Cindy-Lee Dennis

Effect of peer support on prevention of postnatal depression among high risk women: multisite randomised controlled trial

Objective To evaluate the effectiveness of telephone based peer support in the prevention of postnatal depression. Design Multisite randomised controlled trial. Setting Seven health regions across Ontario, Canada. Participants 701 women in the first two weeks postpartum identified as high risk for postnatal depression with the Edinburgh postnatal depression scale and randomised with an internet based randomisation service. Intervention Proactive individualised telephone based peer (mother to mother) support, initiated within 48-72 hours of randomisation, provided by a volunteer recruited from the community who had previously experienced and recovered from self reported postnatal depression and attended a four hour training session. Main outcome measures Edinburgh postnatal depression scale, structured clinical interview-depression, state-trait anxiety inventory, UCLA loneliness scale, and use of health services. Results After web based screening of 21u2009470 women, 701 (72%) eligible mothers were recruited. A blinded research nurse followed up more than 85% by telephone, including 613 at 12 weeks and 600 at 24 weeks postpartum. At 12 weeks, 14% (40/297) of women in the intervention group and 25% (78/315) in the control group had an Edinburgh postnatal depression scale score >12 (χ2=12.5, P<0.001; number need to treat 8.8, 95% confidence interval 5.9 to 19.6; relative risk reduction 0.46, 95% confidence interval 0.24 to 0.62). There was a positive trend in favour of the intervention group for maternal anxiety but not loneliness or use of health services. For ethical reasons, participants identified with clinical depression at 12 weeks were referred for treatment, resulting in no differences between groups at 24 weeks. Of the 221 women in the intervention group who received and evaluated their experience of peer support, over 80% were satisfied and would recommend this support to a friend. Conclusion Telephone based peer support can be effective in preventing postnatal depression among women at high risk. Trial registration ISRCTN 68337727.

Interventions (other than pharmacological, psychosocial or psychological) for treating antenatal depression

BACKGROUNDnA meta-analysis of 21 studies suggests the mean prevalence rate for depression across the antenatal period is 10.7%, ranging from 7.4% in the first trimester to a high of 12.8% in the second trimester. Due to maternal treatment preferences and potential concerns about fetal and infant health outcomes, diverse non-pharmacological treatment options are needed.nnnOBJECTIVESnTo assess the effect of interventions other than pharmacological, psychosocial, or psychological interventions compared with usual antepartum care in the treatment of antenatal depression.nnnSEARCH METHODSnWe searched the Cochrane Pregnancy and Childbirth Groups Trials Register (31 January 2013), scanned secondary references and contacted experts in the field to identify other published or unpublished trials.nnnSELECTION CRITERIAnAll published and unpublished randomised controlled trials of acceptable quality evaluating non-pharmacological/psychosocial/psychological interventions to treat antenatal depression.nnnDATA COLLECTION AND ANALYSISnBoth review authors participated in the evaluation of methodological quality and data extraction. Results are presented using risk ratio (RR) for categorical data and mean difference (MD) for continuous data.nnnMAIN RESULTSnSix trials were included involving 402 women from the United States, Switzerland, and Taiwan. For most comparisons a single trial contributed data and there were few statistically significant differences between control and intervention groups.In a trial with 38 women maternal massage compared with non-specific acupuncture (control group) did not significantly decrease the number of women with clinical depression or depressive symptomatology immediately post-treatment (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.25 to 2.53; mean difference (MD) -2.30, 95% CI -6.51 to 1.91 respectively). In another trial with 88 women there was no difference in treatment response or depression remission rates in women receiving maternal massage compared with those receiving non-specific acupuncture (RR 1.33, 95% CI 0.82 to 2.18; RR 1.14, 95% CI 0.59 to 2.19 respectively).In a trial with 35 women acupuncture specifically treating symptoms of depression, compared with non-specific acupuncture, did not significantly decrease the number of women with clinical depression or depressive symptomatology immediately post-treatment (RR 0.47, 95% CI 0.11 to 2.13; MD -3.00, 95% CI -8.10 to 2.10). However, women who received depression-specific acupuncture were more likely to respond to treatment compared with those receiving non-specific acupuncture (RR 1.68, 95% CI 1.06 to 2.66).In a trial with 149 women, maternal massage by a womans significant other, compared with standard care, significantly decreased the number of women with depressive symptomatology immediately post-treatment (MD -6.70, 95% CI -9.77 to -3.63). Further, women receiving bright light therapy had a significantly greater change in their mean depression scores over the five weeks of treatment than those receiving a dim light placebo (one trial, n = 27; MD -4.80, 95% CI -8.39 to -1.21). However, they were not more likely to have a treatment response or experience a higher remission rate (RR 1.79, 95% CI 0.90 to 3.56; RR 1.89, 95% CI 0.81 to 4.42).Lastly, two trials examined the treatment effect of omega-3 oils. Women receiving omega-3 had a significantly lower mean depression score following eight weeks of treatment than those receiving a placebo (one trial, n = 33; MD -4.70, 95% CI -7.82 to -1.58). Conversely, in a smaller trial (21 women) there was no significant difference in the change in mean depression scores for women receiving omega-3 and those receiving a placebo (MD 0.36, 95% CI -0.17 to 0.89), and women who received omega-3 were no more likely to respond to treatment (RR 2.26, 95% CI 0.78 to 6.49) or have higher remission rates (RR 2.12, 95% CI 0.51 to 8.84). Women in the placebo group were just as likely to report a side effect as those in the omega-3 group (RR 1.12, 95% CI 0.56 to 2.27).nnnAUTHORS CONCLUSIONSnThe evidence is inconclusive to allow us to make any recommendations for depression-specific acupuncture, maternal massage, bright light therapy, and omega-3 fatty acids for the treatment of antenatal depression. The included trials were too small with non-generalisable samples, to make any recommendations.

A systematic review, evidence synthesis and meta-analysis of quantitative and qualitative studies evaluating the clinical effectiveness, the cost-effectiveness, safety and acceptability of interventions to prevent postnatal depression.

BACKGROUNDnPostnatal depression (PND) is a major depressive disorder in the year following childbirth, which impacts on women, their infants and their families. A range of interventions has been developed to prevent PND.nnnOBJECTIVESnTo (1) evaluate the clinical effectiveness, cost-effectiveness, acceptability and safety of antenatal and postnatal interventions for pregnant and postnatal women to prevent PND; (2) apply rigorous methods of systematic reviewing of quantitative and qualitative studies, evidence synthesis and decision-analytic modelling to evaluate the preventive impact on women, their infants and their families; and (3) estimate cost-effectiveness.nnnDATA SOURCESnWe searched MEDLINE, EMBASE, Science Citation Index and other databases (from inception to July 2013) in December 2012, and we were updated by electronic alerts until July 2013.nnnREVIEW METHODSnTwo reviewers independently screened titles and abstracts with consensus agreement. We undertook quality assessment. All universal, selective and indicated preventive interventions for pregnant women and women in the first 6 postnatal weeks were included. All outcomes were included, focusing on the Edinburgh Postnatal Depression Scale (EPDS), diagnostic instruments and infant outcomes. The quantitative evidence was synthesised using network meta-analyses (NMAs). A mathematical model was constructed to explore the cost-effectiveness of interventions contained within the NMA for EPDS values.nnnRESULTSnFrom 3072 records identified, 122 papers (86 trials) were included in the quantitative review. From 2152 records, 56 papers (44 studies) were included in the qualitative review. The results were inconclusive. The most beneficial interventions appeared to be midwifery redesigned postnatal care [as shown by the mean 12-month EPDS score difference of -1.43 (95% credible interval -4.00 to 1.36)], person-centred approach (PCA)-based and cognitive-behavioural therapy (CBT)-based intervention (universal), interpersonal psychotherapy (IPT)-based intervention and education on preparing for parenting (selective), promoting parent-infant interaction, peer support, IPT-based intervention and PCA-based and CBT-based intervention (indicated). Women valued seeing the same health worker, the involvement of partners and access to several visits from a midwife or health visitor trained in person-centred or cognitive-behavioural approaches. The most cost-effective interventions were estimated to be midwifery redesigned postnatal care (universal), PCA-based intervention (indicated) and IPT-based intervention in the sensitivity analysis (indicated), although there was considerable uncertainty. Expected value of partial perfect information (EVPPI) for efficacy data was in excess of £150M for each population. Given the EVPPI values, future trials assessing the relative efficacies of promising interventions appears to represent value for money.nnnLIMITATIONSnIn the NMAs, some trials were omitted because they could not be connected to the main network of evidence or did not provide EPDS scores. This may have introduced reporting or selection bias. No adjustment was made for the lack of quality of some trials. Although we appraised a very large number of studies, much of the evidence was inconclusive.nnnCONCLUSIONSnInterventions warrant replication within randomised controlled trials (RCTs). Several interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty.nnnFUTURE WORK RECOMMENDATIONSnSeveral interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty. Future research conducting RCTs to establish which interventions are most clinically effective and cost-effective should be considered.nnnSTUDY REGISTRATIONnThis study is registered as PROSPERO CRD42012003273.nnnFUNDINGnThe National Institute for Health Research Health Technology Assessment programme.

Preventing and treating postnatal depression

Comprehensive screening programmes and better organisation of care are key