Support and Training to Enhance Primary Care for Postpartum Depression

Brief Review of the Literature on Treating Depression

Women undergo many physiological, psychological, and social changes during pregnancy and after giving birth. For some, the postpartum period is marked by high levels of stress, which carry implications for both the presentation and management of PPD. To complicate matters further, every woman is affected differently by these stressors and changes. The etiology of PPD is thought to be determined by psychological, biological/genetic/hormonal, and environmental factors; thus, treatment decisions consider these factors.

PPD-Specific Treatments

Despite the potentially devastating effects of PPD on the mother, her infant, and her family, there is a paucity of valid and reliable data on PPD-specific treatments. 3 110 Only a few studies exist, and many of the existing studies have small sample sizes or other design flaws that make data interpretation difficult at best. The following is a brief summary of the empirically based research available on treatments for postpartum-specific depression.

Medications

Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) are commonly used with PPD and are equally effective at alleviating depressive symptoms within 4-8 weeks of when the woman begins to take the medication. While SSRIs and TCAs are both effective, some patients experience fewer side effects with SSRIs than with TCAs. 6 92 Common side effects of SSRIs and TCAs include dry mouth, gastrointestinal upset, nausea, and diminished sexual interest; anticholinergic side effects, such as dry mouth and constipation, are common with tricyclics specifically.

Research on mothers who take antidepressants while pregnant or breastfeeding suggests varying degrees of impact on infants. Recently published data indicate that fetal exposure to SSRIs during pregnancy is correlated with lower birth weight, premature labor (less than 37 weeks), neonatal respiratory distress, jaundice, and feeding problems. 59 While a great deal of debate is ongoing about antidepressant usage during pregnancy, there is at present no evidence suggesting that maternal medication usage during the postpartum carries increased risk for breastfeeding infants. Some data show that trace amounts of antidepressants are passed along to the infant through breastfeeding, but other investigators report they did not find any evidence of medication in serum samples taken from infants. 59 Even with cases in which detectable levels of antidepressant medication were found in breastfeeding infants, associated side effects or other adverse outcomes 59 were not observed. However, because the long-term effects of a mother’s medication usage on her breastfeeding infant are unknown, discretion is advised when prescribing antidepressants to breastfeeding mothers.

For more information on specific studies conducted on this topic, click here. 5 28

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Psychotherapy

The consensus of the American Psychiatric Association is that considerations for therapy for depression during and following pregnancy are identical to considerations during other times. 91 Given this fact, psychotherapy should be considered a first-line treatment for PPD (as with other depressive disorders).

The largest study of psychotherapy for PPD is a treatment trial investigating the effects of 12 weeks of Interpersonal Psychotherapy (IPT). In this study, IPT was compared to a waiting list control condition. A significantly larger drop was found in the Hamilton Rating Scale for Depression scores and Beck Depression Inventory scores in the therapy group versus the control group. 81 In addition, significantly fewer women in the therapy group met diagnostic criteria for depression at the 12-week assessment than women in the control group. Women with depression ranging from severe to mild in severity responded well to IPT.

Another study comparing Group Cognitive-Behavioral Therapy (GCBT), group counseling, individual counseling, and a control comparison group found that all three interventions decreased depressive symptoms compared to the control participants. 60 Individual therapy was more effective than group therapy, and the authors postulate that individual CBT would likewise be more effective in relieving depressive symptoms than GCBT.

Several studies have found non-directive listening visits to be effective in reducing Edinburgh Postnatal Depression Scale (EPDS) scores in women with mild to moderate PPD. 38 45 138 This form of counseling is generally provided by nurses or case managers who conduct the visits in the woman’s home. The use of listening visits as a therapeutic intervention is widespread in Europe but less used in the United States.

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Support

When used as part of a treatment regimen, peer support can reduce the effects of depression and improve treatment outcomes. A randomized control trial examining the effects of peer support on depression found a significant decrease in EPDS scores and higher reported satisfaction with treatment for those who received peer support. 33 Another randomized control study evaluating the effects of peer support on PPD found that those who attended four supportive group sessions had decreased BDI and Perceived Stress Scale (PSS) scores by the end of the fourth session in comparison to the control group. 97

Recent studies have found evidence that other types of support, such as that from friends and family, can have significant therapeutic effects on depression. 82 122 A study involving Vietnamese, Arabic, and Anglo-Celtic mothers found women with higher stress levels reported a greater need for social support, and women who reported less support than desired had higher EPDS scores. Cultural differences likely mediated whether the women desired additional support from their partners, mothers, or both. 29

It is important to note, however, that evidence does not support the efficacy of peer support or other types of social support for moderate to severe depression. These interventions should generally be considered as adjunctive treatment to empirically-validated forms of psychotherapy or medication for women with PPD.

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Empirical Research on Treatments for Major Depression

Over the past 20 years, a vast body of literature has emerged examining the efficacy of a variety of treatments for major depression. Recent meta-analyses conclude that the use of antidepressants or psychotherapy is almost twice as efficacious as no treatment (control) in achieving full remission. 61 Some researchers believe combining medication and therapy will provide the best outcome 94 , while others caution that combination therapy drives up cost without significant benefit. 61

Because PPD is different from major depression in several ways, it is important to recognize that what is effective for individuals with depression, in general, may not be effective and appropriate for women with PPD. Nonetheless, it is reasonable to look to the depression literature to learn what treatments might be effective for women with PPD. The dearth of data regarding the treatment of PPD highlights the need for more specific research in this area.

Click on the following links for a brief review of the literature on specific treatments for major depression:

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