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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

SEARCH

 
Characteristics of included studies [ordered by study ID]
Armstrong 1999

MethodsRCT.


Participants181 mothers (90 in the intervention group; 91 in the control group) who gave birth in 1 urban hospital in Queensland, Australia. Families were included where the child, for environmental (home/family) reasons, was at increased risk for poor health and developmental outcomes. Exclusion criteria included poor English literacy skills.


InterventionsIntervention group: home visits by child heath nurses with support from a multidisciplinary team. The visits were weekly until 6 weeks postpartum, every 2 weeks until 12 weeks and then monthly until 52 weeks. The minimum target of 18 visits was exceeded in most cases.

Control group: usual community care (which included the choice of 1 home visit from the child health nurse) and a list of community resources. Extra child care nurse visits were only done for problems, most often with the baby. Research visits were for data collection only.


OutcomesOutcomes included depression (EPDS > 12), parental stress (Parenting Stress Index - PSI), breastfeeding duration, infant immunisation, utilisation of medical services, accidental injury and Child Abuse Potential Inventory at 6,16 and 52 weeks postpartum.


NotesOnly 63% of mothers completed the pre-trial screening questionnaire. The intervention group included significantly more primiparous and aboriginal mothers and fewer women (1) with a past history of depression, (2) with a partner who had a history of psychiatric illness, and (3) who reported physical forms of domestic violence.

During the course of the trial women with an EPDS score > 12 were offered a referral to a healthcare professional of their choice.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"computer generated random numbers table."

Allocation concealment (selection bias)Low risk"completed by clerical staff not involved in the eligibility assessment."

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskData collection was done in the participant's home by a researcher who was blinded to study group and not providing care to the woman. Research assistants were blind to research group when carrying out the 6-week data collection but during that visit the participant often revealed her group assignment. A different research assistant was used for the 52-week visit.

Incomplete outcome data (attrition bias)
All outcomes
Low riskFollow-up rates at 6, 16 and 52 weeks postpartum were 96.1%, 88.4% and 76.2% respectively.

Selective reporting (reporting bias)Low riskAll outcomes were reported on.

Other biasLow riskNo other sources of bias noted.

Austin 2008

MethodsRCT.


Participants277 pregnant women (191 in the intervention group; 86 in the control group) who attended antenatal clinics in an Australian hospital were identified, by screening at the end of their first trimester, to be at an increased risk of postpartum depression. Those with substance or alcohol abuse, organic brain disorder, bipolar disorder, schizophrenia, childhood abuse, suicidal ideation or poor command of English were excluded.


InterventionsIntervention group: information booklet and cognitive behavioural therapy group sessions. There were 6 weekly 2-hour sessions (and a later follow-up session) that were skills based and led by a clinical psychologist. The timing of the follow-up session was not specified by the authors.

Control group: information booklet about postnatal anxiety and depression.


OutcomesOutcomes included depression (EPDS and MINI) and anxiety (STAI) at 8 and 16 weeks postpartum.


NotesAll reported data analyses used imputation. Missing data were imputed using last observation carry forward. The authors were contacted for the raw data but they were not available.

No data from this trial were included in the review.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk"Randomization using a randomization table". No further details available from authors. Randomisation on a 2:1 basis to allow for more drop outs from the intervention group.

Allocation concealment (selection bias)Unclear riskNo information available from authors about process of randomisation.

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskAdministration of MINI done by research assistant 'blind to study allocation'

Incomplete outcome data (attrition bias)
All outcomes
High riskThe follow-up rate at 8 and 16 weeks postpartum was 69.7% and 59.2% respectively. Missing data were imputed using 'last observation carried forward'. Raw data were not available.

Selective reporting (reporting bias)Unclear riskMINI results were reported. EPDS and STAI were not reported and not available from authors.

Other biasUnclear riskNo other sources of bias noted.

Brugha 2000

MethodsRCT with prognostic stratification on 3 factors (level of support, screening, and ethnic group).


Participants209 pregnant women (103 in the intervention group; 106 in the control group) who attended antenatal clinics in a UK hospital between 12 and 20 weeks' gestation are were identified, by screening, to be at an increased risk of postpartum depression. Inclusion criteria: 16 years old, primiparous, residence in reasonable driving distance to hospital, and sufficient English to complete questionnaires.


InterventionsIntervention group: 'Preparing for Parenthood' - 6 structured 2-hour weekly antenatal classes (preceded by an initial introductory meeting with the participant and her partner) and 1 'reunion' class at 8 weeks postpartum. Classes were provided by a trained nurse and occupational therapist and based on established psychological models for tackling depression together with emerging models for enhancing social support.

Control group: routine antenatal care.


OutcomesOutcomes included depression (EPDS > 10) and maternal health service contact since randomisation at 12 weeks postpartum.


NotesWomen in the intervention group were more likely to adopt an avoidant problem-solving style than women in the control group; using logistic modelling to adjust for this covariate at baseline did not alter the trial results. Only 45% of participants in the intervention group attended sufficient sessions to 'likely receive benefit'.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"performed using a computer-based stratification process with minimisation''

Allocation concealment (selection bias)High riskRandomisation done by research interviewer.

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
High riskThe same researcher did the enrolment interview and collected the outcome data. After each interview the researcher was asked to mark which group she thought the participant was in.

Incomplete outcome data (attrition bias)
All outcomes
Low riskThe follow-up rate at 12 weeks postpartum was 90.9%'

Selective reporting (reporting bias)Low riskAll outcomes were reported on.

Other biasLow riskNo other sources of bias noted.

Cupples 2011

MethodsRCT.


Participants343 women (172 to the intervention group; 171 to the control group), pregnant with their first baby and less than 20 weeks' gestation were enrolled from Northern Ireland. They were 16-30 years old, had no co-morbidity and were from disadvantaged areas based on their postcode.


InterventionsIntervention group: peer mentoring provided during home visits or phone calls. The peer mentors were non-health professionals, < 40 years old with at least 1 child < 10 years old. They received an initial 2-hour training session, follow-up training sessions every 6-8 weeks and ongoing supervision from a midwife. The mentoring sessions were offered twice monthly during pregnancy and monthly for the first postpartum year. The peers were matched to the participants based on age and locality. The mean number of contacts was 8.5 (SD 9.3). 29% of the participants had > 12 contacts and 16% received none.

Usual care: routine antenatal and postpartum care.


OutcomesOutcomes included depression (SF36), parental stress (PSI) and the Bayley Scales of Infant Development II at 52 weeks postpartum.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer-generated using alternate blocks of 20 and 40.

Allocation concealment (selection bias)Low risk"Randomization done by independent individuals at a remote location."

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low risk"Assessed by researcher blinded to group allocation."

Incomplete outcome data (attrition bias)
All outcomes
Low riskFollow-up rates at 52 weeks postpartum were 85.3% for questionnaires and 81.6% for the Bayley.

Selective reporting (reporting bias)Low riskAll outcomes were reported on. Non-imputed values used in this review.

Other biasLow riskNo other sources of bias noted.

Dennis 2009

MethodsRCT with stratification on self reported history of depression.


Participants701 postpartum women (349 in the intervention group; 352 in the control group) were enrolled from 7 large health regions in Ontario, Canada. During the routine postpartum phone call (24-48 hours post hospital discharge) public health nurses administered the EPDS and those women scoring > 9 and deemed to be high risk to develop postpartum depression were referred to the study. Women taking antidepressant or antipsychotic drugs at the time of recruitment were excluded. Participants were 2 weeks postpartum or less, aged 18 years or more, able to speak English, had a live birth and were discharged home with their baby.


InterventionsIntervention group: standard community postpartum care plus telephone based peer support from a mother with a history and recovery from postpartum depression. Telephone contact was initiated within 48-72 hours of randomisation. Peer support mothers underwent a 4-hour training session and were asked to make a minimum of 4 contacts with each mother. On average each peer supported 2 women (range 1-7); made 8.8 contacts (SD 6.0) with each contact lasting 14.1 minutes (SD 18.5).

Control group: standard community postpartum care including access to services from public health nurses and other providers (mother initiated) and drop in centres.


OutcomesOutcomes included depression (EPDS > 12 and SCID), anxiety (STAI) and UCLA Loneliness scale at 12 and 24 weeks postpartum.


NotesWomen in both groups with severe depression at 12 weeks were referred for treatment. More women in the control group were referred at 12 weeks so the 24-week results were not included in the meta-analyses.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"done by web randomisation service."

Allocation concealment (selection bias)Low risk"centrally controlled with a web based randomisation service."

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants not possible. Community caregiver was not informed of trial participation or group allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskResearch nurses doing data collection were blinded to group allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low riskFollow-up rates at 12 and 24 weeks postpartum were 87.4% and 85.6% respectively.

Selective reporting (reporting bias)Low riskAll outcomes were reported on.

Other biasLow riskNo other sources of bias noted.

Feinberg 2008

MethodsRCT.


Participants169 couples expecting their first child (89 in intervention group and 80 in control group) were recruited via antenatal education classes at 2 hospitals and doctors' offices in Pennsylvania USA. They were all heterosexual couples living together and were enrolled in the 2nd trimester of pregnancy.


InterventionsIntervention group: 8 group classes (4 in the antenatal and 4 in the postnatal period), focusing on improving co-parenting by encouraging conflict management, sharing tasks and developing supportive roles in parents. The group sessions were in addition to the regular antenatal classes, structured and led by a trained man and woman team. There were 6-10 couples in each group and 2/3 of the couples attended 5 or more of the 8 sessions.

Control group: regular antenatal classes and a mailed brochure about selecting child care.


OutcomesOutcomes included depression (CES-D), anxiety (Taylor Manifest Anxiety Scale), parent child dysfunction, infant regulation and co-parenting at 24 weeks postpartum.


NotesWe used only the data collected from the mothers. We used the 6-item Dysfunction Interaction Scale from the PSI for the Maternal-Infant attachment outcome in this review. We did not use the anxiety data as the Taylor Manifest Anxiety Scale measures chronic anxiety.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"A staff person created a randomisation list of intervention and control assignments base on a computer program" [personal communication].

Allocation concealment (selection bias)Low risk"After collection of baseline data a staff member, not involved in enrolment, assigned group based on the order of receipt of baseline data" [personal communication].

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessment by participant-completed questionnaire sent by mail.

Incomplete outcome data (attrition bias)
All outcomes
Low riskFollow-up rate at 24 weeks postpartum was 89.9%.

Selective reporting (reporting bias)Low riskAll outcomes were reported on.

Other biasLow riskNo other sources of bias noted.

Gamble 2005

MethodsRCT.


Participants103 mothers (50 in the intervention group; 53 in the control group) who were assessed as having a 'distressing or traumatic birth' were enrolled in the immediate postpartum period in a Brisbane, Australia hospital.


InterventionsIntervention group: 1 midwifery-led debriefing session before hospital discharge and another at 6 to 8 weeks postpartum.

Control group: standard care with no midwifery-led debriefing session.


OutcomesOutcomes included depression (EPDS > 12) at 4-6 and 12 weeks postpartum, maternal stress (Depression Anxiety and Stress Scale-21) at 12 weeks.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"computer generated random allocations."

Allocation concealment (selection bias)Low risk"performed using sealed, opaque envelopes." Personal communication confirmed the envelopes were consecutively numbered.

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskA "second research midwife, blinded to group allocation, conducted the follow-up telephone interviews".

Incomplete outcome data (attrition bias)
All outcomes
Low riskFollow-up rates at 4-6 and 12 weeks postpartum were 99.0% and 100% respectively.

Selective reporting (reporting bias)Low riskAll outcomes were reported on. Satisfaction information was collected only from intervention group.

Other biasLow riskNo other sources of bias noted.

Gao 2010

MethodsRCT.


Participants194 low-risk married women having their first babies and attending routine antenatal classes (96 in the intervention group; 98 in the control group) were enrolled at > 28 weeks of pregnancy in a teaching hospital in China. Women with a personal or family history of depression were excluded.


InterventionsIntervention group: routine antenatal classes (as per control group); 2 2-hour IPT-oriented group antenatal classes by trained midwives; and 1 telephone call at 2 weeks postpartum from the same midwife.The extra classes were done immediately following the routine antenatal class and the group size was <= 10 participants.


OutcomesOutcomes included depression (EPDS > 12); psychological well-being (General Helath Questionnaire) and satisfaction with interpersonal relationships (researcher-developed scale) at 6 weeks postpartum.


Notes13.4% of overall sample had EPDS scores of >= 13 at enrolment. 95.8% of women in the intervention group attended all the extra antenatal classes.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer-generated 'table of random numbers'.

Allocation concealment (selection bias)Unclear riskEligiblity screen by prenatal educator. Consent was obtained by the principal investigator. The list of treatment allocations were stored on the computer of the same principal investigator who obtained consent to participate.

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessment was done by "research assistant who was blinded to the treatment condition".

Incomplete outcome data (attrition bias)
All outcomes
Low riskFollow-up rate at 6 weeks postpartum was 90.2%.

Selective reporting (reporting bias)Low riskAll outcomes were reported on.

Other biasLow riskNo other sources of bias noted.

Gjerdingen 2002

MethodsRCT.


Participants151 couples having their first baby (77 in intervention group and 74 in the control group) were enrolled from prenatal classes in Minnesota, USA.


InterventionsIntervention group: 2 30-minute breakout sessions run by a psychologist that occurred during the regular prenatal class program. 1 session dealt with supportive behaviours between the couple and the other discussed planned household work tasks.

Control group: regular prenatal class program which included a video about being a new parent and discussion of infant care during the breakout session times.


OutcomesOutcomes included mental health (5-item SF36 mental health scale), parent support and work measures at 26 weeks postpartum.


NotesOnly data from the mothers were used. Parent/social support was measured with 1 item -"How often did your partner make you feel he cared about you?" (responses from 1 = never to 7 = frequently). Marital discord was measured with 1 item - "How satisfied are you with your relationship with your partner?" (responses 1 = very dissatisfied to 7 = very satisfied).


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"computer generated permuted block random number schedule."

Allocation concealment (selection bias)Low risk"a research assistant randomly assigned couples to groups." "The participants were informed of assignment at next class." We have assumed that the group assignment was done away from the prenatal class itself.

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessment by participant-completed questionnaire sent by mail.

Incomplete outcome data (attrition bias)
All outcomes
Low riskFollow-up rate at 24 weeks postpartum was 87.4%.

Selective reporting (reporting bias)Low riskAll outcomes were reported on.

Other biasLow riskNo other sources of bias noted.

Gorman 1997

MethodsRCT with stratification for past history of depression.


Participants45 pregnant women (24 in the intervention group; 21 in the control group) at-risk for postpartum depression who attended various obstetric clinics in Iowa City and St. Louis, USA.


InterventionsIntervention group: 5 individual sessions based on interpersonal psychotherapy, beginning in late pregnancy and ending at approximately 4 weeks postpartum. The intervention was given by a PhD psychology student.


OutcomesOutcomes included depression (EPDS > 12 and SCID) at 4 and 24 weeks postpartum.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"using a random numbers table" with blocking.

Allocation concealment (selection bias)Low risk"allocations stored securely in student's supervisor's office. Student enrolling women would notify supervisor and he would verbally tell her the group assignment" [personal communication].

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskData collection done by advanced clinical graduate students who were blind to treatment allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low riskA questionnaire was completed and a SCID assessment was done at 4 and 24 weeks postpartum. The completion rates for the SCID were 86.6% and 82.2%, The completion rates for the questionnaire were 73.3% and 66.6%.

Selective reporting (reporting bias)Low riskAll outcomes were reported on.

Other biasLow riskNo other sources of bias noted.

Gunn 1998

MethodsRCT stratified by recruiting centre.


Participants683 healthy mothers (number of women randomised to each group not stated) who gave birth in 1 rural and 1 metropolitan hospital in Victoria, Australia. Women were excluded if they were patients of general practitioners who were the trial reference group, attended the teenage clinic, or delivered by an emergency caesarean section.


InterventionsAll participants received a letter and appointment date to see a general practitioner for a check-up: the intervention group for 1 week after hospital discharge and the control group for 6 weeks postpartum.


OutcomesOutcomes included depression (EPDS > 12), maternal physical and mental well-being (SF-36), and breastfeeding duration at 12 and 24 weeks postpartum.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"variable block randomisation schedule."

Allocation concealment (selection bias)Low risk"via telephone through a centrally controlled randomisation centre."

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessment by participant-completed questionnaire sent by mail.

Incomplete outcome data (attrition bias)
All outcomes
High riskFollow-up rates at 12 and 24 weeks postpartum were 69.7% and 65.3% respectively.

Selective reporting (reporting bias)Low riskAll outcomes were reported on.

Other biasLow riskNo other sources of bias noted.

Harris 2006

MethodsRCT.


ParticipantsPregnant women were screened and those thought to be at risk for depression were contacted about the study. Women with psychotic illness, serious suicidal risk or poor fluency in English were excluded. 117 were found to be at risk during screening and were randomised (61 in intervention group and 56 in control group). 71 of these women consented and completed baseline information at 30 weeks of pregnancy (range 24-36) (32 in the intervention group and 39 in the control group). 3 women in each group had major depression at baseline (8% of total sample) and were excluded at that time.


InterventionsIntervention group: NEWPIN (New Parent Infant Network). The NEWPIN program provides antenatal and postnatal social support with 1-to-1 befriending and psycho-educational group meetings by trained volunteers who themselves are mothers.

Control group: usual care.


OutcomesOutcome was onset of major depression; minor depression requiring medication; or if already depressed, a failure to recover during the time from baseline and follow-up. Outcome data were measured using SCAN (Schedules for assessment in Neuropsychiatry) and yields a diagnosis of depression according to DSM-IV criteria. Personal communication with the authors provided data from the SCAN at 12 weeks postpartum.


NotesThe reference provided outlines the registration of the trial. The trial is complete and the principal investigator was Dr Tirril Harris. She provided slides that outlined many aspects of the trial.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskThe allocation sequence was created by a research assistant not involved in enrolment. S/he filled opaque envelopes with treatment allocations which were sealed, shuffled randomly and then numbered.

Allocation concealment (selection bias)Low riskRandomisation was done by a phone call to the research assistant at a site away from the location of enrolment. She opened the next envelope.

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
High riskOutcome assessment was done by face-to-face interviews and authors state that "interviewers rarely remained unblinded".

Incomplete outcome data (attrition bias)
All outcomes
High risk60.7% of those randomised completed the baseline interview and 55.5% of those randomised provided outcome data at 12 weeks postpartum.

Selective reporting (reporting bias)Low riskAll outcomes were reported on.

Other biasLow riskNo other sources of bias noted.

Heinicke 1999

MethodsRCT.


Participants70 women receiving prenatal care in California, USA (35 to intervention group and 35 to control group) were enrolled in the 3rd trimester of pregnancy. They were having their first baby, had no current mental illness and were identified as 'at risk' by a social history interview. All participants were poor and lacked social support.


InterventionsIntervention group: home visiting by mental health professionals, possible referral to community resources and the availability of a weekly mother-infant group. Visits were done for the first 2 years postpartum. They began at the end of pregnancy, were weekly during pregnancy and the first year, every other week in the second year and 60 minutes in length. Telephone follow-up contacts were done in the 3rd and 4th years.

Control group: paediatric follow-up which entailed developmental evaluation, referrals as needed but no visits or access to the mother-infant group.


OutcomesOutcomes included depression (BDI), anxiety (STAI), maternal support (Cutrona Support Inventory), marital discord (Locke-Wallace Marital Inventory), maternal-infant attachment (Attachment Q-set) and infant development (Bayley Scales of Infant Development) at 4, 24 and 52 weeks postpartum.


NotesAll outcomes except the Bayley were combined into factors in the publication. The authors were unable to supply the raw data.

As depression data were not available (the primary outcome of this review) no data from this trial were included in the review.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskNo allocation sequence was used. A coin toss was done for every 2 families.

Allocation concealment (selection bias)Low risk"Once two consecutive families agreed to participate a coin toss by a person who had had no contact with the families determined the group.

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low risk"Assessments done by staff unaware of treatment assignment."

Incomplete outcome data (attrition bias)
All outcomes
Low riskFollow-up rate at 4, 24 and 52 weeks postpartum were 100%, 91.1% and 91.1% respectively.

Selective reporting (reporting bias)Unclear riskAll outcomes were reported but were combined into factors. No raw data numbers except Bayley were available.

Other biasLow riskNo other sources of bias noted.

Ickovics 2011

MethodsRCT with stratification by site and expected month of delivery.


Participants1047 medically low-risk pregnant women (653 in the intervention group; 394 in the control group) were recruited antenatally from 2 US hospital antenatal clinics (Atlanta GA and New Haven CT). The women were 25 years old or less and < 24 weeks' gestation (mean 18 weeks SD 3.3) at enrolment.


InterventionsIntervention group: group prenatal care. Each prenatal visit was done in a group setting and led by a health professional (midwife or obstetrician). It was integrative prenatal care combining assessment, education, skill building and support. There were 10 2-hour sessions from 16-40 weeks of gestation (20 hours in total).

Usual care: individual prenatal care. Individual contact was made at the same time points as the group sessions. Each contact was 10-15 minutes (2 hours in total).


OutcomesOutcomes included depression (CES-D), stress (Perceived Stress Scale) and social support (Social Relationship Scale) at 24 and 52 weeks postpartum.


NotesIn the trial there were 2 study groups that received group prenatal care. 1 received the standard group care and the other received more information about HIV and sexual risk reduction. For this review the 2 groups will be combined and considered to be the intervention group.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer-generated randomisation sequence. 40% to control group and 60% to the 2 intervention groups (see notes section above).

Allocation concealment (selection bias)Low risk"Allocation was concealed from participant and research staff until eligibility screening was completed and study condition was assigned." "Randomization sequence was password protected to recruitment staff and participants."

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low risk"All measurement and data collection were conducted in blinded fashion independently of the care setting."

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskFollow-up rate at 24 and 52 weeks postpartum were 75.2% and 80.2% respectively.

Selective reporting (reporting bias)Low riskAll outcomes were reported on.

Other biasLow riskNo other sources of bias noted.

Lavender 1998

MethodsRCT.


Participants114 primiparous mothers (60 in the intervention group; 60 in the control group) in a UK teaching hospital. Inclusion criteria: singleton pregnancy, cephalic presentation, spontaneous labour at term, normal vaginal delivery.


InterventionsIntervention group: 1 debriefing session before hospital discharge, which lasted 30 to 120 minutes, provided by a midwife who received no formal training.
Control group: standard care with no midwifery-led debriefing session.


OutcomesOutcomes included depression (HADS) and anxiety (HADS) at 3 weeks postpartum.


Notes59.6% of the participants were single mothers.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"simple random sampling using computer generated numbers."

Allocation concealment (selection bias)Low risk"opening consecutively numbered, sealed opaque envelopes." Done by ward staff.

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessment by participant-completed questionnaire sent by mail.

Incomplete outcome data (attrition bias)
All outcomes
Low riskFollow-up rate at 3 weeks postpartum was 95%. The completion rate by group was not reported.

Selective reporting (reporting bias)Low riskAll outcomes were reported on.

Other biasLow riskNo other sources of bias noted.

Le 2011

MethodsRCT.


Participants217 pregnant Latino women (112 in intervention group; 105 in control group) ≤ 24 weeks' gestation were enrolled from a healthcare centre and hospital clinic in Washington DC. They were screened and considered to be at high risk of depression (CES-D ≥ 16 or self report of personal or family history of depression) but did not currently have a major depressive illness.


InterventionsIntervention group:cognitive behavioural group therapy sessions. Research staff provided 8 weekly sessions during pregnancy and 3 booster sessions at 6, 16 and 52 weeks postpartum. Participants attended a mean of 4.1 sessions during pregnancy (SD 2.9) and 2.0 (SD 1.3) booster sessions.

Usual care: usual prenatal care. This may have included services that participants chose for themselves.


OutcomesOutcomes included depression (Beck and Mood Screener) measured post intervention and at 6, 16 and 52 weeks postpartum.


NotesIt is unknown how many women had a CES-D score > 16 at recruitment.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskAllocation list prepared by principal investigator using a coin toss.[personal communication].

Allocation concealment (selection bias)Low riskAllocations were put in consecutively numbered, sealed opaque envelopes [personal communication]. "Group membership was assigned by the first author; neither participant nor interviewer knew the result of the random assignment until this envelope was opened."

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
High riskOutcome assessors were not blinded.

Incomplete outcome data (attrition bias)
All outcomes
Low riskFollow-up rate at 6, 16 and 52 weeks postpartum were 82.9%, 80.2% and 69.1% respectively.

Selective reporting (reporting bias)Low riskAll outcomes were reported on. Raw data numbers were available.

Other biasUnclear riskIt is unknown how many women had a CES-D score > 16 at recruitment.

Lumley 2006

MethodsRCT with cluster-randomisation stratified on rural and metropolitan. Unit of randomisation was local government authority.


ParticipantsLocal government authorities in Victoria, Australia were matched on location (rural or metropolitan), size, rating of current and recent community activity, annual number of births and non-contiguous boundaries. 16 local government authorities were included (8 in the intervention group and 8 in the control group).

No individual consent was sought from participants. All women giving birth in the participating local government authorities over a 10 month period (19,193) were sent postal questionnaires (10,471 in the intervention group and 8722 in the control group). A pre-paid reply envelope was included and reminder cards were sent at 2 and 4 weeks.


InterventionsIntervention group: PRISM program which 'aimed to refocus the existing postnatal health care contact on maternal physical and mental health, to implement community strategies to increase the availability and accessibility of "time-out", provide better information about common health problems and local services, with encouragement and incentives to use them'. It included an education program for general practitioners and maternal child heath nurses, an information kit given to new mothers at hospital discharge, a community information officer for 2 years, and local steering committees to help with local initiatives.

Control group:usual care. No further details noted.


OutcomesOutcomes included depression (EPDS), general health status (physical and mental component score of the SF36) and women's views at 24 weeks postpartum.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskThe local government authorities were matched (see details above). "randomisation occurred within pairs assigning one to intervention and one to control."

Allocation concealment (selection bias)Unclear risk"Randomisation took place at a public event." No further details were provided.

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessment by participant-completed questionnaire sent by mail.

Incomplete outcome data (attrition bias)
All outcomes
Low riskThe response rates at 24 weeks postpartum was 59.0% (59.9% in the intervention group and 58.0% in the control group). We assessed this as 'very high' for a community mail out.

Selective reporting (reporting bias)Low riskAll outcomes were reported on. Analysis was done using logistic-normal characterised as 'cluster-specific'.

Other biasLow riskBias risk for cluster trial: Community mail outs were done rather than individual consent and thus prior knowledge of cluster group is not applicable to this trial. Clusters were matched and randomisation was done in pairs. There were no differences in the social and perinatal baseline characteristics between the 2 groups. No full clusters were lost to follow-up.

MacArthur 2002

MethodsRCT with cluster design. Unit of randomisation was general practice.


ParticipantsThe general practices had on average 2 or more general practitioners and ≥ 2 midwives. 17 practices were randomised to the intervention group and 19 practices to the control group.

2064 UK postpartum mothers (1087 in the intervention group; 977 in the control group). Only mothers expected to move out of the general practice area were excluded.


InterventionsIntervention group: flexible, individualised, extended home visits by a midwife to 28 days postpartum that included (1) screening with a symptoms checklist and the EPDS, (2) a referral to a general practitioner as necessary, and (3) a 10-12 week discharge visit.

Control group: standard care that included 7 midwifery home visits to 10-14 days postpartum (may extend to 28 days) and care by health visitors thereafter. General practitioners completed routine home visits and a final check-up at 6 to 8 weeks postpartum.


OutcomesOutcomes included depression (EPDS > 12) at 16 and 52 weeks postpartum.


NotesAdditional information (including standard deviations for continuous outcomes) were provided by the trial authors.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"customised, computer program using minimization with 2 factors were included, socioeconomic deprivation and midwife caseload."

Allocation concealment (selection bias)Low riskDone by a "member of the clinical trial unit who was independent of the trial team."

Blinding of participants and personnel (performance bias)
All outcomes
Low riskRecruitment of the participants from the clusters was done by unblinded staff. Blinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessment by participant-completed questionnaire sent by mail.

Incomplete outcome data (attrition bias)
All outcomes
High riskFollow-up rates at 12 and 52 weeks postpartum were 72.8% and 73.3% respectively.

Selective reporting (reporting bias)Low riskAll outcomes were reported on.

Other biasLow riskBias risk for cluster trial: it is not stated whether participants were aware of the group allocation of their cluster before enrolling in the study. Recruitment rates did not differ between clusters. Randomisation of clusters used minimisation based on socioeconomic deprivation and midwife caseload. Mulitvariate model analysis was used to test whether baseline characteristics differed more than would be expected given cluster-randomisation and showed no significant differences. For any proportional differences the ones generally indicative of worse health outcome were biased again the intervention group. 1 cluster was lost from the trial when the single midwife in the cluster went on long-term sick leave and could not be replaced.

Morrell 2000

MethodsRCT.


Participants623 UK postpartum mothers (311 in the intervention group; 312 in the control group). Exclusion criteria: insufficient English to complete questionnaires and an infant in the special care unit for more than 48 hours.


InterventionsIntervention group: postnatal care at home by community midwives plus up to 10 home visits in the first month postpartum lasting up to 3 hours provided by a community postnatal support worker.

Control group: postnatal care at home by community midwives.


OutcomesOutcomes included depression (EPDS > 12), maternal physical and mental well-being (SF-36), social support (Duke Functional Social Support), and breastfeeding duration at 6 and 24 weeks postpartum.


NotesThere were more twins (9/311 vs 1/312) and more women had an adult living with them (87% vs 79%) in the intervention group.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"prepared in advance by using random digit tables in the research office." Done by a statistician.

Allocation concealment (selection bias)Low risk"opening consecutively numbered, sealed opaque envelopes."

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessment by participant-completed questionnaire sent by mail.

Incomplete outcome data (attrition bias)
All outcomes
Low riskFollow-up rates at 6 and 24 weeks postpartum were 88.4% and 79.1% respectively.

Selective reporting (reporting bias)Low riskAll outcomes were reported on. Satisfaction with services was not asked as a general question of all participants. Questions were asked for specific care in each group. EPDS scores were reported as ≥12, rather than the more usual > 12.

Other biasLow riskNo other sources of bias noted.

Priest 2003

MethodsRCT with stratification for parity and mode of delivery.


Participants1745 postpartum mothers (875 in the intervention group; 870 in the control group) from 2 large maternity hospitals in Perth, Australia. Exclusion criteria: insufficient English to complete questionnaires, being under psychological care at the time of delivery, maternal age < 18 years, and infant needing neonatal intensive care.


InterventionsIntervention group: a single, standardised debriefing session provided in-hospital immediately after randomisation or the next day; duration ranged from 15 minutes to 1 hour and all research midwives received training in critical incident stress debriefing.
Control group: standard postpartum care.


OutcomesOutcomes included depression (EPDS > 12) at 8, 24, and 52 weeks postpartum.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot stated.

Allocation concealment (selection bias)Low riskEach woman selected an envelope from a group of at least 6 sealed, opaque envelopes containing random allocation.

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessment by participant-completed questionnaire sent by mail. Some participants were interviewed by clinical psychologist who was blinded to study group.

Incomplete outcome data (attrition bias)
All outcomes
Low riskFollow-up rates at 8, 24, and 52 weeks postpartum were 94.1%, 91.2% and 80.2% respectively.

Selective reporting (reporting bias)Unclear riskClinical interviews were used to determine depression and post traumatic stress based on DSM IV criteria. However interviews were not done for all participants. Interviews were done if: 1) the EPDS score was > 12; 2) women were currently receiving treatment or medication for a psychological disorder; and 3) for a stratified sample of women with lower EPDS scores (59% for those with scores 10-12, 10% with scores 5-9 and 5% with scores < 5). If a woman did not have a clinical interview she was categorised as 'not depressed'. Post traumatic stress was determined during the same clinical interview (driven mostly by the EPDS score) and women with elective caesarean delivery were excluded from the total reported. The denominator for post traumatic stress was not reported.

Other biasLow riskNo other sources of bias noted.

Reid 2002

MethodsRCT with a 2 x 2 factorial design, stratified by centre.


Participants1004 UK mothers (503 in the intervention group; 501 in the control group). Inclusion criteria: all primiparous women attending antenatal clinics in 2 participating hospitals. Exclusion criteria: women whose infant subsequently died or was admitted to the special care unit for more than 2 weeks.


Interventions2 postpartum interventions incorporating 4 groups: 1) control, 2) mailed self-help materials, 3) invitation to support group, and 4) self-help materials plus invitation to support group. The support groups were run on a weekly basis for 2 hours facilitated by trained midwives.


OutcomesOutcomes included depression (EPDS > 11), maternal physical and mental well-being (SF-36), and social support (SSQ6) at 12 and 24 weeks postpartum.


NotesFor this review data were analysed by combining groups 1 and 2 vs groups 3 and 4 to achieve a comparison of support group vs no support group. Only 18% of participants in the intervention group attended a support group session.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"computer generated scheme with randomised permuted blocks."

Allocation concealment (selection bias)Low riskDone by trial co-ordinator after delivery of a live baby was confirmed. The trial co-ordinator was off-site.

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessment by participant-completed questionnaire sent by mail.

Incomplete outcome data (attrition bias)
All outcomes
High riskFollow-up rates at 12 and 24 weeks postpartum were 73.3% and 71.4% respectively.

Selective reporting (reporting bias)Low riskAll outcomes were reported on.

Other biasLow riskNo other sources of bias noted.

Sen 2006

MethodsRCT with stratification by parity.


Participants162 pregnant women with an uncomplicated twin pregnancy were enrolled at < 20 weeks' gestation (80 in the intervention group and 82 in the control group) from a hospital in the UK. Women having fetal or infant death were excluded (3 in each group).


InterventionsIntervention group: care, advice and support from a Twin Midwife Advisor which included: at least 2 home visits (1 antenatal and 1 in the early postpartum); specially designed antenatal preparation for parenting program (4-5 antenatal group classes and 1 postnatal class); care in-hospital and at out-patient hospital clinic.

Control group: standard care and advice which included:shared antenatal care between general practitioner (GP) and consultant obstetrician at a twin clinic; allocation to a community midwife who may provide care in conjunction with GP; invitation to attend community-based antenatal education sessions (normally without a focus on twins); invitation to a breastfeeding workshop (rarely with focus on twins); self-referral to Childbirth Trust antenatal sessions (without focus on twins).


OutcomesOutcomes included depression (EPDS), anxiety (HADS subscale for anxiety); parental stress (PSI); mother-infant attachment (Green scale), social support (subscale of Satisfaction with Motherhood scale), marital relationship (VAS developed by researcher), general outlook on life, emotional well being and satisfaction with care at 6, 12, 24 and 52 weeks postpartum.


NotesFor mother-infant attachment data were collected for each twin. We took the 'worst' score so we did not miss a 'bad outcome'.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"on-line web based electronic randomisation procedure provided by Centre for Health Service Research, Newcaslte University." Used permuted block design.

Allocation concealment (selection bias)Low risk"During the enrolment home visits a laptop was connected to a mobile phone for Internet access to the randomisation service. The participant pressed the randomisation button to obtain group allocation."

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessment by participant-completed questionnaire sent by mail.

Incomplete outcome data (attrition bias)
All outcomes
Low riskFollow-up rates at 6, 12, 24, and 52 weeks postpartum were 81.5%, 79.0%, 82.1% and 75.3% respectively.

Selective reporting (reporting bias)Low riskAll outcomes were reported on.

Other biasLow riskNo other sources of bias noted.

Small 2000

MethodsRCT stratified by research midwife who would give the intervention.


Participants1041 mothers (520 in the intervention group; 521 in the control group) who had an operative delivery in a large maternity teaching hospital in Melbourne, Australia.


InterventionsIntervention group: a midwifery-led debriefing session before discharge to provide women with an opportunity to discuss their labour, birth, and postdelivery events and experiences.
Control group: standard care which included a brief visit from a midwife on discharge to give a pamphlet on sources of assistance.


OutcomesOutcomes included depression (EPDS > 12) and overall maternal health status (SF-36) at 24 weeks postpartum. Depression was measured at 4-6 years but not included in the review.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"allocation determined by computer generated, adaptive biased coin randomisation schedule."

Allocation concealment (selection bias)Low risk"telephone randomisation."

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessment by participant-completed questionnaire sent by mail.

Incomplete outcome data (attrition bias)
All outcomes
Low riskFollow-up rate at 24 weeks was 88.1% and 51.3% at 4-6 years.

Selective reporting (reporting bias)Low riskAll outcomes were reported on.

Other biasLow riskNo other sources of bias noted.

Stamp 1995

MethodsRCT with stratification by parity.


Participants144 pregnant women (73 in the intervention group; 71 in the control group) who screened at-risk for postpartum depression during antenatal clinic visits in Adelaide, Australia. Inclusion criteria: English-speaking, singleton fetus, and < 24 weeks' gestation.


InterventionsIntervention group: routine antenatal care plus 2 antenatal and 1 postnatal midwifery-led group sessions.
Control group: routine antenatal and postnatal care which included a class at 6 weeks postpartum that incorporated a video on postpartum depression.


OutcomesOutcomes included depression (EPDS > 12) at 6, 12, and 24 weeks postpartum.


NotesA high number of women were screened 'vulnerable' and only 31% of participants in the intervention group attended all 3 sessions.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"randomisation schedules were prepared in advance by a researcher not involved in the trial." Variable balanced blocks were used.

Allocation concealment (selection bias)Low risk"allocated by telephone call from clinic to independent researcher who opened the next in a series of sequentially numbered envelopes."

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessment by participant-completed questionnaire sent by mail.

Incomplete outcome data (attrition bias)
All outcomes
Low riskFollow-up rates at 6, 12, and 24 weeks postpartum were 92.1%, 92.8% and 87.1% respectively.

Selective reporting (reporting bias)Low riskAll outcomes were reported on.

Other biasLow riskNo other sources of bias noted.

Tam 2003

MethodsRCT.


Participants560 in-hospital mothers (280 in each group) from Hong Kong, China with at least 1 suboptimal outcome in the perinatal period ranging from antenatal complications requiring hospitalisation, elective caesarean section, labour induction, postpartum haemorrhage, infant admission to special care unit, etc.


InterventionsIntervention group: routine postpartum care plus 1 to 4 sessions of "educational counselling" by a research nurse before hospital discharge that included information related to the adverse event and counselling to assist the mother to "come to terms with her losses and find solutions to specific difficulties" (median total time was 35 minutes). 24 women also received 1 session by a physician.


OutcomesOutcomes included depression (HADS > 4) at 6 and 24 weeks postpartum.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"computer generated numbers."

Allocation concealment (selection bias)Low risk"done by research nurse using sealed, opaque, sequentially numbered envelopes."

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskBlinding of participants was not possible and health professionals were not blinded to group allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskOutcome assessment done before hospital discharge, at 6 weeks postpartum during the routine postnatal follow-up visit and at 24 weeks with a mailed questionnaire. The process of data collection in-hospital and at the follow-up visit is not stated.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskThe authors state that "560 patients were invited to participate, 180 declined", "1 case in the control group was excluded" and "161 participants in the counselling group and 255 in the control completed the study". The numbers at each of the follow-up time points is not stated. The actual numbers of participants at each stage of the study are unclear based on these numbers. The authors have been contacted for clarification.

Selective reporting (reporting bias)Low riskAll outcomes were reported but the time points are unclear.

Other biasLow riskNo other sources of bias noted.

Tripathy 2010

MethodsRCT with cluster design stratified by district and pre-existence of a women's group. Unit of randomisation was geographic area. The existing women's groups carried out financial savings and credit activities.


Participants12 clusters were identified in each of 3 contiguous districts in eastern India (36 in total) (18 in the intervention group and 18 in the control group). The mean cluster size was 6338 (range 3605-7467) and the proportion of Adivasis (indigenous groups) was 58%-70%. The Adivasis are an under-serviced population with lower rates of employment, lower rates of education for children, higher mortality rates and poorer access to health services than non-indigenous populations.

Women were part of clusters based on where they lived. They attended the women's group (for those in the intervention group) during pregnancy if they wished to. Study consent was not required to attend the group. After delivery women, aged 15-49, living in the participating regions during the study period were asked if they would consent to a study interview. Those who consented were the participants in the study. A total of 19,030 women participated (9770 in the intervention group and 9260 in the control group).


InterventionsIntervention group: existing women's groups expanded their function (172 groups) and 72 groups were created. Each group had a local leader and met monthly for a total of 20 meetings. The groups took part in a participatory learning and action cycle that identified problems, planned strategies, put strategies into practice and assessed the effect. Clean obstetrics delivery practices and care-seeking behaviour were shared through stories and games at the groups.

Control group: existing women's groups maintained their financial function but did not add anything else. Clusters without women's groups did not create any.

In both groups health committees were formed so that community members could express their opinions about the design and management of local health services.


OutcomesOutcomes included neonatal mortality, maternal depression (Kessler-10), stillbirths, maternal and perinatal deaths and health resource use. Each month 'key informants' told the researchers about any births or maternal deaths that had occurred in women of reproductive age in their allocated area. The 'key informant' was usually a traditional birth attendant or active village member. A researcher interviewed all women at 6 weeks postpartum who consented and obtained all study outcomes.


NotesMaternal depression was only measured starting in Year 2 of the trial because of 'delays in identification of a contextually appropriate scale'. Group attendance in Year 1 of the study was 18% of newly pregnant women and rose to 55% in Year 3.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskClusters were assigned a number and these numbers were written on pieces of paper and folded. For each region the papers where separated into 2 sets, those clusters with existing women's groups and those without. Each set of numbers was put into a basket.

Allocation concealment (selection bias)Low riskAn external observer drew the papers 1 after the other from the basket to assign group allocations evenly for each set. The first numbers drawn were allocated to the intervention group, the rest were allocated to the control group. The authors presented a chart showing how this process was done in each region based on the size of each set. For sets with an even number of clusters the first half were intervention and the second half were control (i.e. 8 total clusters, the first 4 were intervention, the second 4 were control). For sets with an odd number of clusters the process was the same but it varied if the larger number was in the intervention group or control (i.e. a set with 5 total clusters had 2 allocated to intervention and 3 to control; a set with 9 total clusters had 5 allocated to intervention and 4 to control). How the decision was made for each set was not stated.

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe staff doing the interviews were from different villages than those giving the intervention. They had their training done separately and had review meetings on separate days.

Incomplete outcome data (attrition bias)
All outcomes
Low riskThe follow-up rate for neonatal morbidity (done on the full sample) was 98.6%. As outlined above maternal depression started to be collected in Year 2. There is no evidence presented that the follow-up rate changed over the course of the study so we assumed that the follow-up rate was similar for the depression outcome.

Selective reporting (reporting bias)Low riskAll outcomes were reported on. As outlined above the sample size for the depression outcome is smaller as it was only collected from Year 2 on.

Other biasLow riskBias risk for cluster trial: it is possible that the participants were aware of the group allocation of their cluster before enrolling in the study however, this was not directly discussed during the consent process [personal communication]. Randomisation of clusters was stratified by district and existence of pre-existing women's group. Baseline differences in household assets, maternal education, literacy and tribal membership were noted between the intervention and control groups with women in the intervention group generally poorer and more disadvantaged than those in the control group. No full clusters were lost to follow-up. It is possible that the cluster randomisation resulted in a 'herd-effect' where more women attended a women's group than if individual randomisation had occurred.

Waldenstrom 2000

MethodsRCT.


Participants1000 pregnant mothers (495 in the intervention group; 505 in the control group) attending an antenatal clinic in Melbourne, Australia. Inclusion criteria: > 25 weeks' gestation, English-speaking, and low medical risk.


InterventionsIntervention group: team midwifery care provided antenatally and postnatally in hospital with a focus on continuity.
Control group: standard antenatal and postnatal care by physicians and midwives with no focus on continuity.


OutcomesOutcomes included depression (EPDS > 12) at 8 weeks postpartum.


NotesThe primary outcome of this study was satisfaction with care. Of the 1000 women randomised there were 83 unavoidable exclusions due to miscarriage, termination, transfer to another hospital and perinatal death (intervention group = 39; control group = 44). 3 of these women were excluded for psychiatric problems (2 in the intervention group and 1 in the control group). Demographic differences were found between questionnaire responders and non-responders.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"based on a computerized random procedure" [personal communication].

Allocation concealment (selection bias)Low risk"research midwife telephoned a clerk at hospital's information desk who opened an opaque numbered envelope which contained information about the allocated group."

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessment by participant-completed questionnaire sent by mail.

Incomplete outcome data (attrition bias)
All outcomes
High riskFollow-up rate at 8 weeks postpartum was 68.4%

Selective reporting (reporting bias)Low riskData about depression and satisfaction reported. No details were presented for other outcomes but the authors acknowledge this.

Other biasLow riskNo other sources of bias noted.

Weidner 2010

MethodsRCT.


Participants92 pregnant women admitted to a high-risk antenatal unit in Dreseden, Germany (46 to intervention group and 46 to control group) with elevated scores on the HADS or the Giessen Subjective Complaints List. 17.4% had elevated HADS (depression) scores; 40.2% had elevated HADS (anxiety) scores and 77.2% had elevated complaints scores. The gestational age at entry was not collected (personal communication).


InterventionsIntervention group: individualised psychosomatic intervention by trained psychologist or psychiatrist. `The activation of resources and the dialogue about current conflicts are central aspects of the intervention.` 1-5 session were done while in hospital and continuation on an out-patient basis could be done if needed.

Control group: standard care.


OutcomesOutcomes included depression (HADS subscale), anxiety (HADS subscale) and physical complaints at 52 weeks post-randomisation. The number of weeks postpartum was not collected (personal communication).


Notes7 women in the intervention group (15%) were discharged before receiving the intervention.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"list was generated by an independent Institute for Informatics and Biometry in Medicine of the University Hosptial."

Allocation concealment (selection bias)High risk"according to the mail order of the incoming questionnaires, the next letter (A or B) in the list was assigned to the respective subject and scratched from the list." The person recruiting participants assigned the group.

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessment by participant-completed questionnaire sent by mail.

Incomplete outcome data (attrition bias)
All outcomes
High riskFollow-up rate at 52 weeks post-randomisation was 47.8%.

Selective reporting (reporting bias)Low riskAll outcomes were reported on.

Other biasLow riskNo other sources of bias noted.

Zlotnick 2001

MethodsRCT.


Participants37 pregnant women (18 in the intervention group; 19 in the control group) on public assistance who had at least 1 risk factor for postpartum depression and were attending a prenatal clinic at a general hospital in the northeast USA.


InterventionsIntervention group: "Survival Skills for New Moms", which involved 4 60-minute group sessions over a 4-week period based on the principles of interpersonal psychotherapy. The authors did not state who provided the intervention.

Control group: standard antenatal care.


OutcomesOutcomes included depression (SCID) at 12 weeks postpartum.


Notes50% of eligible women declined trial participation. 77% of participants were single women.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot stated. Authors have been contacted for details.

Allocation concealment (selection bias)Unclear risk"random assignment." No further details reported. Authors have been contacted.

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskOutcome assessment was done by structured interview. Exact process not stated so assessment of blinding not possible. Authors have been contacted.

Incomplete outcome data (attrition bias)
All outcomes
Low riskFollow-up rate at 12 weeks postpartum was 94.6%.

Selective reporting (reporting bias)Low riskAll outcomes were reported.

Other biasLow riskNo other sources of bias noted.

Zlotnick 2006

MethodsRCT.


Participants99 pregnant women (53 in the intervention group and 46 in the control group) who screened at-risk for postpartum depression during antenatal clinic visits in Rhode Island, USA. They were 23-32 weeks' gestation and on public assistance. Those women currently receiving mental health treatment or who met criteria for current depressive disorder or substance abuse were excluded.


InterventionsIntervention group: The ROSE Program (Reach Out, Stand strong, Essentials for new mothers) which involved 4 x 60-minute group session over 4 weeks and 1 x 50-minute individual booster session post-delivery. The intervention was given by nurses who had received intensive training and supervision.

Control group: standard antenatal care


OutcomesOutcomes included depression (Beck) and social adjustment (Range of Impaired Functioning Tool).


NotesThis is a separate trial from Zlotnick 2001. The same intervention (re-named) was used but with a larger sample size.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"win randomization." Not stated who created the sequence.

Allocation concealment (selection bias)Unclear risk"randomly assigned." No details of the process stated. The authors have been contacted.

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of participants and caregivers was not possible.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskThe process for outcome collection was not stated. The authors have been contacted.

Incomplete outcome data (attrition bias)
All outcomes
Low riskFollow-up rate at 12 weeks postpartum was 86.9%.

Selective reporting (reporting bias)Low riskAll outcomes were reported.

Other biasLow riskNo other sources of bias noted.

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Ajh 2006Not an RCT. Odd and even days were used for group allocation.

Appleby 1998Intervention not targeting prevention; all participants had a depressive illness.

Armstrong 2004Intervention (pram-walking vs play group) was not psychosocial or psychological, all participants were depressed and the trial began when babies were 6 weeks to 18 months old.

Bang 2009Not an RCT. The authors state it was a 'quasi-experimental study'.

Barnes 2009Methodological concerns that could lead to selection and outcome bias. This was a cluster design where Home-Start schemes (informal volunteer family support program) were the unit of randomisation. Randomisation allocation scheme was done by the project manager using a coin toss during a phone call with the Home-Start scheme co-ordinator. The participants were aware of the group allocation of their cluster before enrolling in the study. The study began by only following those in the intervention group that accepted the intervention. Started to follow everyone part way through the study. This resulted in a 8-week follow-up rate of 61.3% in the intervention group and 77.1 in the control group (overall 68.9%). At 52 weeks the rates were: intervention 66.8%, control 70.8%, overall 68.7%.

Bastani 2005Postpartum depression was not an outcome. Intervention (applied relaxation therapy) was not psychosocial or psychological.

Buist 1999Pilot trial with unclear randomisation method. Significant group differences in baseline characteristics. No usable outcome data; published data were mean scores without standard deviations.

Bulgay-Morschel 2010Intervention (progressive muscle relaxation) was not psychosocial or psychological.

Chabrol 2002Not an RCT. Odd versus even number group assignment was used. Data were not analysed using 'intent-to-treat'.

Chabrol 2007Intervention was not psychosocial or psychological, but rather included a single educational session about postpartum blues, provided antenatally by a midwife.

Cho 2008Intervention not targeting prevention; all participants had a depressive illness.

Cooper 2002Not an RCT. Study examined the impact of a mother-infant intervention through the comparison of 2 matched groups.

D'Andrea 1994Postpartum depression was not a study outcome.

Dennis 2003Women were 8-12 weeks postpartum on enrolment.

Duggan 200928% of participants had a depressive illness at entry.

El-Mohandes 200662.5% of participants had a depressive illness at entry.

El-Mohandes 200850.7% of participants had a depressive illness at entry.

Elliott 2000Not an RCT. Group allocation based on delivery date. Potential selection bias with significant differences between participating and non-participating eligible women. Data were presented using median instead of mean results.

Fagan 2010RCT trial participants were not women. This is a descriptive report of mother's satisfaction from an RCT for fathers.

Gordon 1960Not an RCT. Inexplicit non-random group allocation. Primary outcome was 'emotional upset' using a subjective measure. All participant characteristics were lacking and 46% of mothers were lost to follow-up.

Gordon 1999A poor measure of postpartum depression was used that included a single item question and subscore on the mental health index of the SF-36. In addition, 30% women were excluded post randomisation.

Goyal 2009Intervention (strategies to improve sleep) was not psychosocial or psychological.

Grote 2009Intervention not targeting prevention; all participants had a depressive illness (EPDS > 12).

Hayes 2001Intervention was not psychosocial or psychological, but rather included a single educational session about postpartum depression, provided antenatally by a midwife.

Heh 2003Intervention was not psychosocial or psychological but rather included only information related to postpartum depression.

Hiscock 2001Intervention (strategies to improve infant sleep) was not psychosocial or psychological. Mothers were enrolled when their Infants were 6-12 months old.

Ho 2009Intervention was not psychosocial or psychological, but rather included discharge education, provided by the postpartum nurse, and a booklet about postpartum depression.

Hodnett 2002The intervention (continuous intrapartum support) was neither psychological nor psychosocial. Postpartum depression was not the primary or secondary outcome.

Imura 2006Not an RCT. Participants were consecutively enrolled to intervention or control group. Intervention (aromatherapy and massage) was not psychosocial or psychological.

Izzo 2005Outcomes were measured 15 years post delivery. No reliable depression measure was used. Women were asked how often they had experienced depression in the last month.

Katz 2009Intervention not targeting prevention; all participants had a depressive illness.

Katz 2009aIntervention not targeting prevention; all participants had a depressive illness.

Kealy 2003Not an RCT.

Keller 2011Participants were women who had given birth within 6-26 weeks.

Kershaw 2005Postpartum depression was not an outcome. Outcomes were fear of childbirth and post-traumatic stress.

King 2009Participants were women who had given birth within 12 months. 19% were currently taking medication for depression or anxiety.

Kleeb 2005Intervention was not psychosocial or psychological, but rather oral and written information about baby blues and postpartum depression.

Koltyn 1997The intervention (aerobic exercise) was neither psychological nor psychosocial.

Lara 2010Methodological concerns that could lead to selection and outcome bias. Inconsistant application of inclusion criteria. The first 44% of sample were assessed before randomisation for depression and those with depressive illness (measured with SCID) were to be ineligible. Howerver, 17.4% of those with a positive SCID were included in the study as decided by researcher. The report states that 'they showed no signs of great distress during the interview, reported having social support, were accepting of their pregnancy, had low anxiety scores and were unlikely to get treatment elsewhere'. The second 55% of the sample were assessed for depression after randomisation to increase recruitment numbers. There was also a differential rate of follow-up. At 6 weeks postpartum follow-up data were obtained on 61.4% of those in the control group and 28.4% in the intervention group. At 4-6 months postpartum the same difference occurred (61.4% vs 31.2%).

Leung 2011Not an RCT. Was a 'quasi-experimental design'.

Lewis 2011Intervention (telephone based exercise program) was not psychosocial or psychological.

Lieu 2000Premature assessment of postpartum depression (2 weeks after delivery), which was neither the primary nor secondary outcome.

Logsdon 200556% of participants 'showed evidence of depression'. The mean CES-D score at entry was 18.0 with standard deviation of 4.7.

Marks 2003Approximately 25% of participants were currently suffering from depression at recruitment and 49% had a depressive episode sometime during the perinatal period.

McKee 2006Intervention was not targeting prevention; non-depressed women were excluded and the mean BDI-II was 21.5 for those included.

Milgrom 201050% of participants had a depressive illness at entry (EPDS > 12). Was the pilot trial for Milgrom 2011.

Milgrom 201130% of participants had a depressive illness at entry (EPDS > 12). Is an RCT that followed the pilot trial (Milgrom 2010)

Mohammadi 2010Intervention (exercise) was not psychosocial or psychological.

Morrell 2009Women were 6 weeks postpartum at first assessment and 8 weeks at start of intervention.

Munoz 2007All participants had a depressive illness at entry (CES-D > 16).

Murphy 1989Premature assessment of postpartum depression (4-15 days after delivery).

Ngai 2009Improper randomisation procedure used. The characteristics of the study population and type of intervention met inclusion criteria for this review however, randomisation of women was not done. 2 hospitals were randomised to provide a childbirth psycho-education program or not. The authors stated that 'randomisation by woman was not feasible because of potential for contamination between study groups'. We considered including this trial as a cluster design but decided against it for the following reasons: 1) the number of clusters was very low (2 hospitals); 2) cluster size was small (92 women per cluster); 3) there were large differences in the baseline characteristics of age, education and income between the groups all favouring the experimental group (older, more educated and higher income); 4) the analysis was not done taking into account the cluster randomisation; and 5) no intra-class correlation coefficient was provided.

Norman 2010The intervention (physical therapy exercise) was neither psychological nor psychosocial.

Oakley 1991Intervention was not targeting the prevention of postpartum depression but depression among mothers of young children.

Okano 1998Not an RCT. Study examined an educational session retrospectively involving 2 non-randomised groups of women who sought psychiatric care postnatally.

Parry 2010Intervention not targeting prevention; all participants had a depressive illness.

Rees 1995Intervention was not targeting the prevention of postpartum depression but rather the treatment of antenatal depression.

Roman 200932% of participants had a depressive illness at entry (CES-D ≥ 24).

Ryding 2004Not an RCT. Women were placed in groups based on 18 pre-determined days of the month.

Saisto 2001Postpartum depression was neither a primary or secondary outcome; statistical results related to postpartum depression were not reported.

Selkirk 2006Not an RCT. Consents were numbered as they arrived, odd numbers were treatment and even numbers were control.

Serwint 1991Not an RCT. Group allocation was based on a 2-week period.

Shields 1997Study reports on an element of a larger trial where the primary and secondary outcome was not postpartum depression. Furthermore, 1 EPDS item (self-harm) was excluded rendering the clinical interpretability of the outcome data questionable.

Spinelli 1997Not an RCT. A single-group study evaluating an interpersonal psychotherapy intervention for the treatment of antenatal depression.

Spinelli 2003Intervention was not targeting the prevention of postpartum depression but rather the treatment of antenatal depression.

Sun 2004Postpartum depression was neither a primary or secondary outcome; outcome was maternal adaptation.

Taghizadeh 2008Postpartum depression was neither a primary or secondary outcome; outcome was post-traumatic stress.

Tandon 2011Women with a child less than 6 months old were enrolled.

Tang 2009Not an RCT. 'Divided into two groups according to their date of hospital visit.'

Teissedre 2004Not an RCT. Group allocated based on pre-numbered questionnaires (odd vs even numbers).

Tezel 2006Not an RCT. Women were matched on BDI score, parity and education level and then placed in treatment or control group.

Tseng 2010Postpartum depression was neither a primary or secondary outcome;outcomes were anxiety and stress. The intervention (listening to music) was neither psychological nor psychosocial.

Urech 2009Postpartum depression was neither a primary or secondary outcome;outcome was maternal affect. The intervention (progressive muscle relaxation and guided imagery) was neither psychological nor psychosocial.

Vieten 200831% of participants had a depressive illness at entry (CES-D > 16).

Webster 2003The intervention was not psychosocial or psychological but rather included antenatal identification as high-risk, an educational booklet and discussion about the risk of developing postpartum depression, and a letter to the woman's referring general practitioner and local Child Health Nurse alerting them of the woman's risk.

Wiggins 2005Intervention began at 10 weeks postpartum.

Wolman 1993The researchers significantly changed the study protocol before trial completion. Inability to assess selection bias. Trial had a 21% loss to follow-up and a poor measure of postpartum depression (Pitt Depression Inventory) was used for the main portion of the trial.

Xu 2003Translation of original article used. Intervention described as 'participants and husbands participate in a nursing course'; 'women visit the maternity ward'. No psychosocial or psychological component described.

Zayas 2002While the author identified the study as an RCT, no information was provided related to the randomisation process or the intervention. It is also unknown whether the outcome assessor was blinded or whether the data were analysed using 'intent-to-treat'. 51% of sample had depressive illness at entry.

 
Characteristics of studies awaiting assessment [ordered by study ID]
Ammaniti 2006

MethodsRCT with stratification by 3 risk categories: 1) low risk; 2) depressive risk but no psychosocial risk, and 3) psychosocial risk but no depressive risk.

Participants110 women were enrolled during the 2nd trimester of pregnancy in Rome, Italy. The number of women randomised to each group was not stated. We have contacted the authors for this information. Screening was done for depression (CES-D > 20) and psychosocial variables (such as education level, socioeconomic status, single motherhood, lack of social support) to determine stratification categories. No participants were receiving treatment for depression.

InterventionsIntervention group: home visits starting in the 8th month of pregnancy and continuing up to 1 year postpartum, with weekly visits in the first half of the programme and every 2 weeks thereafter. The visits were carried out by psychologists and social workers and aimed to improve maternal-infant interaction.

Control group:standard care with home visits for data collection only. No further details provided.

OutcomesOutcomes included maternal-infant attachment (Scales of Mother-Infant Interactional System), depression (CES-D) and maternal representations after birth at 12, 24 and 52 weeks postpartum. ACTUAL NUMBERS FOR DEPRESSION OUTCOME NOT REPORTED. AUTHORS HAVE BEEN CONTACTED FOR THIS INFORMATION AND STUDY WILL BE INCLUDED IN THE REVIEW WHEN WE RECEIVE THE DEPRESSION DATA.

NotesWe used the Cooperation subscale of the Scales of Mother-Infant Interactional System for the Maternal-Infant attachment outcome in this review. It was collected from a videotape of the mother feeding the infant. 2 independent judges rated the behaviours on the video. The Pearson correlation coefficient between judges for this measure was 0.72 (0.55-0.89).

Bernard 2011

Methods

Participants

Interventions

Outcomes

Notes

Bittner 2009

MethodsRCT.

ParticipantsWomen were screened antenatally for stress, anxiety and depression. Those with elevated levels were enrolled. Women with a current severe psychiatric disorder where excluded.

InterventionsIntervention group: in second trimester of pregnancy women took part in a group programme with psycho-educational and cognitive behavioural elements on how to deal with stress, anxiety and depression. There were 8 weekly sessions lasting 90 minutes each.

Control group: standard care.

OutcomesOutcomes included depression (BDI-V), stress (Prenatal Distress Questionnaire), anxiety (STAI) and cortisol levels. Time when outcome data collected not stated.

NotesOnly an abstract with early enrolment numbers is available. We contact the authors for more information. They state that the trial is completed and a publication is being prepared. When data are available we will include this trial in the review.

Caritis 2012

Methods

Participants

Interventions

Outcomes

Notes

Cook 2012

Methods

Participants

Interventions

Outcomes

Notes

Creedy 2011

Methods

Participants

Interventions

Outcomes

Notes

Crockett 2008

MethodsRCT.

Participants36 pregnant low-income, rural, African American women (19 in intervention group and 17 in usual care group) from Mississippi, USA who screened as being at risk for postpartum depression were enrolled at 24-31 weeks' gestation. Those women who met criteria for current depressive disorder or substance abuse were excluded.

InterventionsIntervention group: The ROSE Program (Reach Out, Stand strong, Essentials for new mothers) which involved 4 60-minute group session over 4 weeks and 1 50-minute individual booster session post-delivery. The intervention was given by trained counsellors.

Control group: standard antenatal care which included the usual information pamphlets given to all prenatal women.

OutcomesThe outcomes were depression (EPDS), social adjustment (Social Adjustment Scale), postpartum adjustment (Postpartum Adjustment Questionnaire) and parenting stress (Parenting Stress Index) at 2-3 and 12 weeks postpartum.

NotesThe number of women providing outcome data at each time point by group was not noted in the publication. Results were presented as repeated measures of variance. The authors have been contacted for this information. If such data are available this trial will be included in the review.

Feinstein 2000

MethodsRCT.

Participants106 pregnant women (49 in intervention group and 57 in control group) who admitted to hospital in pre-term labour in Rochester, USA. Women with evidence of psychiatric problems were excluded.

InterventionsIntervention group: information and support about preterm labour, coping with role changes and strategies to seek control over their environments given in mid-pregnancy and then again 1-2 weeks later. The intervention included keeping an activity journal, bi-weekly phone calls from the researcher, information was given by audiotape and written materials.

Control group: audiotapes and written material about nutrition during pregnancy and when to notify healthcare providers given at the same times as intervention group.

OutcomesOutcomes included depression (POMS - depression subscale), Anxiety (STAI) and pregnancy anxiety (Pregnancy Anxiety Scale) twice during pregnancy and 3-4 weeks after the baby was discharged home.

NotesAll data presented as adjusted means. The authors have been contacted for the raw data. If such data are available this trial will be included in the review.

Fenwick 2011

Methods

Participants

Interventions

Outcomes

Notes

Fu 2012

Methods

Participants

Interventions

Outcomes

Notes

Gao 2012

Methods

Participants

Interventions

Outcomes

Notes

Hoseininasab 2009

MethodsUnclear. Report states `randomised in two matched groups`.

Participants80 pregnant women (40 to intervention group and 40 to control group) in Tabriz, Iran.

InterventionsEducation in special classes at 24-30 weeks of pregnancy. No details about what this entailed.

OutcomesDepression (BDI) at 3-10 and 15-21 days postpartum.

NotesShort abstract that does not provide enough detail to determine eligibility for this review. The authors have been contacted for additional information about randomisation process and details of the intervention.

Howell 2011

Methods

Participants

Interventions

Outcomes

Notes

Howell 2012

Methods

Participants

Interventions

Outcomes

Notes

Kenyon 2012

Methods

Participants

Interventions

Outcomes

Notes

Kitamura 2007

MethodsUnclear. Report states `randomly assigned`.

ParticipantsStudy 1: 140 pregnant women in Japan. No further details provided.

InterventionsIntervention: 8 1-hour interviews during pregnancy and 5 group sessions based on interpersonal therapy (4 during pregnancy and 1 postpartum).

OutcomesDepression (EPDS) at 12 weeks postpartum.

Notes2 studies were outlined in the brief abstract. Study #2 appears to be an observational study. There are insufficient details about Study #1 to determine eligibility for this review and no data were presented. The author has been contacted for additional information.

Kozinszky 2012

Methods

Participants

Interventions

Outcomes

Notes

Matthey 2004

MethodsRCT with cluster-randomisation. Unit of randomisation was prenatal class.

Participants3 prenatal classes were randomised to 1 of 3 conditions (empathy class, baby play class and usual class) For the purposes of this review the empathy class will be considered the intervention group and the baby play and usual class will be combined as the control group. Thus there was 1 cluster in the intervention group and 2 in the control group. The number of classes conducted in each cluster during the 18 months of the study was not stated.

268 couples attending prenatal classes were enrolled (89 in the intervention group and 179 in the control group). Only mothers expected to move out of the general practice area were excluded.

InterventionsIntervention group: empathy prenatal classes which included 6 regular classes, 1 additional class focusing on postpartum psychosocial issues and mailouts reinforcing the content of the extra class.

Control group: 1) baby play classes which included 6 regular classes, 1 additional class focusing on baby play with no postpartum psychosocial focus and mailouts reinforcing the content of the extra class; 2) usual classes (6 regular sessions only).

OutcomesOutcomes included depression (EPDS, POMS, CES-D, SCID), social support (Significan Others Scale), self-esteem, parenting competence and infant care tasks at 6 and 26 weeks postpartum.

NotesThe researchers acknowledged the likelihood of contamination if individual couples within 1 prenatal class were randomised but stated 'there is no reason to expect that the within cluster correlation is likely to be different from the between cluster correlation and therefor sample size was not based upon cluster analysis'. No intra-cluster correlation coefficient was provided.

The data presented as adjusted scores and split by level of self-esteem at baseline. The authors have been contacted for data split by study group only. If such data are available this trial will be included in the review as a cluster trial.

Meijer 2011

Methods

Participants

Interventions

Outcomes

Notes

Morrell 2011

Methods

Participants

Interventions

Outcomes

Notes

Morrell 2011a

Methods

Participants

Interventions

Outcomes

Notes

Petrou 2006

Methods

Participants

Interventions

Outcomes

NotesThis reference is an economic analysis. A co-author on this paper (Peter Cooper) appears to be the principal investigator of the main trial and has been contacted for information.

Phipps 2008

Methods

Participants

Interventions

Outcomes

NotesThis is a trial registration only. It is the same trial as Phipps 2011.

Phipps 2011

Methods

Participants106 pregnant adolescent mothers < 18 years of age at first prenatal visit.

Interventions5 interpersonal psychotherapy sessions delivered during the prenatal period.

OutcomesClinical diagnosis of depression (KID-SCID) at 6, 12, and 24 weeks postpartum.

NotesPublished abstract. The authors have been contacted for more information.

Richter 2012

Methods

Participants

Interventions

Outcomes

Notes

Silverstein 2011

Methods

Participants

Interventions

Outcomes

Notes

Surkan 2012

Methods

Participants

Interventions

Outcomes

Notes

Timpano 2011

Methods

Participants

Interventions

Outcomes

Notes

Urizar 2011

Methods

Participants

Interventions

Outcomes

Notes

Varipatis-Baker 2006

Methods

Participants

Interventions

Outcomes

NotesThis is a trial registration only. The contact person Golda Ginsburg states the trial is complete has been asked for additional details.

Vidas 2011

Methods

Participants

Interventions

Outcomes

Notes

Willis 2012

Methods

Participants

Interventions

Outcomes

Notes

Wimmer-Puchinger 2007

Methods?RCT Authors state it was a 'prospective randomised controlled trial' and that women were 'divided'. No further details provided.

Participants3000 pregnant women at high risk for postpartum depression from Vienna Austria.

InterventionsIntervention group: offered psychotherapy. No further details provided.

OutcomesDepression (EPDS) at 12 and 26 weeks postpartum.

NotesThis reference was a short abstract and no data were included. The author has been contacted for additional information.

Wimmer-Puchinger 2011

Methods

Participants

Interventions

Outcomes

Notes

Zlotnick 2008

Methods

Participants

Interventions

Outcomes

NotesThis is a trial registration. The authors have been contacted for more information.

 
Characteristics of ongoing studies [ordered by study ID]
Griffiths 2009

Trial name or titleOnline cognitive behavioural therapy (MoodGYM)BDI for the prevention of postnatal depression in at-risk mothers: a randomised controlled trial.

Methods

Participants175 English-speaking women at 1-5 days postpartum with no clinical diagnosis of depression (as per MINI) but have an EPDS score > 9 (secondary preventative).

InterventionsOnline cognitive behavioural therapy (MoodGYM) - 5 modules which take between 20-40 minutes to complete; mothers to complete 1 module per week at their own pace.

OutcomesClinical diagnosis of depression (MINI) at baseline and 12 months following randomisation; EPDS at baseline, 6, 24, 52 weeks post randomisation.

Starting dateRecruitment to start 2012.

Contact informationBethany Jones,

Centre for Mental Health Research, The Australian National University

Email: bethany.jones@anu.edu.au

Notes

Mann 2001

Trial name or titleA randomised controlled trial of a psychological intervention given in pregnancy to reduce the risk of postnatal depression in a sample of high risk women in India.

Methods

Participants423 pregnant Indian women identified as high-risk based on a researcher developed risk score.

InterventionsHome-based 'listening visits' provided from 30 weeks' gestation to 10 weeks postpartum.

OutcomesPostpartum depression at 6, 12, and 24 weeks as measured using the EPDS and a revised clinical interview schedule providing a diagnosis according to ICD-10 criteria.

Starting dateData collection to end June 2004.

Contact informationDr Anthony Mann, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London, UK, Email: spjuahm@iop.kcl.ac.uk. When contacted Dr Mann stated that the trial was completed and Dr Marcus Hughes was in charge of publication.

Dr Marcus Hughes, South West London and St George's Mental Health NHS Trust, London, UK
Email: marcus.hughes@swlstg-tr.nhs.uk

NotesDr Hughes was contacted for additional information.

 
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]