Postpartum Depression: An Overview Of Treatment And Prevention

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Postpartum Depression:An Overview of Treatment and PreventionElizabeth Corey, MPH, MD CandidateShyam Thapa, PhDWorld Health OrganizationDepartment of Reproductive Health and ResearchFor online course (elective) in Sexual & Reproductive HealthGeneva Foundation for Medical Education and ResearchGeneva, August 2011

Outline General information about postpartum depression Treatments for postpartum depression Prevention methods for postpartum depression Treating and preventing postpartum depression in resource-poorsettingsAssignments

SourcesCochrane Reviews– Psychosocial and Psychological Interventions for PreventingPostpartum Depression (2008)– Psychosocial and Psychological Interventions for TreatingPostpartum Depression (2009)– Oestrogens and Progestins for Preventing and TreatingPostpartum Depression (2010)– Antidepressant Prevention of Postnatal DepressionAdditional articles not cited in the Cochrane Reviews found atthe WHO Library or PubMed searches (search conducted inJuly 2011)

Systematic Reviews (SRs)SR1: Psychosocial and psychological interventions for treating postpartum depression.Primary objective: Assess the effects of all psychosocial and psychological interventions compared withusual postpartum care in the recovery or reduction of depressive symptomatology.Number of studies: 10Type of studies: Randomized controlled trials and quasi-randomized trialsWhere: United Kingdom, Canada, United States, Australia and SwedenReference: Dennis CL and Hodnett ED. Psychosocial and Psychological Interventions for TreatingPostpartum Depression. Cochrane Database of Systematic Reviews. 2009.SR2: Oestrogens and progestins for preventing and treating postpartum depression.Primary objective: Assess the effects of oestrogens and progestins compared with placebo or usual care inthe prevention and treatment of postpartum depression.Number of studies: 2Type of studies: Randomized controlled trials08 XXX MM4Where: United Kingdom and South AfricaReference: Dennis CL, Ross LE and Herxheimer A. Oestrogens and Progestins for Preventing andTreating Postpartum Depression. Cochrane Database of Systematic Reviews. 2010.

Systematic Reviews (cont’d)SR3: Psychosocial and psychological interventions for preventing postpartum depression.Primary objective: Assess the effects of diverse psychosocial and psychological interventions comparedwith usual postpartum care to reduce the risk of developing postpartum depressionNumber of studies: 15Type of studies: Randomized controlled trialsWhere: Australia, United Kingdom, United States and ChinaReference: Dennis CL and Creedy DK. Psychosocial and Psychological Interventions for PreventingPostpartum Depression. Cochrane Database of Systematic Reviews. 2008.SR4: Antidepressant prevention of postnatal depression.Primary objective: To evaluate the effectiveness of antidepressant drugs in addition to standard clinical carein the prevention of postnatal depressionNumber of studies: 2Type of studies: Randomized controlled trials08 XXX MM5Where: United StatesReference: Howard L, Hoffbrand Se, Henshaw C, Boath L and Bradley E. Antidepressant Prevention ofPostnatal Depression. Cochrane Database of Systematic Reviews. 2009.

Definition of Postpartum DepressionNon-psychotic depressive episode that beginsor extends into the first year postpartumPostpartum depression is synonymous withpostnatal depression.Postpartum depression – a special state of mentalhealth disorder and a variant of depression

WHO Definition of Maternal Mental Health“A state of well-being in which a mother realizes her own abilities, cancope with the normal stresses of life, can work productively andfruitfully, and is able to make a contribution to her community.”Not the same as the absence of mental illness, but reflects a capacity toadapt and cope08 XXX MM7Depression -- the most common mental disorder!-- risk of depression in women is approximately two foldhigher than in menEngle PL. Maternal Mental Health: Program and Policy Implications. Am J clin Nutr 2009; 89(suppl): 963S-6S.Rahman A, Patel V, Maselko J and Kirkwood B. The neglected 'm' in MCH programmes- why mental health of mothers is important for childnutrition. Tropical Medicine and International Health 2008; 13(4): 579-583.

Maternal Mental Health and MDGsMental health not specifically mentioned in MDGs, but three goals aredirectly or indirectly related to women's mental health or the impact of theproblem– MDG 3: Promoting gender equality and empowering women– MDG 4: Reducing child mortality– MDG 5: Improving maternal healthEngle PL. Maternal Mental Health: Program and Policy Implications. Am J clin Nutr 2009; 89(suppl): 963S-6S.

Advocacy at the Global LevelLancet (2007, special series) Highlighted the critical lack of attention to mental health issues Emphasized the importance of including maternal depression as a riskfactor for improving women’s health and overall development (Gill et al.) “No health without mental health” (Patel et al.)WHO & UNFPA Joint Statement of June 200708 XXX MM9Maternal mental health is fundamental to attaining 5 of the 8 MDGs. Calledon international agencies and governments to take immediate action toaddress maternal health as part of health services.Engle PL. Maternal Mental Health: Program and Policy Implications. Am J clin Nutr 2009; 89(suppl): 963S-6S. VWorld Health Organization. Maternal mental health and child health and development in low and middle income countries. Report ofthe WHO-UNFPA meeting held in Geneva, Switzerland. 30 January- 1 February 2008.

2007 Joint Statement by WHO and UNFPASpecific recommendations Early detection and validated screening instruments Psychoeducational interventions that combine information withpsychological support Improvement in partner relationship through the promotion of gender equality Culturally sensitive, solution-focused brief psychological therapies Improvement in social support for women08 XXX MM10 Improvement in access to education and vocational training for girls and womenWorld Health Organization. Maternal mental health and child health and development in low and middle income countries. Report ofthe WHO-UNFPA meeting held in Geneva, Switzerland. 30 January- 1 February 2008.Engle PL. Maternal Mental Health: Program and Policy Implications. Am J Clin Nutr 2009; 89(suppl): 963S-6S. V

Why Focus on Postpartum Depression?Postpartum depression is a major health issue for manywomen from diverse cultures, yet it remainsunderdiagnosed and undertreated, especially in lowincome countries.Substantially contributes to maternal and infant morbidityand mortality

Adverse Effects: Maternal ParentingMaternal PPD can negatively affect themother’s ability to parentIt is associated with– Poorer responsiveness to infant cues– More negative, hostile, or disengagedparenting behavior

Adverse Effects: InfantMaternal PPD can also negatively affect the infantIn infants, maternal PPD is associated with––––––––Lower cognitive functioningAdverse emotional developmentProblematic sleep habitsLower preventative health care utilizationUndesirable safety practicesBehavioral problemHigher risk for anxiety, disruptive and affective disordersNegative breastfeeding and nutritional outcomesFitelson E, Kim S, Baker A and Leight K. Treatment of Postpartum Depression: Clinical, Psychological and Pharmacological Options.International Journal of Women’s Health 2011; 1(3): 1-14.

EtiologyUnclearHormonal basis for postpartum depression has beenhypothesized due to sudden and substantial fluctuationsin concentrations of steroid hormones– Little evidence supports a biological basisMultifactorial etiology has been suggested– Unlikely that a single preventive/treatment modality will beeffective for all womenDennis CL and Hodnett ED. Psychosocial and Psychological Interventions for Treating Postpartum Depression. Cochrane Database of SystematicReviews. 2009.

Prevalence13%(from a meta-analysis of 59 studies)More common and more grave for women in low-incomecountries, especially in sub-Saharan Africa and Asia(estimates range from 25% to 60%)Fitelson E, Kim S, Baker A and Leight K. Treatment of Postpartum Depression: Clinical, Psychological and Pharmacological Options. International Journal ofWomen’s Health 2011; 1(3): 1-14.

Risk FactorsPrevious history of depressionDepression or anxiety during pregnancyMarital conflictStressful recent life eventsLow levels of social support or partner supportLow socioeconomic statusObstetric complicationsStewart, D.E., Robertson, E., Dennis, C-L., Grace, S.L., & Wallington, T. (2003). Postpartum depression: Literature Review of Risk Factorsand Interventions.

Clinical ssThoughts of ation of symptoms is generally considered to be thesame as for episodes of major depression at other times.

DiagnosisMajor Depressive Episode (MDE) as defined by theDiagnostic and Statistical Manuel do not differ in thepostpartum period as compared to other timesInclude at least two weeks of persistent low mood oranhedoniaAND at least four of the following:– Increased or decreased appetite, sleep disturbance,psychomotor agitation or retardation, low energy, feelingsof worthlessness, low concentration and suicidal ideationFitelson E, Kim S, Baker A and Leight K. Treatment of Postpartum Depression: Clinical, Psychological and Pharmacological Options. InternationalJournal of Women’s Health 2011; 1(3): 1-14.

Screening for Postpartum DepressionThere are simple, generally reliable and affordable tools for therecognition of mental health problems in women during the perinatalperiodRecommended at first postnatal obstetrical visit (usually 4-6 weeksafter delivery) or in family practice or pediatric settingEdinburgh Postnatal Depression Scale* most commonly usedscreening tool– 10 item self-report that emphasizes emotional and functionalfactors rather than somatic symptoms*See Appendix for additional information

Widely Used Screening Instruments* for CommonMental Disorders in Primary-care Management(for adaptation for postpartum depression) General Health Questionnaires (GHQ, 12 items) Primary Health Questionnaire (PHQ, 9 items) Kessler Psychological Distress Scale (K10, 10 items, 6 items) Self-Reporting Questionnaire (SRQ, 20 items)08 XXX MM20All had relatively good internal consistency. However, predictive validity wasrelatively weak. Importance of balancing for the individual setting.Patel V, Araya R, Chowdhary N, King M, Kirkwood B, Nayak S, Simon G and Weiss HA. Detecting common mentaldisorders in primary care in India: a comparison of five screening questionnaires. Psychological Medicine (2008);38: 221-228.*See Appendix for additional information

Treatment: OverviewPharmacological– Antidepressant medication– Hormone therapyPsychological and Psychosocial––––––Interpersonal therapyCognitive behavioral therapyNondirective counselingPeer and partner supportParent-training programsTelephone interventions

PharmacologicalTreatments

Antidepressant MedicationGrowing amount of literature suggests that postpartumdepression can be thought of as a variant of major depressionthat respond similarly to antidepressant medicationConcerns– Metabolic changes in postpartum period– Exposure of the infant to medication through breast milk– Perceived stigma of being perceived as a “bad mother” forrequiring medicationDennis CL, Ross LE and Herxheimer A. Oestrogens and Progestins for Preventing and Treating Postpartum Depression. CochraneDatabase of Systematic Reviews. 2010.

Hormone TherapyOestrogens– In one trial of women with severe depression,oestrogen therapy was associated with greaterimprovement in depression compared with theplacebo– Additional studies neededProgestogen (synthetic)– May increase depressionDennis CL, Ross LE and Herxheimer A. Oestrogens and Progestins for Preventing and Treating Postpartum Depression. CochraneDatabase of Systematic Reveiws. 2010.

Many women may hesitate to take antidepressantsand hormones due to concerns about infantexposure to medication through breast milk orconcerns about potential side effects and thereforeoften prefer psychological treatments.

Psychological and Psychosocial Treatments

General InformationClear link between postpartum depression andlack of social supportOverall, uncertain effectMore research neededDennis CL and Hodnett ED. Psychosocial and Psychological Interventions for Treating Postpartum Depression. Cochrane Database ofSystematic Reviews. 2009.

Interpersonal Therapy (IPT)Patient and clinician select one of four interpersonalproblem areas (role transition, role dispute, grief orinterpersonal deficits) as treatment focus– Over course of therapy ( 12-20 weeks), strategies are pursuedto assist patients in modifying problematic approaches torelationships and building social support networksPreliminary results: IPT may be an effective treatmentWomen and Babies Health and Wellbeing: Action through Trials (WOMBAT). Maternal Mental Health Synthesis. 2011.

Cognitive Behavioral Therapy (CBT)Focuses on helping depressed patients modify distortedpatterns of negative thinking and to make behavioralchanges that enhance coping and reduce distressWell-studiedMeta-analysis of 28 studies found that CBT is aneffective treatment option– However, considerable time, commitment and cost is required tosuccessfully complete CBTDennis CL and Hodnett ED. Psychosocial and Psychological Interventions for Treating Postpartum Depression. Cochrane Database of SystematicReviews. 2009.

Nondirective CounselingAka “person-centered” counselingCounseling that recognizes people can often solve their ownproblems without being provided with a solution by thecounselorBased on use of empathetic and nonjudgmental listening andsupportFour European trials evaluated effectiveness: Positive resultsDennis CL and Hodnett ED. Psychosocial and Psychological Interventions for Treating Postpartum Depression. Cochrane Database of SystematicReviews. 2009.

Peer and Partner SupportStudies do not provide enough data to recommend aspecific partner-based interventionBut they do suggest that including partner in treatment ofPPD may be beneficial to some womenDennis CL and Hodnett ED. Psychosocial and Psychological Interventions for Treating Postpartum Depression. Cochrane Database of SystematicReviews. 2009.

Parent-Training ProgramsCompilation of 26 studies largely from developedcountries showed that parent programs have beneficialeffects on treating maternal postpartum depression,anxiety, self-esteem and relationship with spouse/marital adjustment, but not for social supportWomen and Babies Health and Wellbeing: Action through Trials (WOMBAT). Maternal Mental Health Synthesis. 2011.

Telephone InterventionsTelephone-based interventions are flexible, private and nonstigmatizing– Increased use of cell phones in low-income countriesPilot study found a positive result on PPD when evaluating theeffect of telephone-based peer (mother-to-mother) supportLarger studies warrantedDennis CL and Hodnett ED. Psychosocial and Psychological Interventions for Treating Postpartum Depression. TheCochrane Collaboration. 2009.

Other Nonpharmacologic Treatmentsfor Postpartum DepressionAdditional research is needed to evaluate their effectivenessElectroconvulsive therapyBright light therapyOmega-3 fatty acidsAcupuncture and massageExerciseFitelson E, Kim S, Baker A and Leight K. Treatment of Postpartum Depression: Clinical, Psychological and Pharmacological Options. InternationalJournal of Women’s Health 2011; 1(3): 1-14.

Prevention Methods

Prevention: OverviewPreventative approaches are needed because of the longterm effects of maternal PPDUsually focus on mitigating risk factorsLimited success of finding effective preventative approachesInterventions targeting “at-risk” women may be morebeneficial to those targeting the general populationDennis CL and Creedy DK. Psychosocial and Psychological Interventions for Preventing Postpartum Depression. Cochrane Database of SystematicReviews. 2008.

Prevention Methods: OverviewPsychosocial and Psychological Interventions– In-hospital psychological debriefings– Antenatal and postnatal classes– Home visits– Continuity of care and early postpartum follow-up– Professional support provided postnatally

Ineffective MethodsEvidence suggests that these methods shouldnot be implemented– In-hospital psychological debriefings after childbirth– Antenatal and postnatal classes about postpartumdepressionDennis CL and Creedy DK. Psychosocial and Psychological Interventions for Preventing Postpartum Depression. Cochrane Database of SystematicReviews. 2008.

Continuity of Care and EarlyPostpartum Follow-UpMixed resultsTwo trials evaluating the effect of early postpartum follow-up foundno preventive effectArmstrong, 1999- Research indicated that intensive nursing homevisits with at-risk mother was protective during the first six weekspostpartumMacArthur, 2002- Cluster randomized control trial found that flexible,individualized, midwifery-based postpartum care that incorporatedpostpartum depression screening tools had a preventative effectiveDennis CL and Creedy DK. Psychosocial and Psychological Interventions for Preventing Postpartum Depression. Cochrane Database of SystematicReviews. 2008.

Professional Support Provided PostnatallyProfessional home visit– Intensive nursing home visits– Flexible postpartum care provided by midwivesShows promise in preventing postpartumdepression– Individual based interventions may be more effectivethan group based interventionsDennis CL and Creedy DK. Psychosocial and Psychological Interventions for Preventing Postpartum Depression. Cochrane Database of SystematicReviews. 2008.

Three RCTs in Depression* Published in 2003Underlying objective -- Identify treatment options that are feasibleand affordable to low-income, poor populations in developingcountriesGroup therapy that emphasized support and sharing between members ofthe same community highly effective (in Uganda and Chile trials) and ChileEvidence to “actively combat the skepticism of policy makers that therenothing to be done against depression in developing countries.” (Patel et al.,2004)08 XXX MM41Araya A et al. Treating depression in primary care among low-income women in Santiago, Chile: a randomizedcontrolled trial. Lancet 2003:361:995-1000.Bolton P et al. Group interpersonal psychotherapy for depression in rural Uganda. J American Medical Association2003;289:3117-3124.Patel V et al. The efficacy and cost-effectiveness of a drug and psychological treatment for common mentaldisorders in general health care in Goa, India: a randomized controlled trial. Lancet 2003;361:33-39.Patel V et al. Editorial: Treating depression in the developing world. Tropical Medicine and International Health2004;9:539-541.*Note that these slides are not focused on postpartum depression, but depression in general. However, weincluded these reviews to emphasize the kinds of studies that can be undertaken focusing on maternal postpartumdepression.

Program Interventions by Community Health WorkersInvolvement of and Treatment by Community HealthWorkers Cognitive behavioral interventionsModified and delivered by CHWs (3 days of training along withintensive monthly group supervision) in a RCT in Pakistan08 XXX MM42Conclusion and ImplicationA health system does not need expensive mental-health specialists todeliver an effective intervention for most people with the most commonof all mental disorders.Rahman A et al. Cognitive behavior therapy-based Interventions by community health workers for mothers withdepression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet 2008; 371: 902-09.

Cognitive Behavioral Interventions by CHWs (cont’d)Participants: Married women in their t

Culturally sensitive, solution-focused brief psychological therapies . Fitelson E, Kim S, Baker A and Leight K. Treatment of Postpartum Depression: Clinical, Psychological and Pharmacological Options. International Journal of Women’s Health 2011; 1(3): 1-14. Screening for Postpartum Depression There are simple, generally reliable and affordable tools for the recognition of mental health .

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