Literature review

The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2232-2237

2232

Received: 20/12/2017 DOI: 10.12816/0045295 Accepted: 30/12/2017

Effectiveness of Psychological Intervention in Management of

Postpartum Depression Abdulrahman Abdulkhaliq Abdullah Alshehri

(1) , Husam Mohsen Bin Alhasel

(2) ,

Hiba Salah Abdelgadir (3)

(1) The faculty of Medicine, Albaha University, (2) Ibn Sina National College for Medical Studies, (3) Family Medicine, UMST University

Corresponding author: Abdulrahman Abdulkhaliq Abdullah Alshehri, Email: [email protected]

ABSTRACT

Background: In order to prevent postpartum depression many primary preventive programs were done.

Psychological interventions are thought to be effective in decreasing the incidence of postnatal depression.

Many studies aimed to evaluate the effect of Psychotherapy in treatment of postpartum depression.

Methods: An electronic search was obtained in MEDLINE and EMBASE databases with search terms such as

psychology, postpartum, depression, intervention, effectiveness. The primary search resulted in 128 studies

which have been screened for eligibility. After exclusion of irrelevant, duplicated and review studies, 11

studies were included in the review as they met the inclusion criteria.

Results: Psychotherapy decrease the likelihood of PPD and decrease postpartum depressive symptoms,

increased awareness, depression reduction, general improvement and psychological health and prevention of

PPD, improve depression, functioning and anxiety. Training for health visitors (HVs) intervention was found

to be cost-effective in reducing the proportion of women at risk. It was only noted that there was no outcome

difference between the CBA and the PCA groups. Health visitor (HV) training was noted to have preventive

effect for depression.

Conclusions: There is evidence to recommend that interventions carried in pregnancy can be effective in

preventing postnatal depression. Interventions are mainly effective when grounded on psychological

treatments and provided to women suffering from antenatal depression.

Keywords: Psychology, Postpartum, Depression, Intervention, Effectiveness

INTRODUCTION

Postpartum depression (PPD) also known as

postnatal depression, is a mood disorder that can

occur in women associated with childbirth (during

the six weeks of the puerperium) (1)

. Symptoms of

PPD include anxiety, irritability, guilt, feelings of

extreme sadness, exhaustion, sleep disorders and

somatic symptoms that affect the mother, children

and the whole family (1, 2)

. PPD is a global

phenomenon that affect large number of women

every year. In 2013 about 8.5% –11% of women

were diagnosed with depression during pregnancy (3)

.

The exact cause of PPD is unknown, but it

thought that combination of physical and emotional

factors which play an important role in its etiology (1,

4) . PPD has many risk factors such as lack of partner

support, single marital status, recent stressful life

events, low levels of social support and few number

of children. In addition, the previous major

depression is considered a risk factor to develop

postnatal attack of depression (5-8)

. Many studies

found that mothers who were satisfied with their

families are less likely to develop PPD, and the vice

versa (9-11)

.

Both counseling and medications are used in

the treatment of PPD. selective serotonin reuptake

inhibitors (SSRIs) is a drug of choice in the

treatment of PPD. Many types of counseling and

psychological therapy were used in treatment of

PPD such as; cognitive behavioral therapy (CBT),

interpersonal psychotherapy (IPT) and

psychodynamic therapy (12, 13)

.

In order to prevent PPD many primary

preventive programs were done. Psychological

interventions are thought to be effective in

decreasing the incidence of postnatal depression (5)

.

Many studies were conducted aiming to evaluate the

effect of Psychotherapy in treatment of PPD (14)

.

Interestingly, it was noted that postpartum

interventions to prevent and treat PPD were more

effective than interventions that done in the prenatal

and antenatal periods (15)

.

The aim of the present systematic review is to

assess all randomized controls trials that studied the

Effectiveness of Psychological Intervention…

2233

effectiveness of psychological intervention in

management of postpartum depression to review the

type of the psychological interventions and to

examine its effects on patients’ outcome. This

review will provide evidence-based data that can

help doctors to improve their patients’ outcome by

applying the best evidence treatment modalities.

METHODS An electronic search was obtained in MEDLINE

and EMBASE databases with search terms such as

psychology, postpartum, depression, intervention,

effectiveness. The primary search resulted in 128

studies which have been screened for eligibility.

After exclusion of irrelevant, duplicated and review

studies, 11 studies were included in the review as

they met the inclusion criteria. Included studies

aimed to assess the effectiveness of psychological

interventions in management of postpartum

depression. The data were extracted from included

studies in data collection forms demonstrated in

table 1.

RESULTS

Out of the 11 included studies, nine studies

were randomized controls trials (RCT), one pilot

study and one experimental trial. The total number

of patients were 18607 women. Age of the women

varies as were reported in 6 studies, with minimum

age of 20 to a maximum age of 37.

Edinburgh Postnatal Depression Scale

(EPDS) scores was used to measure the outcome of

PPD in all included studies. One study used in

addition EPDS, the work and social adjustment

scale, generalized Anxiety Disorder-7, postnatal

bonding questionnaire and social provisions scale.

Another study added state-trait anxiety inventory

(STAI), clinical outcomes in routine evaluation -

outcome measure (CORE-OM) score, 12-item short

form health survey (SF-12) and parenting stress

index short form (PSI-SF) scores in addition to

EPDS to evaluate their patient’s outcome. Hamilton

depression rating scale (HAM-D) and the beck

depression Inventory (BDI) were used too.

Regarding the aggravating factors of PPD

studies reported that risk factors of PPD include;

single women, lack of support from partner,

financial difficulties, assisted reproduction,

unplanned pregnancy and history of previous

unfavorable obstetric outcome. Financial status,

spouse’s job and type of delivery (Caesarean section

delivery) were other risk factors that reported by the

included studies.

Many types of psychological therapy were

used in treatment of the included patients. Cognitive-

behavioral therapy (CBT) was used in 4 studies.

Other interventions include psychotherapy and

relaxation training. Cognitive behavioral approach

(CBA) and person-centered approach (PCA) were

also used as well as training for health visitors (HVs)

plus either cognitive behavioral approach (CBA) or

person-centered approach (PCA) sessions in

treatment of included women. Many other types of

psychological treatment were used such as;

educational workshops, informational support,

encouragement to exercise and to look for social

support to exercise, telephone support sessions,

psychological treatment sessions, discharge

education on postnatal depression and group

interpersonal psychotherapy (IPT-G).

Regarding the effectiveness of psychological

intervention in management of postpartum

depression, this the reviewed studies concluded that;

psychotherapy decrease the likelihood of PPD and

decrease postpartum depressive symptoms,

increased awareness, depression reduction, general

improvement and psychological health and

prevention of PPD, improve depression, functioning

and anxiety. Training for health visitors (HVs)

intervention was found to be cost-effective in

reducing the proportion of women at risk. It was

only noted that there was no outcome difference

between the CBA and the PCA groups. Health

visitor (HV) training was noted to have preventive

effect for depression.

Abdulrahman Alshehri et al.

2234

Table (1): The included studies outcomes regarding Effectiveness of Psychological Intervention in Management

of Postpartum Depression

Study Study

design

Sampl

e size

Mothers

age

Outcome

measure

Aggravating

factors

Type of

psychological

intervention

Effectiveness of

the intervention

Kozinszky

et al. (16)

A

randomized

controlled

trial (RCT)

1,719

Mean

age=26 ±4

Edinburgh

Postnatal

Depression Scale

(EPDS) scores

Single

women,

financial

difficulties,

lack of

support

from partner,

unplanned

pregnancy,

and assisted

reproduction

Psychotherapy,

and cognitive-

behavioral

therapy and

relaxation

training

Reduce the

likelihood

of PPD and reduce

postpartum

depressive

symptoms

Moshki et

al. (17)

Pre-post

experimental

design

230

Mean

age=

28 +/-

6.39

Edinburgh

Postnatal

Depression Scale

(EPDS) scores

Financial

status,

spouse’s

job, and type

of delivery

Educational

workshops

The intervention

lead to increased

awareness,

depression

reduction, and

psychological

health and

prevention of PPD

Morrell et

al. (18)

A

prospective

cluster

randomized

trial

4084

Not

reported

Edinburgh

Postnatal

Depression Scale

(EPDS) scores

Not reported

Cognitive

behavioral

approach (CBA)

and

person centered

approach (PCA)

Reduction in

depressive

symptoms at six

months postpartum

Heh SS et

al. (19)

A

randomized

controlled

trial (RCT)

500 Not

reported

Edinburgh

Postnatal

Depression Scale

(EPDS) scores

Not reported

Informational

support

Lower postpartum

depression in the

controlled group

Daley et

al. (20)

A

randomized

controlled

trial

146

Mean

age=

31.7±5.3

Edinburgh

Postnatal

Depression Scale

(EPDS)

Not reported

Encouragement

to exercise and

to seek out

social support to

exercise

Lower mean EPDS

scores than those

randomized to

usual care only

O'Mahen

et al. (21)

A

randomized

controlled

trial

249 Not

reported

Edinburgh

Postnatal

Depression Scale

(EPDS),

Generalized

Anxiety

Disorder-7,

Work and Social

Adjustment

Scale, Postnatal

Bonding

Questionnaire,

and Social

Provisions Scale

Not reported Telephone

support sessions

Reduce depression,

anxiety and

improve

functioning

Mirabella A 1558 Not Edinburgh Not reported Psychological Significant

Effectiveness of Psychological Intervention…

2235

et al. (22)

randomized

controlled

trial

reported Postnatal

Depression Scale

treatment

sessions

improvements

Shiao-

Ming et

al. (23)

A

randomized

controlled

trial

200 20 -35

Edinburgh

Postnatal

Depression Scale

(EPDS)

Not reported

Discharge

education on

postnatal

depression

Intervention group

were less likely to

have high

depression scores

when compared to

the control group

at three months

postpartum

Morrell et

al. (24)

A

randomized

trial

7649

Not

reported

Edinburgh

Postnatal

Depression Scale

(EPDS)

Not reported

Training for

health visitors

(HVs),

PLUS

either cognitive

behavioral

approach (CBA)

or person-

centered

approach (PCA)

sessions for

eligible women

HV intervention

was highly likely

to be cost-effective

and reducing the

proportion of at-

risk women. There

was no difference

in outcomes

between the CBA

and the PCA

groups.

Brugha et

al. (25)

A

prospective

cluster

randomized

trial

2241

Mean

age=

31.4 +/- 5

Edinburgh

Postnatal

Depression Scale

(EPDS), Clinical

Outcomes in

Routine

Evaluation -

Outcome

Measure (CORE-

OM) score,

State-Trait

Anxiety

Inventory

(STAI), 12-item

Short Form

Health Survey

(SF-12) and

Parenting Stress

Index Short Form

(PSI-SF) scores

Living alone,

previous

postnatal

depression

(PND), the

presence of

one or more

adverse life

events

Health visitor

(HV) training,

and cognitive

behavioral or

person-centered

principles.

Universal,

enduring

preventive effect

for depression in

women who screen

negative for

depression

postnatally.

Reay et

al. (26)

A pilot

study 31

Mean

age=

31.8 +/-

6.2

Hamilton

Depression

Rating Scale

(HAM-D),

The Beck

Depression

Inventory (BDI),

Edinburgh

Postnatal

Depression

Scale (EPDS)

Not reported

Group

interpersonal

psychotherapy

(IPT-G)

Improve symptom

severity for women

suffering from

postnatal

depression

Abdulrahman Alshehri et al.

2236

DISCUSSION

Psychotherapy is thought to be effective in

treatment of postpartum depression (5)

. This meta-

analysis combined the outcomes of 11 RCTs that

included 18607 women with PPD. The review

revealed that psychological interventions are

effective in prevention and treatment of PPD.

All included studies used Edinburgh Postnatal

Depression Scale (EPDS) scores to diagnose and

measure the outcome of PPD treatment (16-26)

. This

means that the results are comparable and can be

generalized. Some studies used additional scales

such as postnatal bonding questionnaire and social

provisions scale (21)

, state-trait anxiety inventory

(STAI), clinical outcomes in routine evaluation -

outcome measure (CORE-OM) score, 12-item short

form health survey (SF-12), parenting stress index

short form (PSI-SF) scores (25)

, Hamilton depression

rating scale (HAM-D) and the beck depression

Inventory (BDI (26)

.

Compared with the usual methods of treatment

or the pharmacological treatment alone,

psychological interventions are associated with

reduction in the symptoms of PPD and outcome

improvement ( 16)

. Moreover, it also found to have

some preventive effects when it used in educational

workshops in prenatal and postnatal periods (17)

.

Prevention of PPD was also noted after using both

health visitor (HV) training and cognitive behavioral

therapy (25)

.

Educational workshops added an important

effect as it increased the awareness of PPD (17)

.

Psychological interventions have a positive effect in

reduction of PPD till six months of follow up (24)

.

Longer duration of follow up maybe needed to

evaluate the long-term effects of the psychological

interventions in patients with PPD. Regarding the

cost of treatment, psychological interventions found

to cost effective (24)

. Statistically significant

improvement in anxiety symptoms was noted (21)

.

PPD has many preventable risk factors as noted

in the reviewed studies. Being a single woman and

lack of partner support are important risk factors (16)

,

because pregnancy and delivery are important

periods in the women’s life in which they need

special care. Absence of partner or lack of support

during this period is thought to have an important

implication in the psychological wellbeing in the

antenatal and postnatal periods. Other important risk

factor was financial problems, as it causes a lot of

stress. Surprisingly, unplanned pregnancy, caesarean

section delivery and history of previous unfavorable

obstetric outcome were found to be a leading cause

to PPD (16, 17)

. As it is known, pregnancy is a special

period, lack of support, unwanted or unplanned

pregnancy and bad past obstetric history can be

precipitating factors for PPD. Fortunately, all these

risk factors are preventable. Manipulation of these

risk factor may decrease the possibility of

developing PPD over many different ways.

CONCLUSION

In conclusion, there is evidence to recommend

that interventions carried in pregnancy can be

effective in preventing postnatal depression.

Interventions are mainly effective when grounded on

psychological treatments and provided to women

suffering from antenatal depression. Prevention of

precipitating factors is important and needed to

decrease in incidence of PPD. There is evidence

suggesting that interventions that emphasis on

relationships problems may be beneficial. Further

studies on prevention of PPD may be needed.

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