the occurrence of postpartum depression or not (however measured by trialists), we incorporated several depression rating scales or cut-off points. To address the potential measurement differences, we used a fixed-effect model to make direct comparisons between trials using the same rating scale and cut-off. If trials used different ways of measuring the same continuous outcome, we used standardised mean differences. We performed meta-analyses using relative risks as the measure of effect size for binary outcomes, and weighted mean differences for continuous outcome measures, both with 95% confidence intervals. We assessed the extent to which there were between-study differences including variations in the population or intervention.

We used fixed-effect meta-analysis to combine study data. We investigated heterogeneity by calculating I2 statistics (Higgins 2002), and if this indicated a high level of heterogeneity among the trials included in an analysis (I2 > 50%), we used random-effects meta-analysis for an overall summary. Where we found high levels of heterogeneity, we explored these by sensitivity analyses excluding the trials most susceptible to bias based on the following quality assessment: (1) those with unclear allocation concealment (B); (2) high levels of postrandomisation losses or exclusions (D); or (3) unblinded outcome assessment or blinding of outcome assessment uncertain.

 

Subgroup analyses

We planned and completed the following six a priori subgroup analyses:

  1. the effectiveness of specific types of psychosocial interventions;
  2. the effectiveness of specific types of psychological interventions;
  3. the effects of intervention mode (e.g. individual versus group-based interventions);
  4. the effects of intervention onset (e.g. antenatal and postnatal interventions versus postnatal only interventions);
  5. the effects of intervention duration (e.g. single-contact interventions versus multiple-contact interventions);
  6. the effects of sample selection criteria (e.g. women with specific risk factors versus the general population).

 

What's new

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

Last assessed as up-to-date: 30 May 2012.


DateEventDescription

31 May 2012New search has been performedSearch updated: 30 November 2011. Since the last published version of the review we have included 11 new trials and excluded a further 45 trials; 13 reports are awaiting further assessment and there are two studies ongoing. The review now includes 30 trials (with data from 28) and excludes 79. We have obtained additional information from trial authors. Other revisions included numerous changes to bring the entire Review up-to-date in terms of current methodological guidelines. We altered the set up of the outcomes to clearly distinguish the time frames for the outcome measurements.

Changes to references in last review:
Dennis 2004a, an ongoing trial in the last review is now Dennis 2009;
Gamble 2003 (abstract) in last review is now Gamble 2005 (full publication); Gorman 2002 in last review is now Gorman 1997 and the title was changed to reflect the actual title listed in Dissertations and Theses; Henderson 1998 listed as excluded trial in last review is part of Priest 2003; Stamp 1996 listed as excluded trial in last review is part of Stamp 1995.

An updated search was run on 31 December 2012 and 22 new reports have been added to Studies awaiting classification for consideration at the next update.

10 April 2012New citation required and conclusions have changedThe conclusions of the review have changed: Overall, women who received a psychosocial or psychological intervention were significantly less likely to develop postpartum depression compared with those receiving standard care.



 

History

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

Protocol first published: Issue 1, 2001
Review first published: Issue 4, 2004


DateEventDescription

8 May 2008AmendedConverted to new review format.



 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

Dr Dennis independently evaluated the trials for quality, extracted and entered data, completed the meta-analysis, and wrote the text of the review and the conclusion. T Dowswell contributed to data extraction in this update, and commented on data analysis and drafts of the text.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

Dr Dennis is a principal investigator for a multi-site trial included in this review that evaluated the effect of telephone-based peer (mother-to-mother) support in the prevention of postpartum depression among mothers identified as high-risk (Dennis 2009).

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
 

Internal sources

  • University of Toronto, Canada.

 

External sources

  • NIHR, UK.
    TD is supported by the NIHR NHS Cochrane Collaboration Programme grant scheme award for NHS-prioritised centrally-managed, pregnancy and childbirth systematic reviews: CPGS 10/4001/02

 

Differences between protocol and review

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

The title of the previously published protocol was 'Psychosocial interventions for preventing postpartum depression'.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé摘要
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. References to ongoing studies
  23. Additional references
  24. References to other published versions of this review
Armstrong 1999 {published data only (unpublished sought but not used)}
Austin 2008 {published data only (unpublished sought but not used)}
  • Austin MP, Frilingos M, Lumley J, Hadzi-Pavlovic D, Roncolato W, Acland S, et al. Brief antenatal cognitive behaviour therapy group intervention for the prevention of postnatal depression and anxiety: a randomised controlled trial. Journal of Affective Disorders 2008;105(1-3):35-44.
Brugha 2000 {published data only}
  • Brugha T, Wheatley S, Taub N, Culverwell A, Friedman T, Kirwan P, et al. Pragmatic randomized trial of antenatal intervention to prevent post-natal depression by reducing psychosocial risk factors. Psychological Medicine 2000;30(6):1273-81.
  • Wheatley SL, Brugha TS, Shapiro DA. Exploring and enhancing engagement to the psychosocial intervention 'preparing for parenthood'. Archives of Women's Mental Health 2003;6(4):275-85.
Cupples 2011 {published data only}
  • Cupples ME, Stewart MC, Percy A, Hepper P, Murphy C, Halliday HL. A RCT of peer-mentoring for first-time mothers in socially disadvantaged areas (the MOMENTS Study). Archives of Disease in Childhood 2011;96(3):252-8.
Dennis 2009 {published data only}
  • Dennis CL, Hodnett E, Kenton L, Weston J, Zupancic J, Stewart DE, et al. Effect of peer support on prevention of postnatal depression among high risk women: multisite randomised controlled trial. BMJ 2009;338:a3064.
  • Dukhovny D, Dennis CL, Hodnett E, Kenton L, Weston J, Stewart DE, et al. Prospective economic evaluation of a peer support intervention for prevention of postpartum depression among high risk women in Ontario, Canada. American Academy of Pediatrics Annual Meeting; 2010 October 2-5; San Francisco, California, USA. 2010.
  • Dukhovny D, Dennis CL, Hodnett E, Kenton L, Weston J, Stewart DE, et al. Prospective economic evaluation of a peer support intervention for prevention of postpartum depression amongst high risk women. Pediatric Academic Societies' 2010 Annual Meeting; 2010 May 1-4; Vancouver, Canada. 2010.
Feinberg 2008 {published and unpublished data}
  • Feinberg ME, Kan ML. Establishing family foundations: intervention effects on coparenting, parent/infant well-being, and parent-child relations. Journal of Family Psychology 2008;22(2):253-63.
Gamble 2005 {published and unpublished data}
  • Creedy D. Reducing postpartum emotional distress: a randomised controlled trial. 10th International Conference of Maternity Care Researchers; 2004 June 13-16; Lund, Sweden. 2004:24.
  • Gamble J, Creedy D. Reducing postpartum emotional distress: a randomised controlled trial. [abstract]. Perinatal Society of Australia and New Zealand. 7th Annual Congress; 2003 March 9-12; Tasmania, Australia. 2003:A29.
  • Gamble J, Creedy D, Moyle W, Webster J, McAllister M, Dickson P. Effectiveness of a counseling intervention after a traumatic childbirth: a randomized controlled trial. Birth 2005;32(1):11-9.
Gao 2010 {published and unpublished data}
  • Gao L, Chan S, Li X, Chen S, Hao Y. Evaluation of an interpersonal-psychotherapy-oriented childbirth education programme for Chinese first-time childbearing women: a randomised controlled trial. International Journal of Nursing Studies 2010;47:1208-16.
Gjerdingen 2002 {published data only}
  • Gjerdingen DK, Center B. A randomized controlled trial testing the impact of a support/work-planning intervention on first-time parents' health, partner relationship, and work responsibilities. Behavioral Medicine 2002;28(3):84-91.
Gorman 1997 {published and unpublished data}
  • Gorman L. Prevention of Postpartum Difficulties in a High Risk Sample [dissertation]. University of Iowa, 1997.
Gunn 1998 {published and unpublished data}
Harris 2006 {unpublished data only}
  • Harris T, Brown GW, Hamilton V, Hodson S, Craig TKJ. The Newpin antenatal and postnatal project: a randomised controlled trial of an intervention for perinatal depression. Personal communication 2011 March 21.
Heinicke 1999 {published data only (unpublished sought but not used)}
Ickovics 2011 {published data only}
  • Ickovics JR, Kershaw T, Westdahl C, Magriples U, Massey Z, Reynolds H, et al. Group prenatal care and perinatal outcomes: a randomized controlled trial. Obstetrics & Gynecology 2007;110(2):330-9.
  • Ickovics JR, Reed E, Magriples U, Westdahl C, Schindler Rising S, Kershaw TS. Effects of group prenatal care on psychosocial risk in pregnancy: results from a randomised controlled trial. Psychology & Health 2011;26(2):235-50.
Lavender 1998 {published data only (unpublished sought but not used)}
Le 2011 {published and unpublished data}
  • Le HN, Perry DF, Stuart EA. Randomized controlled trial of a preventive intervention for perinatal depression in high-risk Latinas. Journal of Consulting and Clinical Psychology 2011;79(2):135-41.
Lumley 2006 {published data only}
  • Lumley J, Small R, Brown S, Watson L, Gunn J, Mitchell C, et al. Prism (program of resources, information and support for mothers) protocol for a community-randomised trial [isrctn03464021]. BMC Public Health 2003;3:36.
  • Lumley J, Watson L, Small R, Brown S, Mitchell C, Gunn J. Prism (program of resources, information and support for mothers): a community-randomised trial to reduce depression and improve women's physical health six months after birth. BMC Public Health 2006;6:37.
MacArthur 2002 {published and unpublished data}
  • MacArthur C, Winter H, Bick D, Knowles H, Liford R, Henderson C, et al. Effects of redesigned community postnatal care on women's health 4 months after birth: a cluster randomised controlled trial. Lancet 2002;359(9304):378-85.
  • MacArthur C, Winter HR, Bick DE, Lilford RJ, Lancashire RJ, Knowles H, et al. Redesigning postnatal care: a randomised controlled trial of protocol-based midwifery-led care focused on individual women's physical and psychological health needs. Health Technology Assessment (Winchester, England) 2003;7(37):1-98.
Morrell 2000 {published data only}
  • Morrell C, Spiby H, Stewart P, Walters S, Morgan A. Costs and effectiveness of community postnatal support workers: randomised controlled trial. BMJ 2000;321(7261):593-8.
  • Morrell CJ, Spiby H, Stewart P, Walters S, Morgan A. Costs and benefits of community postnatal support workers: a randomised controlled trial. Health Technology Assessment (South Hampton, NY) 2000;4(6):1-100.
Priest 2003 {published and unpublished data}
  • Henderson J, Sharp J, Priest S, Hagan R, Evans S. Postnatal debriefing: what do women feel about it?. 4th Annual Congress of the Perinatal Society of Australia & New Zealand; 1998 March 30-April 4; Alice Springs, Australia. 1998:38.
  • Priest S, Henderson J, Evans S, Hagan R. Stress debriefing after childbirth: a randomized controlled trial. Medical Journal of Australia 2003;178:542-5.
Reid 2002 {published data only}
  • Reid M, Glazener C, Connery L, Mackenzie J, Ismail D, Prigg A, et al. Two interventions for postnatal support. British Journal of Midwifery 2003;11(5):294-8.
  • Reid M, Glazener C, Murray G, Taylor G. A two-centred pragmatic randomized controlled trial of two interventions for postnatal support. BJOG: an international journal of obstetrics and gynaecology 2002;109(10):1164-70.
Sen 2006 {published and unpublished data}
  • Sen DM. A Randomized Controlled Trial of Midwife-Led Twin Antenatal Program - The Newcastle Twin Study [thesis]. Newcastle-upon-Tyne: University of Newcastle, 2006.
  • Sen DM, Robson SC, Bond S. Peripartum depression and anxiety in mothers expecting uncomplicated twin infants - an antenatal model of care in the North East of England. Journal of Reproductive and Infant Psychology 2004;22(3):239.
Small 2000 {published data only}
Stamp 1995 {published data only}
Tam 2003 {published data only (unpublished sought but not used)}
Tripathy 2010 {published data only (unpublished sought but not used)}
  • Tripathy P, Nair N, Barnett S, Mahapatra R, Borghi J, Rath S, et al. Effect of a participatory intervention with women's groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster-randomised controlled trial. Lancet 2010;375(9721):1182-92.
Waldenstrom 2000 {published and unpublished data}
Weidner 2010 {published data only (unpublished sought but not used)}
  • Weidner K, Bittner A, Junge-Hoffmeister J, Zimmermann K, Siedentopf F, Richter J, et al. A psychosomatic intervention in pregnant in-patient women with prenatal somatic risks. Journal of Psychosomatic Obstetrics & Gynecology 2010;31(3):188-98.
Zlotnick 2001 {published data only (unpublished sought but not used)}
  • Zlotnick C, Johnson S, Miller I, Pearlstein T, Howard M. Postpartum depression in women receiving public assistance: pilot study of an interpersonal-therapy-oriented group intervention. American Journal of Psychiatry 2001;158(4):638-40.
Zlotnick 2006 {published data only (unpublished sought but not used)}
  • Zlotnick C, Miller IW, Pearlstein T, Howard M, Sweeney P. A preventive intervention for pregnant women on public assistance at risk for postpartum depression. American Journal of Psychiatry 2006;163(8):1443-5.

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé摘要
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. References to ongoing studies
  23. Additional references
  24. References to other published versions of this review
Ajh 2006 {published data only}
  • Ajh N, Unesian, Fili A, Abasi Motejaded. The study of supportive activities during pregnancy on postpartum depression. HAYAT 2006;12(3):73-80.
Appleby 1998 {published data only}
  • Appleby L. A controlled study of fluoxetine and cognitive -behavioural counselling in the treatment of postnatal depression. 9th Congress of the Association of European Psychiatrists; 1998 Sept 20-24; Copenhagen, Denmark. 1998:178s.
Armstrong 2004 {published data only}
  • Armstrong K, Edwards H. The effectiveness of a pram-walking exercise programme in reducing depressive symptomatology for postnatal women. International Journal of Nursing Practice 2004;10:177-94.
Bang 2009 {published data only}
  • Bang KS. Effects of an early nursing intervention program for infants' development and mother's child rearing in poverty. Journal of Korean Academy of Nursing 2009;39(6):796-804.
Barnes 2009 {published and unpublished data}
Bastani 2005 {published data only}
  • Bastani F, Hidarnia A, Kazemnejad A, Vafaei M, Kashanian M. A randomized controlled trial of the effects of applied relaxation training on reducing anxiety and perceived stress in pregnant women. Journal of Midwifery & Women's Health 2005;50(4):e36-40.
Buist 1999 {published data only}
  • Buist A, Westley D, Hill C. Antenatal prevention of postnatal depression. Archives of Women's Mental Health 1999;1:167-73.
Bulgay-Morschel 2010 {published data only}
  • Bulgay-Morschel M, Langlotz F, Ekkehard S. Influence of progressive muscle relaxation training on anxiety and depression levels during pregnancy and puerperium [conference abstract]. Archives of Gynecology and Obstetrics 2010;282:S83.
Chabrol 2002 {published data only}
  • Chabrol H, Teissedre F, Saint-Jean M, Teisseyre N, Roge B, Mullet E. Prevention and treatment of post-partum depression: a controlled randomized study on women at risk. Psychological Medicine 2002;32(6):1039-47.
  • Chabrol H, Teissedre F, Saint-Jean M, Teisseyre N, Sistac C, Michaud C, et al. Detection, prevention and treatment of postpartum depression: a controlled study of 859 patients. Encephale 2002;28(1):65-70.
Chabrol 2007 {published data only}
Cho 2008 {published data only}
Cooper 2002 {published data only}
  • Cooper PJ, Landman M, Tomlinson M, Molteno C, Swartz L, Murray L. Impact of a mother-infant intervention in an indigent peri-urban South African context: pilot study. British Journal of Psychiatry 2002;180:76-81.
D'Andrea 1994 {published data only}
  • D'Andrea M. The family development project: a comprehensive mental health counseling program for pregnant adolescents. Journal of Mental Health Counseling 1994;16:184-95.
Dennis 2003 {published data only}
  • Dennis CL. The effect of peer support on postpartum depression: a pilot randomized controlled trial. Canadian Journal of Psychiatry - Revue Canadienne de Psychiatrie 2003;48(2):115-24.
Duggan 2009 {published data only}
  • Duggan AK, Berlin LJ, Cassidy J, Burrell L, Tandon SD. Examining maternal depression and attachment insecurity as moderators of the impacts of home visiting for at-risk mothers and infants. Journal of Consulting and Clinical Psychology 2009;77(4):788-99.
Elliott 2000 {published data only}
  • Elliott S, Leverton T, Sanjack M, Turner H, Cowmeadow P, Hopkins J, et al. Promoting mental health after childbirth: a controlled trial of primary prevention of postnatal depression. British Journal of Clinical Psychology 2000;39:223-41.
  • Elliott SA, Sanjack M, Leverton TJ. Parents groups in pregnancy. A preventive intervention for postnatal depression?. In: Gottlieb BM editor(s). Marshalling Social Support: Formats, Processes and Effects. Beverley Hills: Sage, 1988:87-97.
El-Mohandes 2006 {published data only}
  • El-Mohandes AAE. A psycho-behavioral intervention on African American pregnant women with a history of intimate partner violence (IPV) improves birth weight distribution of their newborns [abstract]. Pediatric Academic Societies Annual Meeting; 2006 April 29-May 2; San Francisco, CA, USA. 2006.
El-Mohandes 2008 {published data only}
  • El-Mohandes AA, Kiely M, Blake SM, Gantz MG, El-Khorazaty MN. An intervention to reduce environmental tobacco smoke exposure improves pregnancy outcomes. Pediatrics 2010;125(4):721-8.
  • El-Mohandes AA, Kiely M, Joseph JG, Subramanian S, Johnson AA, Blake SM, et al. An intervention to improve postpartum outcomes in African-American mothers: a randomized controlled trial. Obstetrics & Gynecology 2008;112(3):611-20.
  • Joseph JG, El-Mohandes AA, Kiely M, El-Khorazaty MN, Gantz MG, Johnson AA, et al. Reducing psychosocial and behavioral pregnancy risk factors: results of a randomized clinical trial among high-risk pregnant African American women. American Journal of Public Health 2009;99(6):1053-61.
  • Kiely M, El-Khorazaty MN, El-Mohandes AAE. Depression and smoking during pregnancy impact the efficacy of an integral behavioral intervention to resolve risks. Pediatric Academic Societies Annual Meeting; 2007 May 5-8; Toronto, Canada. 2007.
Fagan 2010 {published data only}
  • Fagan J, Lee Y. Perceptions and satisfaction with father involvement and adolescent mothers' postpartum depressive symptoms. Journal of Youth and Adolescence 2010;39(9):1109-21.
Gordon 1960 {published data only}
Gordon 1999 {published data only}
  • Gordon N, Walton D, McAdam E, Derman J, Gallitero G, Garrett L. Effects of providing hospital-based doulas in health maintenance organization hospitals. Obstetrics & Gynecology 1999;93(3):422-6.
Goyal 2009 {published data only}
  • Goyal D, Gay C, Lee K. Fragmented maternal sleep is more strongly correlated with depressive symptoms than infant temperament at three months postpartum. Archives of Women's Mental Health 2009;12(4):229-37.
Grote 2009 {published data only}
  • Grote NK, Swartz HA, Geibel SL, Zuckoff A, Houck PR, Frank E. A randomized controlled trial of culturally relevant, brief interpersonal psychotherapy for perinatal depression. Psychiatric Services 2009;60(3):313-21.
Hayes 2001 {published data only}
  • Hayes B, Muller R, Bradley B. Perinatal depression: a randomized controlled trial of an antenatal education intervention for primiparas. Birth 2001;28(1):28-35.
  • Hayes BA, Muller R. Prenatal depression: a randomized controlled trial in the emotional health of primiparous women. Research & Theory for Nursing Practice 2004;18(2/3):165-83.
Heh 2003 {published data only}
Hiscock 2001 {published data only}
  • Hiscock H, Wake M. Randomised controlled trial of behavioural infant sleep intervention to improve infant sleep and maternal mood. BMJ 2002;324(7345):1062-5.
  • Hiscock H, Wake M. The impact of an infant sleep intervention on postnatal depression: A randomized controlled trial. Journal of Paediatrics & Child Health 2001;37(6):A1.
Ho 2009 {published data only}
  • Ho S-M, Heh S-S, Jevitt CM, Huang L-H, Fu Y-Y, Wang L-L. Effectiveness of a discharge education program in reducing the severity of postpartum depression. A randomized controlled evaluation study. Patient Education and Counseling 2009;77(1):68-71.
Hodnett 2002 {published data only}
  • Hodnett E, Lowe N, Hannah M, Willan AR, Stevens B, Weston JA, et al. Effectiveness of nurses as providers of birth labor support in North American hospitals. JAMA 2002;288(11):1373-81.
Imura 2006 {published data only}
Izzo 2005 {published data only}
  • Izzo CV, Eckenrode JJ, Smith EG, Henderson CR, Cole R, Kitzman H, et al. Reducing the impact of uncontrollable stressful life events through a program of nurse home visitation for new parents. Prevention Science 2005;6(4):269-74.
Katz 2009 {published data only}
  • Katz KS, Gantz M, Rodan M, Blake S, El-Khorazaty N, Kiely M, et al. Depression reduction and adherence to treatment in pregnant African American women. Pediatric Academic Societies Annual Meeting; 2009 May 2-5; Baltimore, Maryland, USA. 2009.
Katz 2009a {published data only}
  • Katz KS, Rodan M, Blake S, El-Khorazaty N, Gantz M, Kiely M, et al. Depression treatment for low income African American women in prenatal care: who fails to benefit?. Pediatric Academic Societies Annual Meeting; 2009 May 2-5; Baltimore, Maryland, USA. 2009.
Kealy 2003 {published data only}
  • Kealy M, Small R, Lumley J. Health and recovery after caesarean - is it as straightforward as we might want to believe?. Perinatal Society of Australia and New Zealand. 7th Annual Congress; 2003 March 9-12; Tasmania, Australia. 2003:A28.
Keller 2011 {published data only}
  • Keller C, Records K, Ainsworth B, Belyea M, Permana P, Coonrod D, et al. Madres para la Salud: design of a theory-based intervention for postpartum Latinas. Contemporary Clinical Trials 2011;32(3):418-27.
Kershaw 2005 {published data only}
King 2009 {published data only}
  • King E. The effectiveness of an internet-based stress management program in the prevention of postpartum stress, anxiety and depression for new mothers [thesis]. Kentucky: Walden University, 2009.
Kleeb 2005 {published data only}
  • Kleeb B, Rageth CJ. Influence of prophylactic information on the frequency of baby blues [Einfluss eines prophylaktischen Aufklarungsgesprachs auf den Baby Blues.]. Zeitschrift fur Geburtshilfe und Neonatologie 2005;209(1):22-8.
Koltyn 1997 {published data only}
  • Koltyn KF, Schultes SS. Psychological effects of an aerobic exercise session and a rest session following pregnancy. Journal of Sports Medicine & Physical Fitness 1997;37(4):287-91.
Lara 2010 {published data only}
  • Lara MA, Navarro C, Navarrete L. Outcome results of a psycho-educational intervention in pregnancy to prevent PPD: a randomized control trial. Journal of Affective Disorders 2010;122(1-2):109-17.
  • Lara MA, Navarro C, Navarrete L, Le HN. Retention rates and potential predictors in a longitudinal randomized control trial to prevent postpartum depression. Salud Mental 2010;33:429-36.
Leung 2011 {published data only}
  • Leung SSK, Lee AM, Chiang VCL, Wong DFK, Lam SK. Efficacy of a brief cognitive-behavioural intervention on pregnant women to prevent postnatal depression. Journal of Obstetrics and Gynaecology 2011;31(Suppl 1):19.
Lewis 2011 {published data only}
  • Lewis B, Avery M, Gjerdingen D, Sirard J. Innovative methods for recruiting pregnant and postpartum women for behavioral intervention trials. Annals of Behavioral Medicine 2011;41 Suppl 1:S114.
Lieu 2000 {published data only}
  • Lieu T, Braveman P, Escobar G, Fischer A, Jensvold N, Capra A. A randomized comparison of home and clinic follow-up visits after early postpartum hospital discharge. Pediatrics 2000;105(5):1058-65.
Logsdon 2005 {published data only}
Marks 2003 {published data only}
  • Marks MN, Siddle K, Warwick C. Can we prevent postnatal depression? A randomized controlled trial to assess the effect of continuity of midwifery care on rates of postnatal depression in high-risk women. Journal of Maternal-Fetal & Neonatal Medicine 2003;13:119-27.
McKee 2006 {published data only}
  • McKee MD, Zayas LH, Fletcher J, Boyd RC, Nam SH. Results of an intervention to reduce perinatal depression among low-income minority women in community primary care. Journal of Social Service Research 2006;32(4):63-81.
  • Zayas LH, McKee MD, Jankowski KR. Adapting psychosocial intervention research to urban primary care environments: a case example. Annals of Family Medicine 2004;2(5):504-8.
Milgrom 2010 {published data only}
  • Milgrom J. Toward parenthood: delivering an antenatal self-help intervention with telephone support for depression, anxiety and parenting difficulties - facilitating the perinatal health journey. Australian New Zealand Clinical Trials Registry (www.anzctr.org.au) (accessed 19 February 2008).
  • Milgrom J, Ericksen J, Leigh B, Romeo Y, Loughlin E, McCarthy R, et al. Development and Feasibility Study of a Monitored Self-Help Antenatal Intervention Program to Enhance Emotional Health and Reduce Parenting Stress. Parent Infant Research Institute, Victoria, Australia (http://www.piri.org.au/Research_Findings_and_Publications.php) (accessed 26 Jan 2011).
Milgrom 2011 {published data only}
  • Milgrom J, Schembri C, Ericksen J, Ross J, Gemmill AW. Towards parenthood: an antenatal intervention to reduce depression, anxiety and parenting difficulties. Journal of Affective Disorders 2011;130(3):385-94.
Mohammadi 2010 {published data only}
  • Mohammadi F. Effect of exercise on postnatal depression and fatigue in clients of health centers: a randomized controlled clinical trial. IRCT Iranian Registry of Clinical Trials (www.irct.ir) (accessed 6 December 2010) 2010.
Morrell 2009 {published data only}
  • Brugha TS, Morrell CJ, Slade P, Walters SJ. Universal prevention of depression in women postnatally: cluster randomized trial evidence in primary care. Psychological Medicine 2011;41(4):739-48.
  • Morrell CJ, Slade P, Warner R, Paley G, Dixon S, Walters SJ, et al. Clinical effectiveness of health visitor training in psychologically informed approaches for depression in postnatal women: pragmatic cluster randomised trial in primary care. BMJ 2009;338:a3045.
  • Morrell CJ, Warner R, Mathers N, Parry G, Dixon S, Slade P, et al. PoNDER: postnatal depression economic evaluation and randomised trial. Journal of Reproductive and Infant Psychology 2004;22(3):236.
  • Morrell CJ, Warner R, Mathers N, Parry G, Dixon S, Slade P, et al. The PoNDER trial - depression in session. Society for Social Medicine 48th Annual Scientific Meeting; 2004 September 15-17; Birmingham, UK. 2004.
  • Morrell CJ, Warner R, Mathers N, Parry G, Dixon S, Slade P, et al. The PoNDER Trial - the early evidence. Society for Academies in Primary Care (SAPC) Annual Scientific Meeting; 2004 July 14-16; Glasgow, Scotland. 2004.
  • Morrell CJ, Warner R, Slade P, Dixon S, Walters S, Paley G, et al. Psychological interventions for postnatal depression: cluster randomised trial and economic evaluation. The PoNDER trial. Health Technology Assessment 2009;13(30):iii-iv, xi-xiii, 1-153.
  • Slade P, Morrell CJ, Rigby A, Ricci K, Spittlehouse J, Brugha TS. Postnatal women's experiences of management of depressive symptoms: a qualitative study. British Journal of General Practice 2010;60(580):e440-8.
  • Slade P, Morrell J, Walters SJ, Dixon S, Brugha T, Paley G, et al. The PoNDER trial: a cost-effectiveness trial of psychological intervention by health visitors for postnatal depression. Journal of Psychosomatic Obstetrics and Gynecology 2007;28(S1):64.
Munoz 2007 {published and unpublished data}
  • Munoz RF, Le HN, Ippen CG, Diaz MA, Urizar Jr GG, Soto J, et al. Prevention of postpartum depression in low-income women: development of the mamas y bebes/mothers and babies course. Cognitive and Behavioral Practice 2007;14:70-83.
Murphy 1989 {published data only}
  • Murphy FL. Effects of Post-Discharge Nursing Visits on Emotional and Parental Adjustment of Postpartum Women [thesis]. Denton, Texas: Texas Woman's University, 1989.
Ngai 2009 {published data only}
  • Ngai FW, Chan SW, Ip WY. The effects of a childbirth psychoeducation program on learned resourcefulness, maternal role competence and perinatal depression: a quasi-experiment. International Journal of Nursing Studies 2009;46(10):1298-306.
Norman 2010 {published data only}
  • Norman E, Sherburn M, Osborne RH, Galea MP. An exercise and education program improves well-being of new mothers: a randomized controlled trial. Physical Therapy 2010;90(3):348-55.
Oakley 1991 {published data only}
  • Oakley AR. Trial to reduce depression among mothers of young children - an intervention study. Personal communication 1991.
Okano 1998 {published data only}
  • Okano T, Nagata S, Hasegawa M, Nomura J, Kumar R. Effectiveness of antenatal education about postnatal depression: a comparison of two groups of Japanese mothers. Journal of Mental Health 1998;7(2):191-8.
Parry 2010 {published data only}
  • Parry B, Meliska C, Sorenson D, Lopez A, Orff H, Martinez F. Early versus late wake therapy effects on mood and sleep in pregnancy and postpartum depression. Journal of Sleep Research 2010;19:272.
Rees 1995 {published data only}
  • Rees BL. Effect of relaxation with guided imagery on anxiety, depression, and self-esteem in primiparas. Journal of Holistic Nursing 1995;13(3):255-67.
Roman 2009 {published data only}
  • Roman LA, Gardiner JC, Lindsay JK, Moore JS, Luo Z, Baer LJ, et al. Alleviating perinatal depressive symptoms and stress: a nurse-community health worker randomized trial. Archives of Women's Mental Health 2009;12(6):379-91.
Ryding 2004 {published data only}
Saisto 2001 {published data only}
Selkirk 2006 {published data only}
  • Selkirk R, McLaren S, Ollerenshaw A, McLachlan AJ. The longitudinal effects of midwife-led postnatal debriefing on the psychological health of mothers. Journal of Reproductive and Infant Psychology 2006;24(2):133-47.
Serwint 1991 {published data only}
  • Serwint J, Wilson M, Duggan A, Mellits E, Baumgardner R, DeAngelis C. Do postpartum nursery visits by the primary care provider make a difference?. Pediatrics 88;3:444-9.
Shields 1997 {published data only}
  • Shields N, Reid M, Cheyne H, Holmes A. Impact of midwife-managed care in the postnatal period: an exploration of psychosocial outcomes. Journal of Reproductive & Infant Psychology 1997;15(2):91-108.
Spinelli 1997 {published data only}
Spinelli 2003 {published data only}
  • Spinelli MG, Endicott J. Controlled clinical trial of interpersonal psychotherapy versus parenting education program for depressed pregnant women. American Journal of Psychiatry 2003;160(3):555-62.
Sun 2004 {published data only}
  • Sun Y, Li H. Influence of psychological intervention on role adaption of mother in primipara. Chinese Nursing Research 2004;18(11B):2023-4.
Taghizadeh 2008 {published data only}
  • Taghizadeh Z, Jafarbegloo M, Arbabi M, Faghihzadeh S. The effect of counseling on post traumatic stress disorder after a traumatic childbirth. Hayat: Faculty of Nursing & Midwifery Quarterly 2008;13(4):23-31.
Tandon 2011 {published data only}
  • Tandon SD, Perry DF, Mendelson T, Kemp K, Leis JA. Preventing perinatal depression in low-income home visiting clients: A randomized controlled trial. Journal of Consulting and Clinical Psychology 2011;79(5):707-12.
Tang 2009 {published data only}
  • Tang YF, Shi SX, Lu W, Chen Y, Wang QQ, Zhu YY, et al. Prenatal psychological prevention trial on postpartum anxiety and depression. Chinese Mental Health Journal 2009; Vol. 23, issue 2:83-9.
Teissedre 2004 {published data only}
  • Teissedre F, Chabrol H. Screening, prevention and postpartum treatment: a randomized comparative study on 450 women [Depistage, prevention et traitement des depressions du post-partum: une etude comparative randomisee chez 450 femmes]. Neuropsychiatrie de l'enfance et de l'adolescence 2004;52:266-73.
Tezel 2006 {published data only}
  • Tezel A, Gozum S. Comparison of effects of nursing care to problem solving training on levels of depressive symptoms in post partum women. Patient Education and Counseling 2006;63(1-2):64-73.
Tseng 2010 {published data only}
Urech 2009 {published data only}
  • Urech C, Alder J, Bitzer J, Hosli I. The effect of relaxation exercises on psychological wellbeing during pregnancy [Entspannungs-Ubungen wahrend der Schwangerschaft: Der Einfluss auf das psychobiologische Wohlbefinden]. Geburtshilfe und Frauenheilkunde 2009;69:163.
Vieten 2008 {published data only}
Webster 2003 {published data only}
Wiggins 2005 {published data only}
  • Wiggins M, Oakley A, Roberts I, Turner H, Rajan L, Austerberry H, et al. Postnatal support for mothers living in disadvantaged inner city areas: a randomised controlled trial. Journal of Epidemiology & Community Health 2005;59:288-95.
Wolman 1993 {published data only}
  • Nikodem C, Nolte A, Wolman W, Gulmezoglu A, Hofmeyr G. Companionship by a lay labour supporter to modify the clinical birth environment: long-term effects on mother and child. Curationis 1998;21(1):8-12.
  • Wolman W, Chalmers B, Hofmeyr J, Nikodem C. Postpartum depression and companionship in the clinical birth environment: a randomized controlled study. American Journal of Obstetrics and Gynecology 1993;168:1388-93.
Xu 2003 {published data only}
  • Xu FS, Liu JX, Zhang SP, Li J, Su Q. Effects of intervening measures on postpartum depression. Chung-Hua Fu Chan Ko Tsa Chih [Chinese Journal of Obstetrics & Gynecology] 2003;38(12):724-6.
Zayas 2002 {published data only}
  • Zayas LH, Cunningham M, McKee MD, Jankowski KR. Depression and negative life events among pregnant african-american and hispanic women. Womens Health Issues 2002;12(1):16-22.

References to studies awaiting assessment

  1. Top of page
  2. AbstractRésumé摘要
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. References to ongoing studies
  23. Additional references
  24. References to other published versions of this review
Ammaniti 2006 {published data only (unpublished sought but not used)}
Bernard 2011 {published data only}
Bittner 2009 {published data only}
  • Bittner A, Richter J, Muller C, Junge-Hoffmeister J, Weidner K. Effects of a group programme on the early intervention of symptoms of stress, anxiety and depression during pregnancy [Effekte eines Gruppenprogramms zur Fruhintervention bei Stress, Angst und depressiven Beschwerden in der Schwangerschaft]. Geburtshilfe und Frauenheilkunde 2009;69:162.
  • Richter J, Bittner A, Eisenhardt U, Lehmann C, Weidner K. Early intervention in the case of stress, anxiety and depressive conditions during pregnancy - proof of effectiveness by means of diurnal cortisol measurements [Fruhintervention bei Stress, Angst und depressiven Beschwarden in der Schwangerschaft: Wirksamkeitnachweis mittels Cortisolmessungen im Tagesverlauf]. Geburtshilfe und Frauenheilkunde 2009;69:163.
Caritis 2012 {published data only}
  • Caritis S. Effect of psycho-education in obese pregnant women on pregnancy outcomes, randomized controlled trial. Reproductive Sciences 2012;19(3 Suppl):114A.
Cook 2012 {published data only}
  • Cook F, Bayer J, Le HND, Mensah F, Cann W, Hiscock H. Baby Business: A randomised controlled trial of a universal parenting program that aims to prevent early infant sleep and cry problems and associated parental depression. BMC Pediatrics 2012;12:13.
Creedy 2011 {published data only}
  • Creedy D, Gamble J, Jarrett V. The effect of midwife-led counselling on mental health outcomes for women experiencing a traumatic childbirth: An RCT [conference abstract]. Australian and New Zealand Journal of Psychiatry [abstracts from the Royal Australian and New Zealand College of Psychiatrists, RANZCP Annual Congress, May 29-Jun 2, 2011; Darwin, NT Australia] 2011;45(Suppl 1):A39.
Crockett 2008 {published data only}
  • Crockett K, Zlotnick C, Davis M, Payne N, Washington R. A depression preventive intervention for rural low-income African-American pregnant women at risk for postpartum depression. Archives of Women's Mental Health 2008;11(5-6):319-25.
Feinstein 2000 {published data only}
  • Feinstein N. Maternal Coping with Preterm Labor: An Intervention [thesis]. New York: University of Rochester, 2000.
Fenwick 2011 {published data only}
  • Fenwick J, Gamble J, Creedy D, Barclay L. Women's experiences of the PRIME midwifery counselling intervention: Promoting Resilience in Mothers Emotions. Women and Birth 2011;24 Suppl 1:S11-2.
Fu 2012 {published data only}
  • Fu D, Yang J, Zhu R, Pan Q, Shen X, Peng Y, et al. Preoperative psychoprophylactic visiting alleviates maternal anxiety and stress and improves outcomes of cesarean patients: A randomized, double-blind and controlled trial. HealthMED 2012;6(1):263-77.
Gao 2012 {published data only}
  • Gao LL, Chan SW, Sun K. Effects of an interpersonal-psychotherapy-oriented childbirth education programme for Chinese first-time childbearing women at 3-month follow up: randomised controlled trial. International Journal of Nursing Studies 2012;49(3):274-81.
Hoseininasab 2009 {published data only}
  • Hoseininasab D, Ahmadian heris S, Taghavi S. The effect of antenatal education on postpartum depression. International Journal of Gynecology & Obstetrics 2009;107(Suppl 2):S607-8.
Howell 2011 {published data only}
  • Howell EA, Balbierz A, Jason W, Howard L. Mothers avoiding depression through empowerment intervention trial (made it). Journal of General Internal Medicine 2011;26:S222-3.
Howell 2012 {published data only}
  • Howell EA, Balbierz A, Wang J, Parides M, Zlotnick C, Leventhal H. Reducing postpartum depressive symptoms among black and latina mothers: a randomized controlled trial. Obstetrics and Gynecology 2012;119(5):942-9.
Kenyon 2012 {published data only}
  • Kenyon S, Jolly K, Hemming K, Ingram L, Gale N, Dann SA, et al. Evaluation of Lay Support in Pregnant women with Social risk (ELSIPS): A randomised controlled trial. BMC Pregnancy and Childbirth 2012;12:11.
Kitamura 2007 {published data only}
  • Kitamura T. Midwives' psychological group and individual support sessions as prevention of postnatal depression: a randomised trial in Japan. Journal of Psychosomatic Obstetrics and Gynecology 2007;28(S1):14.
Kozinszky 2012 {published data only}
  • Kozinszky Z, Dudas RB, Devosa I, Csatordai S, Toth E, Szabo D, et al. Can a brief antepartum preventive group intervention help reduce postpartum depressive symptomatology?. Psychotherapy and Psychosomatics 2012;81(2):98-107.
Matthey 2004 {published data only}
  • Matthey S, Kavanagh DJ, Howie P, Barnett B, Charles M. Prevention of postnatal distress or depression: an evaluation of an intervention at preparation for parenthood classes. Journal of Affective Disorders 2004;79(1-3):113-26.
Meijer 2011 {published data only}
  • Meijer JL, Bockting CL, Beijers C, Verbeek T, Stant AD, Ormel J, et al. PRegnancy Outcomes after a Maternity Intervention for Stressful EmotionS (PROMISES): study protocol for a randomised controlled trial. Trials 2011;12:157.
Morrell 2011 {published data only}
  • Morrell CJ, Ricketts T, Tudor K, Williams C, Curran J, Barkham M. Training health visitors in cognitive behavioural and person-centred approaches for depression in postnatal women as part of a cluster randomised trial and economic evaluation in primary care: the PoNDER trial. Primary Health Care Research & Development 2011;12(1):11-20.
Morrell 2011a {published data only}
  • Morrell J, Slade P, Walters S. The health of postnatal women's partners up to 18 months postnatally: A longitudinal survey alongside a randomised controlled trial. Journal of Reproductive and Infant Psychology 2011;29(3):e12-3.
Petrou 2006 {published data only}
  • Petrou S, Cooper P, Murray L, Davidson LL. Cost-effectiveness of a preventive counseling and support package for postnatal depression. International Journal of Technology Assessment in Health Care 2006;22(4):443-53.
Phipps 2008 {published data only}
  • Phipps M. Interpersonal therapy-based treatment to prevent postpartum depression in adolescent mothers. ClinicalTrials.gov (http://clinicaltrials.gov/) (accessed 20 February 2008).
Phipps 2011 {published data only}
  • Phipps MG, Zlotnick C, Raker CA, Jocelyn CF. Prenatal intervention to prevent postpartum depression in adolescent mothers. Reproductive Sciences 2011;18(3 Suppl 1):282A.
Richter 2012 {published data only}
  • Richter J, Bittner A, Petrowski K, Junge-Hoffmeister J, Bergmann S, Joraschky P, et al. Effects of an early intervention on perceived stress and diurnal cortisol in pregnant women with elevated stress, anxiety, and depressive symptomatology. Journal of Psychosomatic Obstetrics and Gynaecology 2012;33(4):162-70.
Silverstein 2011 {published data only}
  • Silverstein M, Feinberg E, Cabral H, Sauder S, Egbert L, Schainker E, et al. Problem-solving education to prevent depression among low-income mothers of preterm infants: a randomized controlled pilot trial. Archives of Women's Mental Health 2011;14(4):317-24.
Surkan 2012 {published data only}
  • Surkan PJ, Gottlieb BR, McCormick MC, Hunt A, Peterson KE. Impact of a health promotion intervention on maternal depressive symptoms at 15 months postpartum. Maternal & Child Health Journal 2012;16(1):139-48.
Timpano 2011 {published data only}
  • Timpano KR, Abramowitz JS, Mahaffey BL, Mitchell MA, Schmidt NB. Efficacy of a prevention program for postpartum obsessive-compulsive symptoms. Journal of Psychiatric Research 2011;45(11):1511-7.
Urizar 2011 {published data only}
  • Urizar GGJ, Munoz RF. Impact of a prenatal cognitive-behavioral stress management intervention on salivary cortisol levels in low-income mothers and their infants. Psychoneuroendocrinology 2011;36(10):1480-94.
Varipatis-Baker 2006 {published data only}
  • Varipatis-Baker E. Depression prevention program for American Indian adolescents during and after pregnancy (ongoing trial). ClinicalTrials.gov (http://clinicaltrials.gov/) (accessed 21 March 2006).
Vidas 2011 {published data only}
  • Vidas M, Folnegovic-Smalc V, Catipovic M, Kisic M. The application of autogenic training in counseling center for mother and child in order to promote breastfeeding. Collegium Antropologicum 2011;35(3):723-31.
Willis 2012 {published data only}
  • Willis K, Small R, Brown S. Using documents to investigate links between implementation and sustainability in a complex community intervention: the PRISM study. Social Science & Medicine 2012;75(7):1222-9.
Wimmer-Puchinger 2007 {published data only}
  • Wimmer-Puchinger B. Postpartal depression: are prevention strategies successful?. Journal of Psychosomatic Obstetrics and Gynecology 2007;28(S1):63.
Wimmer-Puchinger 2011 {published data only}
  • Wimmer-Puchinger B. Postpartum depression and attachment disorders. Journal of Obstetrics and Gynaecology 2011;31(Suppl 1):14.
Zlotnick 2008 {published data only}
  • Zlotnick C. Interpersonal therapy program for preventing postpartum depression. ClinicalTrials.gov (http://clinicaltrials.gov/) (accessed 9 April 2008).

References to ongoing studies

  1. Top of page
  2. AbstractRésumé摘要
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. References to ongoing studies
  23. Additional references
  24. References to other published versions of this review
Griffiths 2009 {unpublished data only}
  • Griffiths K, Christensen H, Ellwood D, Jones B. Online cognitive behaviours therapy for the prevention of postnatal depression in at-risk mothers: a randomised controlled trial. Australian New Zealand Clinical Trials Registry 2009.
Mann 2001 {published data only}
  • Mann A. A randomised control trial of a psychological intervention given in pregnancy to reduce the risk of postnatal depression in a sample of high risk women in India. National Research Register (www.update-software.com/NRR) 2001 (accessed April 2004).

Additional references

  1. Top of page
  2. AbstractRésumé摘要
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. References to ongoing studies
  23. Additional references
  24. References to other published versions of this review
Abidin 1995
  • Abidin RR. Parenting stress index professional manual. 3rd Edition. Florida: Psychological Assessment Resources Inc, 1995.
Appleby 1997
  • Appleby L, Warner R, Whitton A, Faragher B. A controlled study of fluoxetine and cognitive-behavioural counselling in the treatment of postnatal depression. BMJ 1997;314:932-6.
Austin 2003
Beck 2001
Brown 2011
  • Brown JD, Harris SK, Woods ER, Buman MP, Cox JE. Longitudinal study of depressive symptoms and social support in adolescent mothers. Maternal and Child Health Journal 2011 May 10 [Epub ahead of print].
Chen 1999
  • Chen CH, Wu HY, Tseng YF, Chou FH, Wang SY. Psychosocial aspects of Taiwanese postpartum depression phenomenological approach: a preliminary report. Kao-Hsiung i Hsueh Ko Hsueh Tsa Chih [Kaohsiung Journal of Medical Sciences] 1999;15:44-51.
Cohen 2000
  • Cohen S. Underwood LG. Gottlieb B (editors). Social Support Measurement and Intervention: A Guide for Health and Social Scientists. New York: Oxford University Press, 2000.
Collins 2011
  • Collins CH, Zimmerman C, Howard LM. Refugee, asylum seeker, immigrant women and postnatal depression: rates and risk factors. Archives of Womens Mental Health 2011;14(1):3-11.
Cooper 1997
  • Cooper P, Murray L. The impact of psychological treatments of postpartum depression on maternal mood and infant development. In: Cooper P, Murray L editor(s). Postpartum Depression and Child Development. New York: Guilford, 1997:201-20.
Cooper 2003
  • Cooper PJ, Murray L, Wilson A, Romaniuk H. Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression. I. Impact on maternal mood. British Journal of Psychiatry 2003;182:412-9.
Dennis 2003a
Dennis 2003b
Dennis 2004a
  • Dennis CL, Hodnett E, Affonso D, Stewart DE, Zupancic J, Weston J. An RCT to evaluate the effect of peer (mother-to-mother) support for the prevention of postpartum depression among mothers at high-risk. Personal communication 2004.
Dennis 2007
  • Dennis CL, Hodnett E. Psychosocial and psychological interventions for treating postpartum depression. Cochrane Database of Systematic Reviews 2007, Issue 4. [DOI: 10.1002/14651858.CD006116.pub2]
Dennis 2012
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References to other published versions of this review

  1. Top of page
  2. AbstractRésumé摘要
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. References to ongoing studies
  23. Additional references
  24. References to other published versions of this review
Dennis 2001
  • Dennis CL, Kavanagh J. Psychosocial interventions for preventing postpartum depression. Cochrane Database of Systematic Reviews 2001, Issue 4. [DOI: 10.1002/14651858.CD001134]
Dennis 2004
  • Dennis CL, Creedy DK. Psychosocial and psychological interventions for preventing postpartum depression. Cochrane Database of Systematic Reviews 2004, Issue 4. [DOI: 10.1002/14651858.CD001134.pub2]