EVIDENCE-BASED ANSWER
No, in most cases, counseling does not prevent postpartum depression (PPD), though it can treat the disorder. Overall, psychosocial interventions don’t offer a significantly greater benefit than standard care in preventing PPD—although studies do suggest a preventive benefit when the intervention is administered postnatally, in the home, and targeted toward individual at-risk women (strength of recommendation [SOR]: A, meta-analysis of 15 randomized, controlled trials [RCTs] and 1 subsequent RCT).
Psychotherapy and counseling—including interpersonal therapy, individual and group cognitive behavioral therapy (CBT), psychodynamic therapy, and nondirective counseling—are effective in treating PPD (SOR: A, systematic review of 15 RCTs and 1 later RCT). Not enough evidence exists to compare the benefits of antidepressant medication with CBT (SOR: B, 2 low-quality RCTs).
Clinical commentary
Do some research before you refer
Patrick O. Smith, PhD
University of Mississippi Medical Center, Department of Family Medicine, Jackson
Postpartum depression negatively impacts maternal satisfaction and is a major women’s health issue. Recognizing that psychosocial interventions are considered first-line, evidence-based treatments is important, but, beyond that, knowing how to locate a licensed professional who delivers these treatments may be critical to your patient.
One way to identify such a clinician is to use a Web-based search tool such as www.findapsychologist.org, provided by the National Register of Health Service Providers in Psychology (www.nationalregister.org). Once identified, contact the clinician and ask how s/he does what s/he does. If the answer is evidence-based treatments, you may have a strong candidate for treating a woman with PPD. Just remember: A referral is as important as the care you, yourself, provide.
Evidence summary
Prevention: No overall benefit, but some approaches may help
A Cochrane meta-analysis of pooled data from 15 RCTs (7697 women) found that psychological interventions didn’t prevent PPD based on comparison of initial depression scores with scores at the conclusion of the studies (relative risk [RR]=0.81; 95% confidence interval [CI], 0.65-1.02).1 Although some studies suggested short-term benefit (N=4091; RR=0.65; 95% CI, 0.43-1.00), benefits diminished over time and weren’t noted when the definition of depression was limited to an Edinburgh Postpartum Depression Scale (EPDS) score below 12 (out of a maximum of 30). Some differences were found when the data were stratified.
Certain interventions were found to prevent depressive symptoms (defined differently in the various studies). They were: home visits provided by healthcare professionals (2 RCTs, N=1663; RR=0.68; 95% CI, 0.55-0.84), interventions targeting at-risk women (7 RCTs, N=1162; RR=0.67; 95% CI, 0.51-0.89), and interventions begun postnatally (10 RCTs, N=6379; RR=0.76; 95% CI, 0.58-0.98). Notably, the level of training of providers of psychological interventions included in the meta-analysis was highly variable.
A later RCT of a 6-session cognitive-behavioral, midwife-administered intervention in mothers of preterm infants showed no preventive benefit (N=176; RR=1.02; 95% CI, 0.87-1.20).2
Treatment: Counseling helps, especially in the near term
A recent systematic review of 5 RCTs (N=450) investigated the effectiveness of interpersonal psychotherapy, CBT (individual and group), nondirective counseling, and psychodynamic therapy in reducing PPD symptoms.3
Interpersonal therapy (12 weekly sessions) significantly reduced PPD symptoms as measured by the Hamilton Depression Rating Scale (HAM-D) compared with a wait-list control group (1 RCT, N=120, RR=2.11; 95% CI, 1.04-4.28).