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The US Preventative Services Task Force (USPSTF) has issued a final statement of recommendation and a summary of evidence on interventions to prevent depression in women during pregnancy and / or after delivery.
Based on "convincing evidence", the task force recommended counseling – particularly cognitive behavioral therapy (CBT) and interpersonal therapy – as being effective in preventing perinatal depression.
These modalities are particularly recommended for women with a history of depression, current depressive symptoms or economic risk factors such as low income or young or single parent parents.
"[Perinatal depression] is a very common problem. Our badysis of the evidence suggests that one in seven pregnant women will become depressed and that up to 40% will suffer during the postpartum period that will last one year, "said Task Force member and co-author, Ph.D., MSc. Medscape Medical News.
"Effective counseling interventions, especially CBT and interpersonal therapy, can help prevent perinatal depression before it develops," she added.
The recommendations were published online on February 12 in JAMA.
Reply to comments
USPSTF has a "very transparent and open process" that leads to "reviewing new recommendations," Davidson said.
The new recommendation was finalized following a preliminary draft that could be commented by the public from August 28, 2018 to September 24, 2018.
"We welcome suggestions from the public and society, and we regularly review the literature in areas related to screening and prevention to see if there is a new topic to develop."
"When we released our 2016 recommendations on screening for depression in all adults – including pregnant women – clinicians told us that it was very helpful to tell them what to do if a patient presented a screening test for probable depression – in other words, further diagnosis and treat depression if it were present, "she said.
"But there is of course a very large group of people who are not currently depressed but have depressive symptoms and are at risk of depression, including women during the perinatal period," she continued.
Since the role of the USPSTF is to make recommendations on the effectiveness of preventive care services for patients with no obvious signs or symptoms, it has focused its attention on this population, has it? she said.
Risk factors
The USPSTF "recommends clinicians to provide or refer pregnant or postnatal persons at increased risk of perinatal depression to counseling interventions."
This population is composed of pregnant women or women who have less than one year after delivery and who have not been diagnosed with depression, but who are at increased risk.
The recommendation is categorized as B, which means "there is great certainty that the net benefit is moderate, or moderate certainty that the health benefit is moderate to substantial".
Clinical risk factors that may be badociated with the development of perinatal depression include:
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Personal or family history of depression
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Physical or badual violence
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Have an unplanned or unwanted pregnancy
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Current stressful life events
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Gestational or gestational diabetes
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Complications during pregnancy (eg, premature delivery or pregnancy loss)
Social risk factors include:
Pragmatic approach
The authors cautioned that there was "no specific screening tool to identify women at risk for perinatal depression and who could benefit from preventive interventions".
Nevertheless, they encourage a "pragmatic approach based on populations included in the systematic examination of evidence".
This would involve providing counseling interventions to women with one or more of the following problems:
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History of depression
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Current depressive symptoms (not reaching a diagnostic threshold)
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Socio-economic risk factors (eg, low income, adolescence or single parenthood, recent intimate partner violence)
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Factors related to mental health (eg, high anxiety symptoms)
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History of significant negative life events
Effective interventions
The main interventions included in perinatal impression prevention studies were CBT and interpersonal therapy.
CBT "emphasizes the concept that positive mood and behavior changes can be achieved by addressing and managing negative thoughts, beliefs and attitudes, as well as by increasing events. and positive activities, "explain the authors.
Interpersonal therapy "focuses on the treatment of interpersonal problems that are supposed to contribute to the development or maintenance of psychological disorders," they say.
"We looked at studies of other interventions, such as physical activity education, pharmacotherapy, dietary supplements, and health system interventions, but we have not found enough evidence to judge their usefulness, "said Davidson.
She added that the working group "looks forward to further research in these areas".
The therapeutic programs included in the exam were mainly in person and used a group session format, with counseling sessions ranging from four to 20 sessions (median, eight meetings) lasting 4 to 70 hours. weeks.
The intervention staff included psychologists, midwives, nurses, and other mental health professionals.
The authors provide several examples of therapeutic programs, including the "Mothers and Babies" program, which uses a cognitive-behavioral approach, and the "Reach Out, Stay Strong, Essential for New Mothers" (ROSE) program, which uses a interpersonal therapy.
More than the 'Baby Blues & # 39;
"I can tell you, from other evidence, that the researchers studied the comparative effectiveness of online and in-person formats and face-to-face telephone deliveries, but we did not find no evidence of these types of delivery methods [online or telephone-based] in our review. "
She added that they "would certainly like more research so that we can evaluate the effectiveness of other approaches."
The authors note that no data are available on the "ideal time" to suggest or refer patients for counseling interventions, although most were initiated during the second or third trimester of the pregnancy.
"A continuous badessment of the risks incurred during pregnancy and the immediate postnatal period would be reasonable and a reference could be made at any time," they said.
Davidson pointed out that postpartum symptoms, sometimes called "baby blues," are different from actual clinical depression.
"Generally, the" baby blues "is a transitional period of irritability, crying and changes in sleep, while depression lasts more than 2 weeks, is accompanied by anhedonia or depressed mood and causes other additional symptoms, "she said.
"The key differentiator for clinicians is whether there are symptoms that clinically alter the patient and if the symptoms persist, clinicians must begin to think diagnostically if they meet the criteria for depression," he said. she added.
Real world challenges
Commenting on the recommendations for Medscape Medical NewsMarlene P. Freeman, MD, badociate professor of psychiatry at Harvard Medical School and badociate director of the Ammon-Pinizzatto Center for Women's Mental Health, Boston, Mbadachusetts, who was not involved in the task force, said that new guidelines have potential to help many women and their children ".
However, although the potential benefits are "notable", there are "major challenges to implementing the guidelines," warned Freeman, who is the author of an accompanying editorial.
One of the challenges is that it is "easier to detect acute perinatal depression than women at risk" because there are "easy-to-use screening tools for acute depression that have been used in obstetrics", but there is currently no "simple balance". "or" simple standards "for preventive screening.
In addition, screening for perinatal depression is "just a first step" and, after screening, "it is important that women receive treatment recommendations, that these recommendations are accessible and used, and that Follow-up is in place to ensure that women who: suffer from perinatal depression improve, "she said.
This poses a challenge because specialized psychotherapies may not be accessible to the large number of women who could benefit because "access to mental health care remains a major challenge in this country," she said. she observed.
For this reason, "it will be imperative for multidisciplinary health care providers, advocacy groups and other stakeholders to reflect together on how to ensure that women identified as" at risk "receive appropriate referrals. and can engage in care. "
She emphasized that it was important to take into account the many factors that would determine the most appropriate strategies for particular women's groups, including cultural, geographical, educational and socio-economic differences, as well as coverage of women's groups. 39, health insurance.
"It is likely that creative solutions will have to be found to ensure that treatments are available to women who need them," she said.
Davidson acknowledged that it can be difficult for health care providers to offer or refer patients to these interventions because "access to this type of care is not easy everywhere. "
She indicated that the USPSTF recommendation provides suggested resources for clinicians, including the SAMHSA (Administration of Psychoactive Substance Abuse and Mental Health) and the Center for Integrated Health Solutions (HRSA) proposing resources integrating the primary and behavioral health; the SAMHSA website, which provides resources to locate mental health services; and the website of the mothers and babies program.
In addition, Davidson encouraged clinicians to use the USPSTF's recommendation for screening for depression in adults.
The USPSTF is an independent and voluntary organization. The US Congress has asked the Agency for Health Research and Quality to support the operations of the USPSTF. No disclosure is listed for Davidson. Disclosures regarding other members of the working group are listed here. Freeman said he participated in research-initiated trials / research for Takeda, JayMac, and Sage; serving on advisory committees for Otsuka, Alkermes, Janssen, Sage and Sunovion; sits on an independent security and data monitoring committee for Janssen (Johnson & Johnson); and edit the newsletter GOED (World Organization for EPAs and Omega-3 DHA). Additional information provided by Freeman is listed with the original article.
JAMA. Published online February 12, 2019. Guidelines, Editorial 1, Editorial 2, Editorial 3, Editorial 4, Patient Page
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