Individual CBT and ideal standard care (weekly 20- to 60-minute supportive meetings) were equally effective in reducing depression scores immediately postintervention and 6 months thereafter as measured by the EPDS (1 RCT, N=37). Although a trend toward greater benefit for CBT was noted, the study was underpowered to identify a significant difference.
Nondirective counseling reduced the proportion of women with depression (N=55; RR=0.49; 95% CI, 0.26-0.95) and lowered EPDS scores (N=193; treatment effect=-2.1; 95% CI, -3.8 to -0.3; P=.02) compared with routine primary care. Individual CBT also reduced EPDS scores, when compared to routine primary care (N=55; treatment effect=-2.7; 95% CI, -4.5 to -0.9; P=.003).
Psychodynamic therapy reduced the proportion of women with major depression (N=55; RR=1.89; 95% CI, 1.33-2.33).
All of these interventions improved PPD immediately following treatment compared with routine primary care, but the benefits were not sustained at long-term follow-up (6 months). Study limitations included failure to control for multiple comparisons, pretreatment group differences, differential attrition among groups, and lack of sufficient power.
A later RCT (N=121) also found psychological interventions (group CBT and group and individual counseling) to be superior to routine primary care, with individual counseling yielding the greatest improvement in PPD symptoms (P<.05).4
Antidepressants vs CBT: Too little information
Two RCTs compared antidepressant medications to CBT.3 In the first (N=87), fluoxetine and placebo were each paired with 1 or 6 CBT sessions. After 12 weeks of treatment, fluoxetine was superior to placebo as measured by mean symptom score reduction on the HAM-D, EPDS, and clinical interview schedule; 6 CBT sessions were superior to a single session as measured by mean symptom score reduction on the Hamilton Depression Scale and clinical interview schedule.5 No significant interaction effect was found.
The authors reported “highly significant” improvements, but didn’t specify significance level or provide adequate information to calculate number needed to treat. Interpretation of the findings is limited by methodologic weaknesses, high withdrawal rate, and exclusion of breast-feeding women.3
A second, small RCT (N=35) compared 12 weeks of paroxetine with a combination of paroxetine and CBT.6 Significant improvements—defined as percentage of patients in each group demonstrating at least a 50% score reduction on the HAM-D (paroxetine, 87.5%; combination, 78.9%) and EPDS (paroxetine, 61.5%; combination, 58.3%)—occurred in both groups (P<.01), but no difference was found between the groups. The study didn’t include a placebo control group.
Recommendations
The National Collaborating Centre for Women’s and Children’s Health recommends against offering educational interventions to pregnant women because such interventions haven’t been found to reduce PPD.7
The Scottish Intercollegiate Guidelines Network recommends “postnatal visits, interpersonal therapy, and/or antenatal preparation” to prevent PPD. To treat PPD, they recommend psychosocial interventions, preferably those that include more than 1 family member.8