Make 4 different Literature reviews (part of a project) upon 4 researches. Avoid Plagiarism.The topic is Postpartum depression.Major: clinical psychologyThe 4 research are attached.

CONCISE REVIEW FOR CLINICIANS

Concise Review for Physicians and Other
Clinicians: Postpartum Depression

William V. Bobo, MD, MPH, and Barbara P. Yawn, MD, MSc, MSPH

CME Activity

Ma
ww

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Learning Objectives: On completion of this article, you should be able to
(1) describe the clinical features, onset, and course of postpartum depression,
(2)identifyappropriatetoolsandhowtheyareusedinscreeningforpostpartum
depression, (3) outline a clinical system to conduct appropriate screening
and evaluation of postpartum depression, and (4) evaluate and select appro-
priate initial interventions for patients diagnosed with postpartum depression.
Disclosures: As a provider accredited by ACCME, Mayo Clinic College of Med-
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Abstract

Postpartum depression (PPD) is a common, potentially disabling, and, in some cases, life-threatening
condition. Fortunately, PPD is also readily detectable in routine practice and is amenable to treatment
by a wide variety of modalities that are effective for treating nonpuerperal major depression. Postpartum
depression screening can improve case identification (an Edinburgh Postnatal Depression Scale score of
�13 indicates a high risk of PPD) and, when associated with a diagnostic and follow-up program, leads
to improved clinical outcomes. Symptom severity, patient preference, past response to treatment,
availability of local mental health care resources, and patient decisions about breast-feeding will drive
management decisions. In general, cognitive-behavioral therapy and interpersonal therapy are preferred
psychotherapies for women with mild to moderate PPD, whereas antidepressants are appropriate in
more severe cases. Many patients will require other types of assistance, such as parenting support, case
management, or care coordination because many barriers to receiving adequate PPD treatment must still
be overcome.

ª 2014 Mayo Foundation for Medical Education and Research n Mayo Clin Proc. 2014;89(6):835-844

From the Department of
Psychiatry and Psychology,
Mayo Clinic (W.V.B.), and
Department of Research,
Olmsted Medical Center
(B.P.Y.), Rochester, MN.

P
ostpartum depression (PPD), the onset
of depressive episodes after childbirth,
is the most common postnatal neuro-

psychiatric complication. Postpartum depres-
sion affects 10% to 20% of women after
delivery, regardless of maternal age, race,
parity, socioeconomic status, or level of edu-
cation.1 Postpartum depression can lead to

impaired maternal functioning and child
development.2,3 Yet, fewer than half of PPD
cases are diagnosed in clinical practice, thus
prompting vigorous efforts at improving
case detection and implementing evidence-
based treatment.3 This article provides a
clinical update on the etiology, risk factors,
diagnosis, and treatment of PPD.

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836

CLINICAL FEATURES

Diagnostic Criteria
There is no specific diagnostic classification for
PPD. However, signs and symptoms of PPD
are identical to those of nonpuerperal major
depression,3 and major depressive episodes
are diagnosed by using the usual criteria, but
with a pregnancy or postpartum onset specifier.
Previously adopted diagnostic criteria for PPD
(major depressive disorder, with postpartum
onset) required an onset of major depressive ep-
isodes within 4 weeks after childbirth (Table 1).
The “postpartum onset” specifier has been crit-
icized because a large number of diagnosed PPD
episodes actually begin during pregnancy.4

Thus, recently updated diagnostic criteria in
Diagnostic and Statistical Manual for Mental Dis-
orders, 5th edition (DSM-5) now classify major
depressive episodes “with peripartum onset,”
encompassing cases with symptom onset dur-
ing pregnancy or in the 4 weeks after delivery.4

Currently, depressive episodes occurring
after the end of the fourth postpartum week
would not meet DSM-5 diagnostic criteria for
“peripartum onset.” The 4-week time frame af-
ter delivery for defining PPD, however, may be
overly conservative. Indeed, longer time frames
(up to 12 months postpartum) have been used
in research studies to define PPD.2 Further-
more, the onset of depressive episodes remains
high for several months after delivery in post-
partum women (see below). And finally, in
practical terms, women are usually available
for depression screening between 4 and 12
weeks during routine postpartum follow-up,
and it seems unlikely that the optimal time
for PPD screening and evaluation would end
at 4 weeks postpartum.

Onset and Course
The prevalence of PPD appears to peak at 2
to 6 months after delivery, and as many as
14.5% of postpartum women may experience
a new depressive episode within 3 months af-
ter delivery.1 Most patients experience mild
depressive symptoms; however, 10% to
15% will have more severe symptoms that
clearly worsen maternal functioning. Post-
partum depression persists for more than 7
months after delivery for 25% to 50% of
women, and many remain depressed after 1
year.5

Mayo Clin Proc. n June 2014

Consequences
Postpartum depression is associated with im-
paired mother-infant bonding, negative par-
enting practices, unsuccessful breast-feeding,
and marital discord, as well as worse cognitive
and social development in offspring.2,3 However,
remission of maternal depression reduces the risk
of behavioral problems and psychiatric symp-
toms in offspring.2,6 A previous episode of PPD
increases the risk of future episodes of PPD, a
future diagnosis of bipolar disorder, and non-
puerperal major depressive episodes.7 Post-
partum depression is a risk factor for maternal
suicide, which accounts for up to 20% of post-
partum deaths.8

DIFFERENTIAL DIAGNOSIS AND
COMORBIDITY

Differential Diagnosis
Disturbed sleep and appetite are normal post-
partum occurrences; however, the onset of
clinically significant depression and anxiety
should prompt clinicians to consider a diag-
nosis of PPD. Coexisting medical conditions
that can mimic or exacerbate PPD include
postpartum thyroid disorders and anemia. De-
ficiencies in selected micronutrients (eg, B vi-
tamins and vitamin D) have been linked with
nonpuerperal major depression, but a firm as-
sociation with PPD has not been established.

Signs and symptoms of several psychiatric
conditions overlap with PPD, and must be
ruled out. These include the following:

d Postpartum blues occurs in 50% to 80% of
new mothers. Signs and symptoms appear
within 1 to 2 days postpartum and include
depressed mood, anxiety, tearfulness, irri-
tability, poor appetite, and sleep problems.
These changes are mild and resolve spon-
taneously within 10 to 14 days5; however,
up to 25% of the patients with postpartum
blues develop PPD.9

d Postpartum psychosis is a rare (<2 cases per 1000 postpartum women) but serious con- dition characterized by delusions, halluci- nations, severe and rapid mood swings, sleep disturbances, and obsessive preoccu- pation about the baby. These signs and symptoms emerge within 1 to 4 weeks after delivery and require urgent evaluation and hospitalization given a high risk of suicide

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POSTPARTUM DEPRESSION

and infanticide.10 Antipsychotic treatment is
usually required to manage hallucinations,
delusions, and agitation; electroconvulsive
therapy may be needed if antipsychotic
agents are ineffective or poorly tolerated.10

The risk of recurrence with future deliveries
after an index postpartum psychosis episode
is high.10 Therefore, women with a history of
postpartum psychosis must be closely fol-
lowed during the postpartum period.10

d Bipolar disorders (type I or II) are characterized
by episodes of depression, mania, hypoma-
nia, and mixed episodes (depression con-
current with mania). Bipolar and major
(unipolar) depressive episodes have the same
general diagnostic criteria4 but a history of
manic, mixed, or hypomanic episodes dis-
tinguishes bipolar depressive episodes. This
distinction is important because pharmaco-
therapy for bipolar and unipolar depression is
markedly different. The postpartum period
is a period of high risk for new-onset or
recurrent bipolar depressive episodes, and in
DSM-5, the peripartum onset specifier can be
applied to both bipolar and unipolar
depressive episodes.4 Brief screening tools for
bipolar disorder are available,11 but psychi-
atric referral may be needed to establish a
bipolar disorder diagnosis.

d Bereavement may occur in response to termi-
nation or lossof pregnancy, or neonatal death.
The rapid emergence of intense feelings of
grief, poor sleep and appetite, and rumination
about the loss can mimic PPD. Significant
losses can also precipitate PPD episodes.
Psychological support and careful follow-up
are recommended.

Psychiatric Comorbidity
Anxiety disorders and substance abuse are com-
mon in women with PPD. Women with PPD
frequently experience panic attacks, obsessions,
or compulsions. Obsessions and compulsions
may be particularly distressing and can com-
monly include thoughts about harming oneself
or the infant. However, they are recognized by
the mother as intrusive and irrational, and these
symptoms do not generally predict suicide or
infanticide.5 Still, obsessions about harming
oneself or the infant warrant careful evaluation
to rule out postpartum psychosis.

Women with substance use problems,
including use of alcohol, illicit drugs, and

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cigarettes, are at high risk for developing
PPD.12 Comorbid substance use worsens prog-
nosis and treatment response in patients with
nonpuerperal major depression, and similar
effects in women with PPD may be expected.
Screening for comorbid substance use disor-
ders can help tailor treatment interventions to
address co-occurring disorders.

CAUSES AND RISK FACTORS

Etiology
The causes of PPD are unknown; however, the
pathophysiology of PPD is thought to involve in-
teractions between biological susceptibility and
other risk factors (discussed below). Genetic
factors; declines in reproductive hormone levels
(ie, estrogen, progesterone, and testosterone);
changes in thyroid, hypothalamic-pituitary-
adrenal axis, and neuroactive steroid functioning;
and abnormalities in neurotransmitter, choles-
terol, and fatty acid activity are being investigated,
but no single causal factor has emerged.13

Risk Factors
A large number of risk factors for PPD have
been identified (Table 1). In general, history
of depression or anxiety problems (puerperal
or nonpuerperal), absent or inadequate sup-
port at home, ongoing stressful life events,
low income, and emotionally abusive or other
relationship problems with the partner appear
to have moderate to strong predictive effects
for PPD.2,14 Patients with a history of premen-
strual dysphoric disorder or depressive symp-
toms while taking oral contraceptives may
also be at a higher risk for PPD.15 Other higher
risk groups include adolescent mothers and
mothers of preterm babies.12

CLINICAL EVALUATION

Screening
Depression screening in the general population
is recommended by the US Preventive Services
Task Force,16 but routine PPD screening has
not been widely adopted.3 Effectiveness studies
of PPD screening have shown improved rates of
depression diagnosis and treatment, and a few
also demonstrate improved PPD outcomes.17

The effect of PPD screening programs on clin-
ical outcome may depend on availability of
adequate mental health resources, important

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TABLE 1. Keys to the Diagnosis of Postpartum Depression

1. Establish diagnostic threshold for major depressive disorder (MDD): 5 or more of 9 signs or symptoms (a through i below) persisting for �2 wk, with
at least 1 being an essential diagnostic feature (a or b below):
d Essential diagnostic features:
a. Persisting depressed mood Have you been feeling depressed or down most of the day, nearly

every day? How long has it lasted?
b. Persisting anhedonia Have you lost interest or pleasure in things that you usually enjoy? How

long has it lasted?
d Additional diagnostic signs and symptoms:
c. Changes in appetite or body weight (increase or decrease) Has your appetite changed from normal during the time you have been

feeling depressed? Have you started eating (more/less) than usual? Did
you intend to (gain/lose) weight?

d. Persisting insomnia or hypersomnia Have you noticed any changes in the amount or quality of your sleep during
the time you have been feeling depressed? How many yours a night
compared with normal? Do you have problems falling asleep, staying
asleep, or waking up too early (or a combination of these)?

e. Changes in psychomotor activity (agitated or slowed) Have you been so fidgety or restless that you couldn’t sit still? Have others
noticed (what did they say)? Have you or others noticed that you have
been talking or moving more slowly than usual?

f. Persisting fatigue or energy loss Have you felt tired or run down all the time, or nearly every day, during
the time you have been feeling depressed?

g. Feelings of worthlessness or excessive guilt Have you been feeling worthless on a daily or near-daily basis during the time
you have been feeling depressed? Have you been feeling more guilty than
usual about mistakes, things you have done, or even things you have not done?

h. Persisting problems concentrating or making decisions Has it been harder for you than normal to maintain your focus or think
through things during the time you have been feeling depressed?
Has it been harder to make everyday decisions?

i. Recurring thoughts of death or suicide Have you been thinking a lot about death, or that you might be better
off dead? Have you been thinking of hurting yourself? Have you done
anything to hurt yourself? Are you having these thoughts now?

2. Establish peripartum onset of depression according to updated (DSM-5 criteria):
Previously adopted (DSM-IV-TR) diagnostic criteria Updated (DSM-5) diagnostic criteria
d MDD with postpartum onset: onset of depressive symptoms
within 4 wk postpartum

d MDD with peripartum onset: onset of depressive symptoms during
pregnancy or within 4 wk postpartum

3. Link depressive signs and symptoms with maternal dysfunction: “Has your depression caused you to have any problems with .”
d . your ability to take care of yourself, eat right, or maintain
your hygiene?

d . your relationships, such as family, friends, or your partner? .
maintaining connection with others in your life?

d . your ability to take care of your baby, or feel close to (him/her)? d . your ability to work, study, or keep up around the house?
d . your ability to breast-feed (for those who choose to)? d . your ability to deal effectively with life stressors and solve problems

(specify the most important problems)?
4. Estimate the severity of symptoms on the basis of their level of impact on daily functioning:

Mild: mild disability, but can function normally
with considerable extra effort

Moderate: clear maternal dysfunction;
cannot be overcome with
extra effort, but not incapacitated

Severe: inability to function in most if not
all important life domains; suicidal
thinking is often prominent

Otherwise, the 10th item on the PHQ-9 (“. how difficult have these problems made it for you .”) can be used to estimate depressive
symptom severity:
Mild ¼ PHQ-9 item 10 “somewhat difficult” Moderate ¼ PHQ-9 item 10 “very

difficult”
Severe ¼ PHQ-9 item 10 “extremely

difficult”
5. Rule out postpartum thyroid disorders, anemia, and other medical illnesses that overlap with depression

d Consider: complete blood cell count (CBC), thyroid-stimulating hormone (TSH), vitamin D level, vitamin B12 and folate level, and other
laboratory screening tests as otherwise indicated

6. Rule out psychiatric disorders that overlap with major depression (as discussed in the article text)
d Screening questions for past mania or hypomania can
include the following:

Have you ever had a period of time in your life when you were not feeling
like yourself because your mood and your energy were unusually high,
and the speed of your thoughts was unusually fast? Did others tell you or
become concerned that you were behaving abnormally or talking too fast?

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TABLE 1. Continued

7. Screen for common comorbid psychiatric disorders (eg, anxiety and substance use disorders, as discussed in article text), and associated illness
features of potential concern (obsessive thoughts of harming the infant, psychotic signs and symptoms)
d Screening questions for pathological anxiety can include
the following:

Do you also have problems with anxiety, panic attacks, or worry that you
can’t seem to control? Do these problems interfere with your ability to
function in any way? How often does this occur?

d Screening questions for alcohol abuse can include the
following:

How often do you have a drink? Has your drinking caused problems for you?
Have you felt you ever needed to cut back or stop drinking because of this?
Have you taken a drink to try to reduce your depression? Has anyone
expressed concern about your drinking?

d Screening questions for other substance abuse can
include the following:

Have you ever used street drugs? Have you ever gotten hooked on a
prescribed medicine or taken one to get high (specify name of
medicine[s])? Have you ever taken more than you were supposed to?

d Screening questions for obsessive thinking (not necessarily
a diagnosis of obsessive-compulsive disorder) can include
the following:

Have you ever been disturbed by thoughts that made no sense, but kept coming
back, even when you tried to ignore them? Like being contaminated by germs,
or hurting someone else even if you really didn’t want to? Some women even
have thoughts about harming their baby that really upset them because they
don’t want to do thatdhave you also had these kinds of thoughts?

d Screening questions for psychosis can include the following: Do you ever hear things that others can’t, such as noises or voices of other people?
Do you ever hear voices that tell you to harm yourself or your baby? Have you
been concerned about people talking about you, spying on you, or planning to do
bad things to you? Do you receive special messages from the TV, radio, newspaper,
or the Internet? Have you felt that you were especially important or powerful in
some way, or had special powers to do things that others can’t do? Have you
been concerned that you have terrible disease or physical problem doctors can’t
explain or fix? Have you been concerned that you have committed some sort of
crime or done something so terrible that you need to be punished?

DSM-5 ¼ Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; DSM-IV-TR ¼ Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision;
PHQ-9 ¼ Patient Health Questionnaire 9.

POSTPARTUM DEPRESSION

nonclinical services (such as transportation,
child care, case management, lactational, and
parenting support), and insurance coverage.18

Screening should occur between 2 and 6
months after delivery at postpartum or well-
child visits.3 Several effective PPD screening tools
are available. The Edinburgh Postnatal Depres-
sion Scale (EPDS) is a 10-item self-report ques-
tionnaire that takes 5 minutes to complete.19 An
EPDS score of 13 or more is an accepted cutoff
score for identifying patients at risk for PPD.5

The Patient Health Questionnaire 9 (PHQ-9;
withan elevated cutoff score of�10) is an alterna-
tive to the EPDS that may be more familiar to pri-
mary care clinicians and can also be used to assess
depression severity and monitor effects of PPD
treatment.20 Special attention should be paid to
affirmative responses to the EPDS and PHQ-9
items that address suicidal ideation, regardless of
the total scores. Fathers are at risk for depression
if their partners develop PPD12 and may also
benefit from depression screening. Postpartum
depression screening should not be undertaken

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until a program for PPD evaluation, diagnosis,
and follow-up is linked to the screening
program.21

Evaluation and Diagnosis
The EPDS and other screening measures pro-
vide a basis for further clinical evaluation but
should not be considered a substitute for a
detailed clinical interview and diagnostic tests,
where indicated. The objectives of the clinical
evaluation are as follows: (1) to establish that
diagnostic criteria for PPD are met; (2) to assess
suicide and infanticide risk; (3) to distinguish
PPD from medical or other psychiatric
disorders discussed above; and (4) to identify
important psychiatric comorbidities or associ-
ated symptoms (such as anxiety, obsessions,
psychosis, and substance use disorders)
(Table 1). All prescription and over-the-
counter medications, drug use, smoking status
(and amount smoked), and herbal or homeo-
pathic remedies should be recorded during
evaluation and throughout treatment.

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MAYO CLINIC PROCEEDINGS

840

The effect of maternal depressive symptoms
on functional status during the postpartum
period should also be assessed (Table 1). Impor-
tantdomainsofmaternalfunctioningincludeper-
sonal care and hygiene, care of the infant, breast-
feeding success or difficulties, maintaining the
household, participation in social activities, and
ability to work.12 Current stressors, level of social
and financial support, and quality of relationships
with the partner and others should be queried.
The effect of depressive symptoms on daily func-
tioning can be grossly estimated using the final
item on the PHQ-9 that assesses how difficult
depressive symptoms have made it to work,
perform usual duties, or function in relationships.

Evaluation of medical history should in-
clude any chronic or active medical problem,
psychiatric diagnoses, and treatment (including
hospitalizations, medications, and nonpharma-
cological treatments [eg, psychotherapy and
electroconvulsive therapy]). The effectiveness,
tolerability, and reasons for discontinuing spe-
cific treatments are also included in this assess-
ment. Personal and family history of PPD and
postpartum psychosis should also be specif-
ically examined.

MANAGEMENT

Treatment Approach
Patients who screen positive and meet diagnostic
criteria for PPD need prompt treatment (Table 2).
Achieving remission of maternal depression im-
proves the psychiatric health of not only the
mother but also her children.6 Therefore, the
goal of depression treatment is to achieve remis-
sion of depressive symptoms. In general, treat-
ment decisions are driven by the severity of PPD
symptoms, patient preferences, past response to
treatment(s), availability of local mental health re-
sources,and patientchoices about breast-feeding.
Involving the patient’s support system in treat-
ment planning may help the patient feel less
burdened with difficult decisions about which
interventions to choose. Monitoring clinical re-
sponse with validated patient-rated depression
scales, such as the PHQ-9, can be a useful adjunct
to clinical observation and more general patient
self-report.

Mild to Moderate Depression
Psychotherapy is considered first-line treat-
ment for patients with mild (minimum

Mayo Clin Proc. n June 2014

diagnostic criteria met, negative effect on daily
activities overcome with extra effort) or mod-
erate PPD (symptoms cannot be overcome
with extra effort, but are not incapacitating).
Cognitive-behavioral therapy and interpersonal
therapy (IPT) are time-limited approaches
delivered over 10 to 20 weekly sessions. Both
are associated with moderate to large reductions
in PPD symptoms in controlled trials.22,23 For
patients with PPD who elect to forego formal
psychotherapy or in areas where cognitive-
behavioral therapy and IPT are unavailable,
weaker evidence supports the use of nondirec-
tive counseling for short-term benefit, but
longer-term effectiveness is uncertain.23 If psy-
chotherapy and counseling are unavailable or
unacceptable to the patient, or if depressive
symptoms become more severe,a trial of antide-
pressants can be considered.24 These recom-
mendations apply to women with mild to
moderate PPD, whether or not they are breast-
feeding.

Moderate to Severe Depression
Not Breast-Feeding. For women with moder-
ate to severe PPD who are not breast-feeding,
antidepressant medication with or without psy-
chotherapy is recommended. This also includes
women with initially mild PPD that increases in
severity, or moderate PPD that is poorly respon-
sivetopsychotherapyalone.Nosingleantidepres-
sant has shown greater benefit over others for
treating PPD. Therefore, antidepressants that
have been helpful and well tolerated in the past
are preferred, with continuation of effective anti-
depressant treatment for at least 6 months to pre-
vent relapses. For antidepressant-naive patients,
selective serotonin reuptake inhibitors such as
fluoxetine, paroxetine, and sertraline may be
considered on the basis of limited evidence in
patients with PPD and established effectiveness
for treating major depression in the general pop-
ulation.23 Otherwise, family history of positive
response to a given antidepressant for PPD or
nonpuerperal major depression can help guide
antidepressant selection. If there is a strong pref-
erenceforpsychotherapyalone,thisapproachcan
be supported as long as depressive symptoms are
carefully tracked.

Currently (or planning) Breast-Feeding.
Addressing PPD symptoms in the context of
breast-feeding can be challenging. Breast-feeding

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TABLE 2. Key General Management Considerations for PPD

1. Factors to consider when planning treatment:
d Severity of depressive signs and symptoms d Concurrent medical and psychiatric diagnoses
d Depression history/response to treatment d Current medications (including over-the-counter)
d Patient preferences regarding treatment d Local mental health care resources
d Choices about breast-feeding d Psychosocial supports

2. Involve the patient’s support system in treatment planning decisions, when appropriate
3. Consider case management or care coordinator for women who are eligible for such services based on economic, logistic, and clinical factors
4. Generate a reasonable menu of treatment options based on depressive symptom severity and decision to breast-feed. For example:

Severity Breast-feeding (Yes/No) Options

Mild to moderate Yes or no d Psychotherapy (interpersonal therapy [IPT] or cognitive-behavioral therapy
[CBT]) considered first-line

d Weaker evidence supports nondirective counseling
for short-term benefit

Moderate to severe No d Antidepressant medication, with or without psychotherapy
d Psychotherapy alone is still reasonable for many, as long as depressive symptoms
are carefully tracked

d Adding an antidepressant becomes higher priority in patients not responding well
to psychotherapy

Moderate to severe Yes d Antidepressant medication, with or without psychotherapy
d Many women elect not to receive antidepressants. If this occurs, psychotherapy
alone is still reasonable, as long as depressive symptoms are carefully tracked

d Antidepressants are higher priority when depressive symptoms persist or worsen
in spite of nonpharamacological treatment, or when depressive symptoms are severe

d Hospitalization, antipsychotic medication, and/or ECT if psychotic symptoms are present

5. Consider other psychosocial treatment options based on individual patient factors and available resources.
Group psychotherapy d Depressive symptoms are mild to moderate

d May benefit patients who struggle with isolation and low psychosocial support
Marital or couples therapy d Same as above, but prioritize if marital strain or difficulties with partner are clearly contributing to depression

d IPT can address interpersonal contributors to depression if the patient prefers an individual psychotherapy
approach, if the spouse/partner is unwilling or unavailable for therapy, or if local resources do not support
marital/couples therapy

Nondirective counseling d Depressive symptoms are mild, and symptoms can be carefully tracked
d Other resources are available should longer-term depression management be needed

Community supports d These are not generally considered stand-alone treatments for PPD
d Local support groups and organizations can be helpful by providing peer-to-peer support and, occasionally,
assistance with logistical difficulties

6. When choosing among antidepressants, consider past treatment response and available lactational safety data:
d Previously effective antidepressants (PPD or nonpuerperal major depression) should generally be given higher priority
d Otherwise, sertraline, paroxetine, fluvoxamine, and nortriptyline have the most evidence of lactation safety based on low (though not
absent) infant exposure through breast-feeding and fewest reported adverse effects

7. Nursing infants of mothers who are treated with antidepressants should be monitored for side effects (below). Infant blood levels of antidepressants
do not generally need to be monitored
d Drowsiness d Poor feeding
d Irritability d Poor weight gain

8. Consider referral to specialty mental health services when:
d Severe depression d Suicidal or homicidal ideation (urgent)
d Depression not responding to first-line treatment d Infanticidal ideation (urgent)
d Comorbid anxiety or obsessions d Psychotic signs and symptoms (urgent)
d Comorbid substance abuse d When uncomfortable managing the case
d Bipolar disorder suspected

ECT ¼ electroconvulsive therapy; PPD ¼ postpartum depression.

POSTPARTUM DEPRESSION

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MAYO CLINIC PROCEEDINGS

842

has numerous documented short- and long-
term health benefits for mother and child.
But these benefits must be weighed carefully
against risks of untreated PPD and risks and
benefits associated with antidepressants. All
antidepressants are passed from maternal
plasma to breast milk; thus, many women may
prefer psychotherapy over medication while
breast-feeding. Again, if there is a strong pref-
erence for psychotherapy alone, this approach
is reasonable if depressive symptoms are
closely monitored.

A role for antidepressants is more evident
when depressive symptoms persist in spite of
nonpharmacological interventions, and when
maternal illness is clearly interfering with self-
care, careof the infant, or interaction withthe in-
fant or other children. Use of a single agent with
an acceptable lactation safety profile at a mini-
mumeffectivedoseispreferred.Antidepressants
that have been effective and well tolerated dur-
ing past PPD or nonpuerperal major depressive
episodes are given higher priority but should be
initiatedatlowdosestolimit adverse effects.Ser-
traline is thought to be relatively safer than other
agents because of lower translactal passage and
fewerreportedeffectsontheinfant.25,26 Second-
ary options with most evidence of lactation
safety include paroxetine, fluvoxamine, and
nortriptyline.25,26 Paroxetine is a US Food and
Drug Agency pregnancy category D drug based
on risk of congenital (primarily cardiac) malfor-
mations with first-trimester use; however, this
does not apply to the use of paroxetine during
the postpartum period.

Mothers who are taking antidepressants
should be closely followed. Effective antide-
pressant treatment should continue for at
least 6 months to prevent relapse. Infant
behavior should be monitored for adverse
effects such as drowsiness, poor feeding/
weight gain, and irritability. If high antide-
pressant doses or multiple medications are
required, breast-feeding may need to be discon-
tinued. Pumping and discarding breast milk dur-
ing estimated times of peak antidepressant drug
concentrations in milk or taking antidepressants
immediatelyafterbreast-feedingissometimesrec-
ommended to limit infant antidepressant expo-
sure.24 However, there is little evidence of
benefit with either approach,24 and lag times to
peak drug concentration in breast milk vary by
individual.27

Mayo Clin Proc. n June 2014

Additional Considerations
Other Supports. Many women will benefit
from parenting support, case management, or
care coordination services to secure or maintain
insurance coverage and facilitate referrals to local
support groups, subsidized mental health cen-
ters, and other community-based resources. Pa-
tients and clinicians are encouraged to consult
with their local social service agencies to identify
additional resources, including public health
nurses, that are available in some counties in the
United States for following new mothers or
motherspreviouslyidentifiedasbeing ata higher
risk for problems with their newborns.

Other Interventions. Other nonpharmacologi-
cal treatment approaches with preliminary sup-
porting evidence include aerobic exercise, light
therapy, and infant massage.23 These can be
used as an adjunct to psychotherapy or phar-
macotherapy, but their effectiveness as stand-
alone treatments for PPD has not yet been
established. Electroconvulsive therapy may be
required in particularly severe cases, in consul-
tation with a psychiatrist. Preliminary support
for repetitive transcranial magnetic stimulation
for treating PPD awaits replication in random-
ized trials.28

Symptom Worsening. The published litera-
ture provides little guidance for addressing
worsening of PPD during active treatment. If
depressive symptoms worsen, reevaluating
the diagnosis and patient adherence to treat-
ment, assessing for comorbid psychiatric or
substance use disorders that may have been
previously missed, identification of new or
previously unaddressed life stressors, and
optimization of psychosocial treatment and
other supports (discussed above) are recom-
mended. Worsening depression in women
who receive psychotherapy alone should
prompt discussion about potential benefits
and risks of supplemental antidepressant
pharmacotherapy.

Referral. Psychiatric referral should also be
considered for patients with severe depression,
depression that is not responding adequately
to initial treatment, comorbid obsessions, or
other comorbid psychiatric illnesses. Patients
who express suicidal ideation or homicidal

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POSTPARTUM DEPRESSION

ideation, auditory hallucinations or delusional
thoughts, or bizarre behavior indicative of psy-
chosis require emergency mental health evalu-
ation and very careful follow-up.5 Some will
require hospitalization for intensive mental
health care.10 Obtaining periodic psychiatric
consultation or use of telehealth capabilities, if
available, may be useful if regular follow-up
visits with a psychiatrist are infeasible.

Patients Presenting on Maintenance Anti-
depressant Treatment. For patients who are
receiving maintenance pharmacotherapy due
to a history of severe, recurrent, or difficult-to-
treat depression, continuation of such treat-
ment into the postpartum period may be the
safest approach. This may be particularly so for
patients with a history of relapse after antide-
pressant discontinuation.

Prevention. For women with a history of PPD
or nonpuerperal major depression who are at
high risk for subsequent PPD episodes, the
optimal preventive approach has not been estab-
lished. Interpersonal therapy and postpartum
home visits can prevent PPD onset based on re-
sults of a recent meta-analysis.29 However, in-
terventions of this scope, particularly home
visits, are difficult to implement in everyday
practice. There are still few randomized trials of
antidepressants for preventing recurrence of
PPD in high-risk patients.

CONCLUSION
Postpartum depression is a common, potentially
disabling, and, in some cases, life-threatening
condition. Fortunately, PPD is also readily
detectable in routine practice and is amenable
to treatment by a wide variety of modalities
that are effective for treating nonpuerperal major
depression. Postpartum depression screening
improves case identification and can lead to bet-
ter clinical outcomes, although many barriers to
receiving adequate PPD treatment must often be
overcome. Cognitive-behavioraltherapy andIPT
are preferred psychotherapies for women with
mild to moderate PPD, whereas antidepressants
are appropriatefor moreseverecases.Inaddition
to symptom severity, treatment decisions will be
driven by patient preference, past response to
treatment, availability of local mental health
care resources, and patient decisions about
breast-feeding.

Mayo Clin Proc. n June 2014;89(6):835-844 n http://dx.doi.org/10.1
www.mayoclinicproceedings.org

Abbreviations and Acronyms: DSM-5 = Diagnostic and
Statistical Manual for Mental Disorders, 5th edition; EPDS =
Edinburgh Postnatal Depression Scale; IPT = interpersonal
therapy; PHQ-9 = Patient Health Questionnaire 9; PPD =
postpartum depression

Grant Support: The work was supported by grant K23
MH087747 (W.V.B.) from the National Institutes of Health,
grant R01-AG034676 (B.P.Y.) from the National Institutes
of Aging, and grant R01-HS40471 (B.P.Y.) from the Agency
for HealthCare Research and Quality.

Correspondence: Address to William V. Bobo, MD, MPH,
200 First St SW, Generose 2A, Rochester, MN 55905
(bobo.william@mayo.edu).

REFERENCES
1. Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G,

Swinson T. Perinatal depression: a systematic review of pre-
valence and incidence. Obstet Gynecol. 2005;106(5, Pt 1):
1071-1083.

2. O’Hara MW, McCabe JE. Postpartum depression: current
status and future directions. Annu Rev Clin Psychol. 2013;9:
379-407.

3. Gjerdingen DK, Yawn BP. Postpartum depression screening:
importance, methods, barriers, and recommendations for prac-
tice. J Am Board Fam Med. 2007;20(3):280-288.

4. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition. Washington, DC:
American Psychiatric Publishing; 2013:186-187.

5. Sit DK, Wisner KL. Identification of postpartum depression. Clin
Obstet Gynecol. 2009;52(3):456-468.

6. Pilowsky DJ, Wickramaratne P, Talati A, et al. Children of
depressed mothers 1 year after the initiation of maternal treat-
ment: findings from the STAR*D-Child Study. Am J Psychiatry.
2008;165(9):1136-1147.

7. O’Hara MW, Swain AM. Rates and risk of postpartum
depressionea meta-analysis. Int Rev Psychiatry. 1996;8(1):
37-54.

8. Lindahl V, Pearson JL, Colpe L. Prevalence of suicidality during
pregnancy and the postpartum. Arch Womens Ment Health.
2005;8(2):77-87.

9. Josefsson A, Berg G, Nordin C, Sydsjö G. Prevalence of depres-
sive symptoms in late pregnancy and postpartum. Acta Obstet
Gynecol Scand. 2001;80(3):251-255.

10. Sit D, Rothschild AJ, Wisner KL. A review of postpartum psy-
chosis. J Womens Health (Larchmt). 2006;15(4):352-368.

11. Hirschfeld RM, Calabrese JR, Weissman MM, et al. Screening for
bipolar disorder in the community. J Clin Psychiatry. 2003;64(1):
53-59.

12. Clare CA, Yeh J. Postpartum depression in special populations:
a review. Obstet Gynecol Surv. 2012;67(5):313-323.

13. Zonana J, Gorman JM. The neurobiology of postpartum
depression. CNS Spectr. 2005;10(10):792-799, 805.

14. Robertson E, Grace S, Wallington T, Stewart DE. Antenatal risk
factors for postpartum depression: a synthesis of recent litera-
ture. Gen Hosp Psychiatry. 2004;26(4):289-295.

15. Buttner MM, Mott SL, Pearlstein T, Stuart S, Zlotnick C,
O’Hara MW. Examination of premenstrual symptoms as a
risk factor for depression in postpartum women. Arch Womens
Ment Health. 2013;16(3):219-225.

16. The Agency for Healthcare Research and Quality. Recommen-
dations of the U.S. Preventive Services Task Force: the guide to
clinical preventive services 2007. Publication No. 07-05100.
2007. http://www.ncbi.nlm.nih.gov/books/NBK16363/. Accessed
January 14, 2014.

17. Effective Healthcare Program. Efficacy and safety of screening for
postpartum depression. AHRQ Publication No. 13-EHC064-EF.

016/j.mayocp.2014.01.027 843

mailto:bobo.william@mayo.edu

http://www.ncbi.nlm.nih.gov/books/NBK16363/

http://dx.doi.org/10.1016/j.mayocp.2014.01.027

http://www.mayoclinicproceedings.org

MAYO CLINIC PROCEEDINGS
844

2013. http://www.effectivehealthcare.ahrq.gov/ehc/products/
379/1437/postpartum-screening-report-130409 . Accessed
January 14, 2014.

18. Institute of Medicine. Depression in Parents, Parenting, and
Children. Washington, DC: National Academies Press; 2009.
http://books.nap.edu.openbook.php?record_id¼12565. Accessed
January 14, 2014.

19. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depres-
sion: development of the 10-item Edinburgh Postnatal Depres-
sion Scale. Br J Psychiatry. 1987;150(6):782-786.

20. Yawn BP, Pace W, Wollan PC, et al. Concordance of Edin-
burgh Postnatal Depression Scale (EPDS) and Patient Health
Questionnaire (PHQ-9) to assess increased risk of depres-
sion among postpartum women. J Am Board Fam Med.
2009;22(5):483-491.

21. Yawn BP, Olson AL, Bertram S, Pace W, Wollan P, Dietrich AJ.
Postpartum depression: screening, diagnosis, and management
programs 2000 through 2010. Depress Res Treat:363964. http://
www.ncbi.nlm.nih.gov/pmc/articles/PMC3413986. Accessed
January 14, 2014.

22. Sockol LE, Epperson CN, Barber JP. A meta-analysis of treatments
for perinatal depression. Clin Psychol Rev. 2011;31(5):839-849.

Mayo Clin Proc. n June 2014

23. Craig M, Howard L. Postnatal depression. Clin Evid (Online):
1407. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907780.
Accessed January 14, 2014.

24. Academy of Breastfeeding Medicine Protocol Committee.
ABM clinical protocol #18: use of antidepressants in nursing
mothers. Breastfeed Med. 2008;3(1):44-52.

25. Fortinguerra F, Clavenna A, Bonati M. Psychotropic drug use
during breastfeeding: a review of the evidence. Pediatrics.
2009;124(4):e547-e556.

26. Davanzo R, Copertino M, De Cunto A, Minen F, Amaddeo A.
Antidepressant drugs and breastfeeding: a review of the litera-
ture. Breastfeed Med. 2011;6(2):89-98.

27. Sie SD, Wennink JM, van Driel JJ, et al. Maternal use of SSRIs,
SNRIs and NaSSAs: practical recommendations during preg-
nancy and lactation. Arch Dis Child Fetal Neonatal Ed. 2012;
97(6):F472-F476.

28. Garcia KS, Flynn P, Pierce KJ, Caudle M. Repetitive transcranial
magnetic stimulation treats postpartum depression. Brain Stimul.
2010;3(1):36-41.

29. Dennis CL, Dowswell T. Psychosocial and psychological inter-
ventions for preventing postpartum depression. Cochrane Data-
base Syst Rev. 2013;(2):CD001134.

;89(6):835-844 n http://dx.doi.org/10.1016/j.mayocp.2014.01.027
www.mayoclinicproceedings.org

http://www.effectivehealthcare.ahrq.gov/ehc/products/379/1437/postpartum-screening-report-130409

http://www.effectivehealthcare.ahrq.gov/ehc/products/379/1437/postpartum-screening-report-130409

http://books.nap.edu.openbook.php?record_id=12565

http://books.nap.edu.openbook.php?record_id=12565

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3413986

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3413986

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907780

http://dx.doi.org/10.1016/j.mayocp.2014.01.027

http://www.mayoclinicproceedings.org

• Concise Review for Physicians and Other Clinicians: Postpartum Depression

Clinical Features
Diagnostic Criteria
Onset and Course
Consequences
Differential Diagnosis and Comorbidity
Differential Diagnosis
Psychiatric Comorbidity
Causes and Risk Factors
Etiology
Risk Factors
Clinical Evaluation
Screening
Evaluation and Diagnosis
Management
Treatment Approach
Mild to Moderate Depression
Moderate to Severe Depression
Not Breast-Feeding
Currently (or planning) Breast-Feeding
Additional Considerations
Other Supports
Other Interventions
Symptom Worsening
Referral
Patients Presenting on Maintenance Antidepressant Treatment
Prevention

Conclusion
References

TheEgyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2232-2237

2232

Received: 20/12/2017 DOI: 10.12816/0045295
Accepted: 30/12/2017

Effectiveness of Psychological Intervention in Management of

Postpartum

Depression

Abdulrahman Abdulkhaliq Abdullah Alshehri

(1)
, Husam Mohsen Bin Alhasel

(2)

,

Hiba Salah Abdelgadir
(3)

(1) The faculty of Medicine, Albaha University, (2) Ibn Sina National College for Medical Studies,
(3) Family Medicine, UMST University

Corresponding author: Abdulrahman Abdulkhaliq Abdullah Alshehri, Email: a.a.a.z.1412@hotmail.com

ABSTRACT

Background: In order to prevent postpartum depression many primary preventive programs were done

.

Psychological interventions are thought to be effective in decreasing the incidence of postnatal depression.

Many studies aimed to evaluate the effect of Psychotherapy in treatment of postpartum depression.

Methods: An electronic search was obtained in MEDLINE

and EMBASE databases with search terms such as

psychology, postpartum, depression, intervention, effectiveness. The primary search resulted in 128 studies

which have been screened for eligibility. After exclusion of irrelevant, duplicated and review studies, 11

studies were included in the review as they met the inclusion criteria.

Results: Psychotherapy decrease the likelihood of PPD and

decrease postpartum depressive symptoms,

increased awareness, depression reduction, general improvement and psychological health and prevention of

PPD, improve depression, functioning and anxiety. Training for health visitors (HVs) intervention was found

to be cost-effective in reducing the proportion of women at risk. It was only noted that there was no outcome

difference between the CBA and the PCA groups. Health

visitor (HV) training was noted to have preventive

effect for depression.

Conclusions: There is evidence to recommend that interventions carried in pregnancy can be effective in

preventing postnatal depression. Interventions are mainly effective when grounded on

psychological

treatments and provided to women suffering from antenatal depression.

Keywords: Psychology, Postpartum, Depression, Intervention, Effectiveness

INTRODUCTION

Postpartum depression (PPD) also known as

postnatal depression, is a mood disorder that can

occur in women associated with childbirth (during

the six weeks of the puerperium)
(1)

. Symptoms of

PPD include anxiety, irritability, guilt, feelings of

extreme sadness, exhaustion, sleep disorders

and

somatic symptoms that affect the mother, children

and the whole family
(1, 2)

. PPD is a global

phenomenon that affect large number of women

every year. In 2013 about 8.5% –11% of women

were diagnosed with depression during pregnancy
(3)

.

The exact cause of PPD is unknown, but it

thought that combination of physical and emotional

factors which play an important role in its etiology
(1,

4)
. PPD has many risk factors such as lack of partner

support, single marital status, recent stressful life

events, low levels of social support and few number

of children. In addition, the previous major

depression is considered a risk factor to develop

postnatal attack of

depression

(5-8)

. Many studies

found that mothers who were satisfied with their

families are less likely to develop PPD, and the vice

versa
(9-11)

.

Both counseling and medications are used in

the treatment of PPD. selective serotonin reuptake

inhibitors (SSRIs) is a drug of choice in the

treatment of PPD. Many types of counseling and

psychological therapy were used in treatment of

PPD such as; cognitive behavioral therapy (CBT),

interpersonal psychotherapy (IPT) and

psychodynamic therapy
(12, 13)

.

In order to prevent PPD many primary

preventive programs were done. Psychological

interventions are thought to be effective in

decreasing the incidence of postnatal depression
(5)

.

Many studies were conducted aiming to evaluate the

effect of Psychotherapy in treatment of PPD
(14)

.

Interestingly, it was noted that

postpartum

interventions to prevent and treat PPD were more

effective than interventions that done in the prenatal

and antenatal periods
(15)

.

The aim of the present systematic review is to

assess all randomized controls trials that studied the

Effectiveness of Psychological Intervention…

2233

effectiveness of psychological intervention in

management of postpartum depression to review the

type of the psychological interventions and to

examine its effects on patients’ outcome

. This

review will provide evidence-based data that can

help doctors to improve their patients’ outcome by

applying the best evidence treatment modalities.

METHODS
An electronic search was obtained in MEDLINE

and EMBASE databases with search terms such as

psychology, postpartum, depression, intervention,

effectiveness. The primary search resulted in 128

studies which have been screened for eligibility.

After exclusion of irrelevant, duplicated and review

studies, 11 studies were included in the review as

they met the inclusion criteria. Included studies

aimed to assess the effectiveness of psychological

interventions in management of postpartum

depression. The data were extracted from included

studies in data collection forms demonstrated in

table 1.

RESULTS

Out of the 11 included studies, nine studies

were randomized controls trials (RCT), one pilot

study and one experimental trial. The total number

of patients were 18607 women. Age of the women

varies as were reported in 6 studies, with minimum

age of 20 to a maximum age of 37.

Edinburgh Postnatal

Depression Scale

(EPDS) scores was used to measure the outcome of

PPD in all included studies. One study used in

addition EPDS, the work and social adjustment

scale, generalized Anxiety Disorder-7,

postnatal

bonding questionnaire and social provisions scale.

Another study added state-trait anxiety inventory

(STAI), clinical outcomes in routine evaluation –

outcome measure (CORE-OM) score, 12-item short

form health survey (SF-12) and parenting stress

index short form (PSI-SF) scores in addition to

EPDS to evaluate their patient’s outcome.

Hamilton

depression rating scale (HAM-D) and the beck

depression Inventory (BDI) were used too

.

Regarding the aggravating factors of PPD

studies reported that risk factors of PPD include;

single women, lack of support

from partner,

financial difficulties, assisted reproduction,

unplanned pregnancy and history of

previous

unfavorable obstetric outcome. Financial

status,

spouse’s job and type of delivery (Caesarean section

delivery) were other risk factors that reported by the

included studies.

Many types of psychological therapy were

used in treatment of the included patients. Cognitive-

behavioral therapy (CBT) was used in 4 studies.

Other interventions include psycho

therapy and

relaxation training. Cognitive behavioral approach

(CBA) and person-centered approach (PCA) were

also used as well as training for health visitors (HVs)

plus either cognitive behavioral approach (CBA) or

person-centered approach (PCA) sessions in

treatment of included women. Many other types of

psychological treatment were used such as;

educational workshops, informational support,

encouragement to exercise and to look for social

support to exercise, telephone support sessions,

psychological treatment sessions, discharge

education on postnatal depression and group

interpersonal psychotherapy (IPT-G).

Regarding the effectiveness of psychological

intervention in management of postpartum

depression, this the reviewed studies concluded that;

psychotherapy decrease the likelihood of PPD and

decrease postpartum depressive symptoms,

increased awareness, depression reduction, general

improvement and psychological

health and

prevention of PPD, improve depression,

functioning

and anxiety. Training for health visitors (HVs)

intervention was found to be cost-effective in

reducing the proportion of women at risk. It was

only noted that there was no outcome difference

between the CBA and the PCA groups. Health

visitor (HV) training was noted to have preventive
effect for depression.

Abdulrahman Alshehri et al.

2234

Table (1): The included studies outcomes regarding Effectiveness of Psychological Intervention in Management

of Postpartum Depression

Study
Study

design

Sampl

e size

Mothers

age

Outcome

measure

Aggravating

factors

Type of

psychological

intervention

Effectiveness of

the intervention

Kozinszky

et al.
(16)

A

randomized

controlled

trial (RCT)

1,719

Mean

age=26 ±4

Edinburgh

Postnatal

Depression Scale

(EPDS) scores

Single

women,

financial

difficulties,

lack of

support

from partner,

unplanned

pregnancy,

and assisted

reproduction

Psychotherapy,

and cognitive-

behavioral

therapy and

relaxation

training

Reduce the

likelihood

of PPD and reduce

postpartum

depressive

symptoms

Moshki et

al.
(17)

Pre-post

experimental

design

230

Mean

age=

28 +/-

6.39

Edinburgh
Postnatal
Depression Scale
(EPDS) scores

Financial

status,

spouse’s

job, and type

of delivery

Educational

workshops

The intervention

lead to increased

awareness,

depression

reduction, and

psychological
health and

prevention of PPD

Morrell et

al.
(18)

A

prospective

cluster

randomized

trial

4084

Not

reported

Edinburgh
Postnatal
Depression Scale
(EPDS) scores

Not reported

Cognitive

behavioral

approach (CBA)

and

person

centered

approach (PCA)

Reduction in

depressive

symptoms at six

months postpartum

Heh SS et

al.
(19)

A
randomized
controlled
trial (RCT)

500
Not

reported
Edinburgh
Postnatal
Depression Scale
(EPDS) scores
Not reported

Informational

support

Lower postpartum

depression in the

controlled group

Daley et

al.
(20)

A
randomized
controlled
trial

146

Mean
age=

31.7±5.3

Edinburgh
Postnatal
Depression Scale

(EPDS)

Not reported

Encouragement

to exercise and

to seek out

social support to

exercise

Lower mean EPDS

scores than those

randomized to

usual care only

O’Mahen

et al.
(21)

A
randomized
controlled
trial

249
Not

reported
Edinburgh
Postnatal
Depression Scale

(EPDS),

Generalized

Anxiety

Disorder-7,

Work

and Social

Adjustment

Scale, Postnatal

Bonding

Questionnaire,

and Social

Provisions Scale

Not reported
Telephone

support

sessions

Reduce depression,

anxiety and

improve

functioning

Mirabella A 1558 Not Edinburgh Not reported Psychological Significant

Effectiveness of Psychological Intervention…

2235

et al.
(22)

randomized

controlled
trial

reported Postnatal

Depression Scale

treatment

sessions

improvements

Shiao-

Ming et

al.
(23)

A
randomized
controlled
trial

200 20 -35

Edinburgh
Postnatal
Depression Scale
(EPDS)
Not reported

Discharge

education on

postnatal
depression

Intervention group

were less likely to

have high

depression scores

when compared to

the control group

at three months

postpartum
Morrell et

al.
(24)

A
randomized
trial

7649

Not
reported
Edinburgh
Postnatal
Depression Scale
(EPDS)
Not reported

Training for

health visitors

(HVs),

PLUS

either cognitive

behavioral
approach (CBA)

or person-

centered
approach (PCA)

sessions for

eligible women

HV intervention

was highly likely

to be cost-effective

and reducing the

proportion of at-

risk women. There

was no difference

in outcomes

between the CBA

and the PCA

groups.

Brugha et

al.
(25)

A
prospective
cluster
randomized
trial

2241

Mean
age=

31.4 +/- 5

Edinburgh
Postnatal
Depression Scale

(EPDS), Clinical

Outcomes in

Routine

Evaluation –

Outcome

Measure (CORE-

OM) score,

State-Trait

Anxiety

Inventory

(STAI), 12-item

Short Form

Health Survey

(SF-12) and

Parenting Stress

Index Short Form

(PSI-SF) scores

Living alone,

previous
postnatal
depression

(PND), the

presence of

one or more

adverse life

events

Health visitor

(HV) training,

and cognitive

behavioral or

person-centered

principles.

Universal,

enduring

preventive effect

for depression in

women who screen

negative for

depression

postnatally.

Reay et

al.
(26)

A pilot

study
31

Mean
age=

31.8 +/-

6.2

Hamilton
Depression

Rating Scale

(HAM-D),

The Beck

Depression

Inventory (BDI),

Edinburgh
Postnatal
Depression

Scale (EPDS)

Not reported

Group

interpersonal

psychotherapy

(IPT-G)

Improve symptom

severity for women

suffering from

postnatal
depression

Abdulrahman Alshehri et al.

2236

DISCUSSION

Psychotherapy is thought to be effective in

treatment of postpartum depression
(5)

. This meta-

analysis combined the outcomes of 11 RCTs that

included 18607 women with PPD. The review

revealed that psychological interventions are

effective in prevention and treatment of PPD.

All included studies used Edinburgh Postnatal

Depression Scale (EPDS) scores to diagnose and

measure the outcome of PPD treatment
(16-26)

. This

means that the results are comparable and can be

generalized. Some studies used additional scales

such as postnatal bonding questionnaire and social

provisions scale
(21)

, state-trait anxiety inventory

(STAI), clinical outcomes in routine evaluation –
outcome measure (CORE-OM) score, 12-item short

form health survey (SF-12), parenting stress index

short form (PSI-SF) scores
(25)

, Hamilton depression

rating scale (HAM-D) and the beck depression

Inventory (BDI
(26)

.

Compared with the usual methods of treatment

or the pharmacological treatment alone,

psychological interventions are associated with

reduction in the symptoms of PPD and outcome

improvement (
16)

. Moreover, it also found to have

some preventive effects when it used in educational

workshops in prenatal and postnatal periods
(17)

.

Prevention of PPD was also noted after using both

health visitor (HV) training and cognitive behavioral

therapy
(25)

.

Educational workshops added an important

effect as it increased the awareness of PPD
(17)

.

Psychological interventions have a positive effect in

reduction of PPD till six months of follow up
(24)

.

Longer duration of follow up maybe needed to

evaluate the long-term effects of the psychological

interventions in patients with PPD. Regarding the

cost of treatment, psychological interventions found

to cost effective
(24)

. Statistically significant

improvement in anxiety symptoms was noted
(21)

.

PPD has many preventable risk factors as noted

in the reviewed studies. Being a single woman and

lack of partner support are important risk factors
(16)

,

because pregnancy and delivery are important

periods in the women’s life in which they need

special care. Absence of partner or lack of support

during this period is thought to have an important

implication in the psychological wellbeing in the

antenatal and postnatal periods. Other important risk

factor was financial problems, as it causes a lot of

stress. Surprisingly, unplanned pregnancy, caesarean

section delivery and history of previous unfavorable

obstetric outcome were found to be a leading cause

to PPD
(16, 17)

. As it is known, pregnancy is a special

period, lack of support, unwanted or unplanned

pregnancy and bad past obstetric history can be

precipitating factors for PPD. Fortunately, all these

risk factors are preventable. Manipulation of these

risk factor may decrease the possibility of

developing PPD over many different ways.

CONCLUSION

In conclusion, there is evidence to recommend

that interventions carried in pregnancy can be

effective in preventing postnatal depression.

Interventions are mainly effective when grounded on

psychological treatments and provided to women

suffering from antenatal depression. Prevention of

precipitating factors is important and needed to

decrease in incidence of PPD. There is evidence

suggesting that interventions that emphasis on

relationships problems may be beneficial. Further

studies on prevention of PPD may be needed.

REFERENCES

1.Kozinszky Z, Dudas RB, Devosa I, Csatordai S, Toth
E, Szabo D et al. (2012): Can a brief antepartum

preventive group intervention help reduce postpartum

depressive symptomatology? Psychother Psychosom.,

81(2):98-107.

2.Thomas LJ, Scharp KM, Paxman CG (2014): Stories

of postpartum depression: exploring health constructs

and help-seeking in mothers’ talk. Women health,

54(4):373-387.

3.Ikeda M, Kamibeppu K (2013): Measuring the risk

factors for postpartum depression: development of the

Japanese version of the Postpartum Depression

Predictors Inventory-Revised (PDPI-RJ). BMC

pregnancy childbirth, 13(1):112-116.

4.Dennis C-L, Creedy D (2004): Psychosocial and

psychological interventions for preventing postpartum

depression. Cochrane Database Syst Rev., 4(1):1356-

1360.

5.Bledsoe SE, Grote NK (2006): Treating depression

during pregnancy and the postpartum: a preliminary

meta-analysis. Res Social Work Prac., 16(2):109-120.

6.Dudas RB, Csatordai S, Devosa I, Töreki A, Andó B,

Barabás K et al. (2012): Obstetric and psychosocial

risk factors for depressive symptoms during pregnancy.

Psychiatry Res., 200(2):323-328.

Effectiveness of Psychological Intervention…

2237

7.Lee DT, Yip AS, Leung TY, Chung TK (2004):

Ethnoepidemiology of postnatal depression. Br J

Psychiatry, 184(1):34-40.

8.Robertson E, Grace S, Wallington T, Stewart DE

(2004): Antenatal risk factors for postpartum

depression: a synthesis of recent literature. Ann Gen

Psychiatry, 26(4):289-295.

9.Tammentie T, Tarkka MT, Åstedt‐Kurki P,
Paavilainen E (2002): Sociodemographic factors of

families related to postnatal depressive symptoms of

mothers. Int J Nurs Pract., 8(5):240-246.

10.Tammentie T, TARKKA MT, ÅSTEDT‐KURKI P,
Paavilainen E, Laippala P (2004): Family dynamics

and postnatal depression. J Psychiatr Ment Health

Nurs., 11(2):141-149.

11.Eberhard‐Gran M, Eskild A, Tambs K, Samuelsen
S, Opjordsmoen S (2002): Depression in postpartum

and non‐postpartum women: Prevalence and risk
factors. Acta Psychiatr Scand., 106(6):426-433.

12.O’hara MW, Swain AM (1996): Rates and risk of

postpartum depression—a meta-analysis. Int Rev

Psychiatry, 8(1):37-54.

13.Paulson JF (2010): Focusing on depression in

expectant and new fathers: prenatal and postpartum

depression not limited to mothers. Psychiatr Times,

27(2):48-53.

14.Misri S, Kendrick K (2007): Treatment of perinatal

mood and anxiety disorders: a review. Can J Psychiatry,

52(8):489-498.

15.Dennis C-LE (2004): Treatment of postpartum

depression, part 2: a critical review of nonbiological

interventions. J Clin Psychiatry, 65(9):1252-1265.

16.Kozinszky Z, Dudas RB, Devosa I, Csatordai S,

Tóth É, Szabó D et al. (2012): Can a brief antepartum

preventive group intervention help reduce postpartum
depressive symptomatology? Psychother Psychosom.,
81(2):98-107.

17.Moshki M, Baloochi Beydokhti T, Cheravi K

(2014): The effect of educational intervention on

prevention of postpartum depression: an application of

health locus of control. J Clin Nurs., 23(15-16):2256-

2263.

18.Morrell CJ, Ricketts T, Tudor K, Williams C,

Curran J, Barkham M (2011): Training health

visitors in cognitive behavioural and person-centred

approaches for depression in postnatal women as part of

a cluster randomised trial and economic evaluation in

primary care: the PoNDER trial. Prim Health Care Res

Dev., 12(1):11-20.

19.Heh SS, Fu YY (2003): Effectiveness of

informational support in reducing the severity of

postnatal depression in Taiwan. J Adv Nurs., 42(1):30-

36.

20.Daley A, Blamey R, Jolly K, Roalfe A, Turner K,

Coleman S et al. (2015): A pragmatic randomized

controlled trial to evaluate the effectiveness of a

facilitated exercise intervention as a treatment for

postnatal depression: the PAM-PeRS trial. Psychol

Med., 45(11):2413-2425.

21.O’mahen H, Richards D, Woodford J, Wilkinson E,

McGinley J, Taylor RS et al. (2014): Netmums: a

phase II randomized controlled trial of a guided Internet

behavioural activation treatment for postpartum

depression. Psychol Med., 44(8):1675-1689.

22.Mirabella F, Michielin P, Piacentini D, Veltro F,

Barbano G, Cattaneo M et al. (2016): Effectiveness

of a postnatal psychological treatment for women who

had screened positive for depression. Riv Psichiatr.,

51(6):260-269.

23.Ho S-M, Heh S-S, Jevitt CM, Huang L-H, Fu Y-Y,

Wang L-L (2009): Effectiveness of a discharge

education program in reducing the severity of

postpartum depression: a randomized controlled

evaluation study. Patient Educ Couns., 77(1):68-71.

24.Morrell CJ, Warner R, Slade P, Dixon S, Walters

S, Paley G et al. (2009): Psychological interventions

for postnatal depression: cluster randomised trial and

economic evaluation. The PoNDER trial. Health

Technol Assess., 13(30):141-153.

25.Brugha TS, Morrell C, Slade P, Walters S (2011):

Universal prevention of depression in women

postnatally: cluster randomized trial evidence in

primary care. Psychol Med., 41(4):739-748.

26.Reay R, Fisher Y, Robertson M, Adams E, Owen C

(2006): Group interpersonal psychotherapy for

postnatal depression: a pilot study. Arch Womens Ment

Health, 9(1):31-39.

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REVIEWARTICLE

Interpersonal psychotherapy for postpartum depression:
a systematic review

Mario Miniati & Antonio Callari & Simona Calugi &
Paola Rucci & Mario Savino & Mauro Mauri &
Liliana Dell’Osso

Received: 23 January 2014 /Accepted: 11 June 2014 /Published online: 24 June 2014
# Springer-Verlag Wien 2014

Abstract Interpersonal psychotherapy (IPT) is a dynamically
informed and present-focused psychotherapy originally con

–

ceived for patients with unipolar depression and subsequently
modified for other disorders, including postpartum depression
(PPD). The aim of this paper is to review the evidence on the
efficacy of IPT for PPD. We conducted a systematic review of
studies published between 1995 and April 2013 assessing the
efficacy of IPT for PPD using PubMed and PsycINFO. We
included the following: (i) articles that presented a combina-
tion of at least two of the established terms in the abstract,
namely, interpersonal [all fields] and (“psychotherapy”
[MeSH terms] or psychotherapy [all fields]) and (perinatal
[all fields] or postpartum [all fields]) and (“depressive disor-
der” [MeSH terms] or (“depressive” [all fields] and “disorder”

[all fields]) or depressive disorder [all fields] or “depression”
[all fields] or depression [MeSH terms]); (ii) manuscripts in
English; (iii) original articles; and (iv) prospective or retro-
spective observational studies (analytical or descriptive), ex-
perimental, or quasi-experimental. Exclusion criteria were as
follows: (i) other study designs, such as case reports, case
series, and reviews; (ii) non-original studies including edito-
rials, book reviews, and letters to the editor; and (iii) studies
not specifically designed and focused on IPT. We identified 11
clinical primary trials assessing the efficacy of IPT for PPD,
including 3 trials with group interventions (G-IPT) and one
that required the presence of the partner (PA-IPT). We also
identified six studies interpersonal-psychotherapy-oriented
preventive interventions for use in pregnancy. IPT studies
showed overall clinical improvement in the most commonly
used depression measures in postpartum depressed women
(EPDS, HDRS, BDI) and often-full recovery in several cases
of treated patients. Evidence from clinical trials indicates that,
when administered in monotherapy (or in combination with
antidepressants), IPT may shorten the time to recovery from
PPD and prolong the time spent in clinical remission.

Keywords Interpersonal psychotherapy . Postpartum
depression . Depression . Treatment efficacy

Introduction

Postpartum depression (PPD) is a subtype of major depres-
sion, characterized by the onset within 4 weeks after delivery
(American Psychiatric Association 2000) and by a number of
symptoms including depressed mood, anxiety, feelings of
inadequacy or guilt specifically related to the ability to care
for the newborn, inability to cope, loss of control, intrusive
presence of compulsive thoughts, irrational fears, and despair.
Sometimes, new mothers develop suicidal and/or infanticide

M. Miniati: A. Callari (*): M. Mauri: L. Dell’Osso
Department of Clinical and Experimental Medicine, Section of
Psychiatry, University of Pisa, Via Roma, 67, 56100 Pisa, Italy
e-mail: antoncallari@libero.it

M. Miniati
e-mail: m.miniati@med.unipi.it

M. Mauri
e-mail: mauro.mauri@med.unipi.it

L. Dell’Osso
e-mail: liliana.dellosso@med.unipi

S. Calugi: P. Rucci
Department of Medicine and Public Health, Alma Mater Studiorum,
University of Bologna, Scuola di Eccellenza dell’Università di
Bologna, Via Zamboni, 33, 40126 Bologna, Italy

S. Calugi
e-mail: si.calugi@gmail.com

P. Rucci
e-mail: paola.rucci2@unibo.it

M. Savino
Istituto Neurologico C. Besta, Via Celoria 11, 20133 Milano, Italy
e-mail: msavino@mariosavino.com

Arch Womens Ment Health (2014) 17:257–268
DOI 10.1007/s00737-014-0442-7

thoughts and plans (Miller 2002) or precipitate in a chronic
depressive episode (Cooper and Murray 1995; Goodman and
Santangelo 2011). Approximately 13 % of women fulfill the
diagnostic criteria for a major depressive episode with post-
partum onset (APA 2000; Dietz et al. 2007; O’Hara and Swain
1996). A recent study estimated the point prevalence for major
and minor depression, ranging from 8.5 to 11.0 % during
pregnancy and from 6.5 to 12.9 % during the first postpartum
year (Gaynes et al. 2005). Postpartum depression can nega-
tively impact both on mothers and on newborns. They tend to
develop attachment insecurity and impaired emotional/
cognitive development (Field 1995; Tronick and Reck 2009;
Grace et al. 2003). The negative effects on newborns are also
described for the infants of women who suffer from sub-
clinical or incomplete forms of depression (Weinberg et al.
2001; Tronick and Reck 2009).

Effective pharmacological treatments for PPD are avail-
able, but according to the literature, very low percentages of
depressed women receive a specific treatment during postpar-
tum (Goodman and Tyer-Viola 2010; Horowitz and Cousins
2006; Marcus et al. 2003). Antidepressants are considered
effective for PPD (Cohen et al. 2001; Appleby et al. 1997;
Yonkers et al. 2008; Wisner et al. 2006), even if the vast
majority of data in this field derives from case reports, case
series, or open trials (Abreu and Stuart 2005; Dennis and
Stewart 2004). To our knowledge, no data are available from
randomized or controlled studies, and many observations
exclude mothers who are breastfeeding (Appleby et al.
1997; Misri and Kendrick 2007). Although data suggests
minimal or no short-term adverse effects in infants (Burt
et al. 2001; Misri and Kostaras 2002; Weissman et al. 2004),
mothers are frequently hesitant when asked to start a treatment
with antidepressants (Sit and Wisner 2005) and have a pref-
erence for psychotherapy (Whitton et al. 1996a, b). Boath and
Henshaw (2001) reported that 31 % of breastfeeding mothers
with PPD refused antidepressants. Moreover, even if not
breastfeeding, many women are reluctant to take medication
(Goodman 2009), mainly for the subjective perception of an
excessive sedation (“not hearing the baby at night”) and for
the fear of “potential long-term side effects” (Boath and
Henshaw (2001). As a consequence, psychotherapies have
been proposed in monotherapy or in combined/sequential
treatment for this special population, with the rationale of
providing effective treatments devoid of side effects. Several
studies support the clinical usefulness of individual and group
psychotherapies for postpartum depression (Appleby et al.
1997; Misri and Kendrick 2007; O’Hara et al. 2000; Dennis
and Stewart 2004; Goodman and Santangelo 2011; Mulcahy
et al. 2010; Milgrom et al. 2005; Clark et al. 2003).

Interpersonal psychotherapy (IPT) is a time-limited, dy-
namically informed, and present-focused psychotherapy that
emphasizes the interpersonal context of depression (Klerman
et al. 1984). Mainly based on Sullivan’s Interpersonal Theory

and on Bowlby’s Attachment Theory (Sullivan 1953; Bowlby
1969; Stuart 2006) and originally conceptualized for “pure”
unipolar depression, IPT has been subsequently modified for
other disorders, including postpartum depression (Stuart and
O’Hara 1995; Stuart and Robertson 2003; Stuart 2006, 2012.
IPT has been proposed mainly considering its bifocal ap-
proach to mood disorders that enhances the importance of
both biological and psychosocial factors in the pathogenesis
of postpartum depression (Cox et al. 1983; Meltzer-Brody
2011; Ross et al. 2004). The clinical manifestations of post-
partum depression are affective, cognitive, neurovegetative,
and behavioral. As a consequence, symptoms disrupt inter-
personal relationships and social functioning at different levels
(O’Hara 1994). Lower income problems, the lack of perceived
interpersonal support (especially poor practical or emotional
support from partners and reduced social and family support),
and the physiological role transition related to motherhood
have been shown to be specific risk factors for the occurrence
of depression during the postpartum period (O’Hara and
Swain 1996). Moreover, controversial familial expressed
emotions may exacerbate the course of depressive symptoms
or complicate treatment response (Miklowitz and Hooley
1998). The aim of this paper is to provide a systematic review
of the major findings for efficacy of IPT for postpartum
depression.

Methods

We conducted a review of studies published between 1995
and May 2013 assessing the efficacy of IPT for postpartum
depression using PubMed and PsycINFO databases. Analysis
of the articles followed previously established inclusion and
exclusion criteria. We included the following: (i) articles that
presented a combination of at least two of the established
terms in the abstract, namely, interpersonal [all fields] and
(“psychotherapy” [MeSH terms] or psychotherapy [all fields])
and (perinatal [all fields] or postpartum [all fields]) and (“de-
pressive disorder” [MeSH terms] or (“depressive” [all fields]
and “disorder” [all fields]) or depressive disorder [all fields] or
“depression” [all fields] or depression [MeSH terms]); (ii)
manuscripts in English; (iii) original articles; and (iv) prospec-
tive or retrospective observational studies (analytical or de-
scriptive), experimental, or quasi-experimental. Exclusion
criteria were as follows: (i) other study designs, such as case
reports, case series, and reviews; (ii) non-original studies
including editorials, book reviews, and letters to the editor;
and (iii) studies not specifically designed and focused on IPT.
Initially, the search retrieved 58 papers including 20 reviews
of literature and 3 meta-analyses. After analyzing their titles
and abstracts, according to the eligibility criteria, 47 papers
were excluded and 11 were chosen and included in the final
sample (Fig. 1).

258 M. Miniati et al.

Results

Table 1 summarizes the studies assessing IPT for PPD re-
trieved by the search. The first open trial with IPT for PPD
was a 12-week study on six patients who met the DSM-III-R
criteria for a major depressive episode during the postpartum
period (MDD) (Stuart and O’Hara 1995). Patients were in
remission at the end of the study, according to the Beck
Depression Inventory (BDI) (Beck et al. 1961), the
Hamilton Rating Scale for Depression (HRSD) (Hamilton
1967), and the Edinburgh Postnatal Depression Scale
(EPDS) (Cox et al. 1987). They also showed a significant
improvement with the Social Adjustment Scale (SAS)
(Weissman and Bothwell 1976). None of the patients met
the DSM criteria of major depressive episode at the end of
treatment. A randomized study on 120 subjects subsequently
compared IPT vs a “waiting list condition” (WLC) (O’Hara
et al. 2000). Patients randomized to WLC remained without
therapy and waited 12 weeks before receiving treatment. They
were followed up with a bi-weekly telephone assessment, in
order to evaluate the suicide risk. A significantly greater

proportion of women who received 12 weekly individual
session of IPT recovered from their depressive episode when
compared to women randomized to WLC, with an important
improvement of their social adjustment. IPT showed long-
term benefits after the acute treatment phase: 20 patients out
of 35 (57 %) recovered with the acute IPT treatment and
achieved sustained recovery during the follow-up. Moreover,
the 80 % of women who did not recover during the acute
treatment achieved recovery, at some point during the follow-
up. Posttreatment depression severity, personal history of
depression, and weeks of treatment were significant predictors
of recovery in the mid-term.

In an interesting brief report from Nylen et al. (2010) the
mid-term course and the potential predictors of postpartum
depression in the 18 months following IPT have been de-
scribed. Evaluations at 6, 12, and 18 months posttreatment
were completed. This study revealed that 20 patients (57 %)
achieved sustained recovery during follow-up out of 35 who
recovered with acute treatment. The average time to recur-
rence was 33.40 weeks (SD±18.43 weeks). Over 80 % of
women who did not recover with acute treatment experienced

Fig. 1 Flow chart summarizing
the procedure for selecting studies
for review

Interpersonal psychotherapy for postpartum depression 259

T
ab

le
1

E
v
id
en
ce

o
f
ef
fi
ca
cy

of

IP
T

fo
r
po
st
p
ar
tu
m

d
ep
re
ss
io
n

A
u
th
o
rs

N
u
m
b
er

D
es
ig
n

S
el
ec
ti
o
n

cr
it
er
ia

In
st
ru
m

en
ts

IP
T
in
te
rv
en
ti
o
n
s

R
es
u
lt
s

S
tu
ar
t

an
d

O
’H

ar
a
(1
9
9
5
)

1
2

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pe
n

tr
ia
l

M
D
D
(D

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M
-I
II
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)

H
R
S
D

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D
I

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P
D
S

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d
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id
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al
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T
,
1
2
w

ee
k
s

M
ea
n
b
as
el
in
e
B
D
I

sc
o
re

2
7
.7
±
5
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.
M
ea
n

H
R
S
D
b
as
el
in
e
sc
o
re

1
8

.2
±
6
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.
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ea
n

en
d
p
o
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t
B
D
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re

5
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±
4
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;
m
ea
n

en
d
p
o
in
tH

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S
D
sc
o
re
5
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±
4
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(p
< 0 .0 2 ).

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o
pa
ti
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ts
m
ee
ti
ng

cr
it
er
ia
fo
r
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D
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at

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d
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o
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t.

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’H

ar
a
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al
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(2
0
0
0
)

1
2
0

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an
d
o
m
iz
ed

co
n
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o
ll
ed

tr
ia
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b
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S
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in
te
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w

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1
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2
3.
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to

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k
s)

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ce
n
ta
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es

o
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m
is
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at

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d
p
o
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t
(1
2
w
ee
k
s)
.
H
R
S
D
≤
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:
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T

(3
7
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%
)>

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(1
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)
o
f

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om

en
re
ce
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in
g
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T

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co
v
er
ed

B
D
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:
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T

(4
3
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%
)>
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L
C
(1
3
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%
).
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p
at
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ts

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ad

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if
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im

p
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ro
up

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T
(1
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se
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s)

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re
ss
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n

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o
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s
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re
as
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si
g
n
if
ic
an
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y

(2
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-i
te
m

H
R
S
D
fr
o
m

1
9.
7
to

8
.0
;
E
P
D
S

fr
o
m

1
6
.1
to

8
.9
)
(p
< 0 .0 1 ). P ar ti ci p an ts ’

d
ep
re
ss
io
n
sc
o
re
s
at
6
-m

o
n
th

fo
ll
o
w
-u
p

w
er
e
si
g
n
if
ic
an
tl
y
lo
w
er

th
an

at
b
as
el
in
e

(E
P
D
S
F
=
2
4
.3
0
,
p
< 0 .0 0 1 ; H R S D -2 1

F
=
3
3
.5
9
,
p
< 0 .0 0 1 ).

C
la
rk

et
al
.
(2
0
0
3
)

6
6

Q
u
as
i-
ra
n
d
o
m
iz
ed

cl
in
ic
al
tr
ia
l

M
D
D
(q
u
es
ti
o
n
n
ai
re

w
it
h

D
S
M
–
IV

cr
it
er
ia
)

C

E
S
-D

B
D
I

M
o
th
er
/i
n
fa
n
t
th
er
ap
y

(M
-I
T
G
)
v
s

in
d
iv
id
u
al

IP
T
(1
2
w
ee
k
s)
v
s
W
L
C

M
-I
T
G
B
D
I
fr
o
m
2
6
.9
to

1
5

.9
;C

E
S
-D
fr
o
m

4
1
.1
to

1
9
.2

(p
< 0 .0 2 ); IP T B D I fr om

2
6
.2
to

1

6
.4

;

C
E
S
-D

fr
o
m

36
.2
to

2
0
.1

(p
< 0 .0 4 ); W L C B D I fr o m

2
4
.5
to

2
0
.6
;

C
E
S
-D
fr
o
m

3
2
.4
to

2
6
.6
(p
=
n
s)

R
ea
y
et
al
.
(2
0
0
6
)

1
8
O
p
en
tr
ia
l

E
P
D
S
≥
1
3
M
D
D
ac
co
rd
in
g

to
D
S
M
-I
V
-R

cr
it
er
ia

H
R
S
D

E
P
D
S
B
D
I

G
ro
up

IP
T
(2

in
d
iv
id
u
al

se
ss
io
n
s,
8
g
ro
u
p

se
ss
io
n
s+

2
h
p
ar
tn
er
s

ev
en
in
g
)

B
D
I
(2
6
.1
6
–
1
5
.1
7
),

E
P
D
S
(1
8
.3
3
–
9
.1
6
)

an
d
H
R
D
S
(1
3
.9
4
–
7
.8
9
)
se
v
er
it
y

sc
o
re
s
d
ec
re
as
ed
fr
o
m

p
re
–
to

p
o
st
–

tr
ea
tm

en
t.

T
h
es
e
re
su
lt
s
w
er
e

m
ai
n
ta
in
ed

af
te
r

th
e

3
-m

o
n
th
s
fo
ll
o
w

u
p
.
5
8
%

fu
ll
re
m
is
si
o
n
(p
o
st
-t
re
at
m
en
t

H
R
S
D
sc
o
re

< 9 ). 2 9 %

pa
rt
ia
l

re
m
is
si
o
n
(p
o
st
-t
re
at
m
en
t
H
R
S
D

sc
o
re
<

5
0

%
)
11

%
n
o
im

p
ro
v
em
en
t.

P
ea
rl
st
ei
n
et
al
.
(2
0
0
6
)

2
3

Q
u
as
i-
ra
n
d
o
m
iz
ed
cl
in
ic
al
tr
ia
l

M
D
D
(c
li
n
ic
al

in
te
rv
ie
w
)

B
D
I
≥
2
5
o
r
1
7
it
em

s
H
R
S
D
≥
1
4

E
P
D
S
B
D
I
E
P
D
S

S
er
tr
al
in
e
v
s
IP
T
vs

th
ei
r

co
m
b
in
at
io
n
1
2
-w

ee
k
s

st
u
d
y

C
o
m
p
le
te
rs
o
f
th
e
3
tr
ea
tm

en
t
g
ro
u
p
s

si
g
n
if
ic
an
tl
y
im

p
ro
v
ed

.
IP
T
H
R
S
D
fr
o
m

1
7
.4
to

5
.5

(p
< 0 .0 0 1 ); B D I fr o m

2
0
.0
to

6
.3
(p
< 0 .0 0 1 );

E
P
D
S
fr
o
m

1
6
.7
to

6
.4

(p
< 0 .0 0 1 ); S er tr al in e H R S D fr o m

2
0
.5

to
1
0
.0
;
B
D
I
fr
o
m

20
.0
to

7
.0
;
E
P
D
S

260 M. Miniati et al.

T
ab
le
1

(c
o
n
ti
n
u
ed
)

A
u
th
o
rs
N
u
m
b
er
D
es
ig
n

S
el
ec
ti
o
n
cr
it
er
ia

In
st
ru
m
en
ts

IP
T
in
te
rv
en
ti
o
n
s
R
es
u
lt
s
fr
o
m

1
5
.0

to
4
.5
;
S
er
tr
al
in
e
+
IP
T
H
R
S
D

fr
o
m

1
8
.8

to
3
.8
;
B
D
I
fr
o
m

2
5
.3

to
6
.1
;

E
P
D
S
fr
o
m

1
8
.7
to

5
.5

G
ro
te
et
al
.
(2
0
0
9
)

5
3

R
an
d
o
m
iz
ed
co
n
tr
o
ll
ed
tr
ia
l

E
P
D
S
>
1
2

E
P
D
S
B
D
I

A
n
te
n
at
al
en
g
.,
8
IP
T
-B

se
ss
io
n
s
b
ef
o
re

bi
rt
h
,
IP
T
–

M
(6

m
o
n
th
s.
)
vs

T
A
U

E
nd
po
in
t
si
x
m
on
th
af
te
r
de
li
ve
ry

50
%

im
pr
ov
em

en
t
on

th
e
E
P
D
S
sc
or
es

88
%

of
re
sp
on
se

w
it
h
IP
T
vs

25
%

w
it
h
T
A
U
.

M
u
lc
ah
y
et
al
.
(2
0
1
0
)

5
0
R
an
d
o
m
iz
ed
co
n
tr
o
ll
ed
tr
ia
l

M
D
D
b
as
ed

on
D
S
M
-I
V

cr
it
er
ia

M
C
M
I-
II
I
H
R
D
S
-1
7
≥
1
4

E
P
D
S

B
D
I-
II

G
ro
up

IP
T
V
S
.
T
A
U

(t
re
at
m
en
t
as

u
su
al
)

fo
r
8
w
ee
k
s

T
A
U

an
d

IP
T
-G

g
ro
u
p
s
si
g
ni
fi
ca
n
tl
y

im
p
ro
v
ed

(m
ea
n
sc
o
re
s
at

B
D
I-
II
an
d

E
P
D
S
).
T
h
e
IP
T
-G

w
om

en
im

p
ro
v
ed

si
g
n
if
ic
an
tl
y

m
o
re

an
d
h
ad

co
n
ti
n
u
ed

im
p
ro
v
em

en
ts

af
te
r
3
m
o
n
th
s
o
f

fo
ll
o
w
-u
p
.

N
y
le
n
et
al
.
2
0
1
0

1
2
0
R
an
d
o
m
iz
ed
co
n
tr
o
ll
ed
tr
ia
l
M
D
D
(D
S
M
-I
V
-R
in
te
rv
ie
w
)

L
IF
E
ID

D
H
R
D
S
B
D
I

In
d
iv
id
u
al
IP
T
,
1
2
w
ee
k
s

v
s.
W
L
C

T
h
ir
ty
-f
iv
e
w
o
m
en

re
co
v
er
ed

(L
IF
E

cr
it
er
ia
)
in

ac
u
te
;
2
0
w
o
m
en

ac
h
ie
v
ed

su
st
ai
n
ed

re
co
v
er
y
d
ur
in
g
fo
ll
o
w
-u
p
.

A
v
er
ag
e
ti
m
e
to

re
cu
rr
en
ce

33
.4

w
ee
ks

(±
18
.4
).
80

%
of

w
om

en
w
ho

di
d
no
t

re
co
ve
r
in
ac
ut
e
ex
pe
ri
en
ce
d
re
co
ve
ry

at
so
m
e
po
in
td
ur
in
g
fo
llo
w
-u
p.
A
ve
ra
ge

tim
e

to
re
co
ve
ry

28
.6

w
ee
ks

(±
17
.5
).

R
ea
y
et
al
.
(2
0
1
2
)

5
0
R
an
d
o
m
iz
ed
co
n
tr
o
ll
ed
tr
ia
l

S
ee

M
u
lc
ah
y
et
al
.
2
0
1
0

S
ee
M
u
lc
ah
y
et
al
.
2
0
1
0
G
ro
up
IP
T

A
t
2
-y
ea
r
p
o
st
tr
ea
tm

en
t,

m
o
th
er
s

w
h
o

re
ce
iv
ed

IP
T
-G
im
p
ro
v
ed
m
o
re

ra
p
id
ly

in
th
e
sh
or
t-
te
rm

an
d
w
er
e
le
ss

li
k
el
y
to

d
ev
el
o
p
p
er
si
st
en
t
d
ep
re
ss
iv
e
sy
m
p
to
m
s

in
th
e
lo
n
g
-t
er
m
.5
7
%

o
f
IP
T
-G

m
o
th
er
s
m
ai
n
ta
in
ed

th
ei
r
re
co
v
er
y
o
v
er

th
e

fo
ll
o
w
-u
p
p
er
io
d
.L

im
it
at
io
n
s
in
cl
u
d
e
th
e

u
se
o
f
se
lf
-r
ep
o
rt
q
u
es
ti
o
n
n
ai
re
s
to
d
ef
in
e

re
co
v
er
y
an
d
u
se

o
f
an
ti
d
ep
re
ss
an
t.

H
ow

ev
er
,m

ot
he
rs
w
ho

re
ce
iv
ed

co
m
bi
ne
d

IP
T
-G

an
d
an
tid
ep
re
ss
an
t
m
ed
ic
at
io
n
di
d

no
t
sh
ow

a
si
gn
if
ic
an
tly

gr
ea
te
r

im
pr
ov
em

en
t
in
de
pr
es
si
on

co
m
pa
re
d
to

th
os
e
w
ho

re
ce
iv
ed
IP
T
-G

al
on
e.

B
ra
n
d
o
n
et
al
.
(2
0
1
2)

1
5
O
p
en
tr
ia
l

1
7
-i
te
m

H
R
S
D
≥
1
6
M
D
D

(D
S
M
-I
V
-R

in
te
rv
ie
w
)

H
R
S
D
E
P
D
S
D
A
S

P
ar
tn
er
-A

ss
is
te
d
IP
T
.

9
o
f
1
0
w
o
m
en

(9
0
%
)
m
et
cr
it
er
ia
fo
r

cl
in
ic
al
re
sp
o
n
se

(H
R
S
D
1
7
< 9 ) at th e

en
d
o
f
ac
u
te
ph
as
e;
8
o
f
ni
n
e
(8
9
%
)

at
a
6
-w

ee
k
fo
ll
o
w
-u
p
as
se
ss
m
en
t
m
et

cr
it
er
ia
fo
r
re
co
v
er
y.
W
o
m
en

h
ad

h
ig
h

le
v
el
s
o
f
d
ep
re
ss
iv
e
sy
m
p
to
m
s
at
in
ta
k
e

(m
ea
n
±
S
D
)
(1
9.
11

±
6.
13
)
th
at
de
cl
in
ed

si
gn
if
ic
an
tl
y
by

se
ss
io
n
ei
gh
t(
6.
00

±
4.
47
)

an
d
re
m
ai
ne
d
lo
w
at
th
e
6-
w
ee
k
fo
ll
ow

–

Interpersonal psychotherapy for postpartum depression 261

recovery at some point during follow-up, and the average time
to recovery was 28.60 weeks (SD±17.51 weeks). Several
predictors were identified with growth curve modeling tech-
niques, namely, the posttreatment depressive severity, the
length of the index episode (as predictors of changes in
depression over time), a personal history of depression, and
the weeks of treatment in the follow-up. The strength of this
study was mainly on the adoption of gold-standard instru-
ments, such as the Structured Clinical Interview for DSM-IV
(First et al. 1997) to assess symptoms criteria, the HRSD, the
BDI, and the Longitudinal Interval Follow-Up Evaluation
(LIFE) (Keller et al. 1987) to evaluate course and outcomes.

Klier et al. (2001) utilized a group IPT (G-IPT) approach
(12 sessions) in a sample of 17 women diagnosed with PPD,
according to DSM-IV criteria. Mean scores of HDRS and
EPDS decreased significantly comparing the pre-treatment
and the posttreatment period. Moreover, examination of indi-
vidual 21-item HDRS score profiles revealed that 10 patients
(58 %) achieved a full remission (posttreatment score <9) and five patients (29 %) demonstrated a partial remission (score decrease >50 %) at the end of treatment. Only two patients
(11 %) did not improve. Study limitations included the ab-
sence of a control group, the small sample size, the possible
bias in therapist’s assessments, and the lack of monitoring
adherence, which may have jeopardized the accuracy of the
results.

The postpartum depression efficacy study performed by
Clark et al. (2003) was a quasi-randomized clinical trial with a
comparison of three conditions: mother/infant therapy, WLC,
and individual IPT (12 sessions). Women who met the criteria
for major depression during the postpartum period were se-
quentially assigned to one of the first two conditions: a
mother/infant therapy (M-ITG) or a WLC. A comparison,
individual IPT, was added. Participants in the active treatment
groups (M-ITG and IPT) completed a pre- and a posttreatment
(12 weeks) assessment. Those in the WLC were assessed at
the point of entry into the study and 12 weeks later. The
relationship-focused M-ITG model utilized for this study in-
volved three treatment group components: (a) a mother’s
group that provided therapeutic intervention and peer support;
(b) a concurrent infant developmental therapy group that
assisted infants in becoming more emotionally regulated,
focused, and socially engaged; and (c) a mother/infant dyadic
group with activities designed to promote sensitive, respon-
sive mother/infant interactions. Fathers attended two of the
group therapy sessions, one focused on demystifying depres-
sion and the second focused on enhancing mutual spousal
support through the use of communication and problem-
solving exercises. Fathers also joined the mother and infant
in the interactional activities during the last half hour of each
of those sessions. Sixty-six women were recruited into the
study. Nonetheless, data were only analyzed for participants
who scored 16 or higher at the BDI. This cutoff was chosen toT

ab
le
1

(c
o
n
ti
n
u
ed
)
A
u
th
o
rs
N
u
m
b
er
D
es
ig
n
S
el
ec
ti
o
n
cr
it
er
ia
In
st
ru
m
en
ts
IP
T
in
te
rv
en
ti
o
n
s
R
es
u
lt
s

up
.
W
om

en
ha
d
hi
gh

le
ve
ls
of

E
P
D
S
at

in
ta
ke

(1
7.
30

±
4.
47
)
th
at
de
cl
in
ed

by
se
ss
io
n
ei
gh
t
(6
.0
0
±
3.
97
).
P
ar
tn
er
s
ra
te
d

th
e
in
te
ns
it
y
of

w
om

en
’s
de
pr
es
si
ve

sy
m
pt
om

s
as

lo
w
er
at
in
ta
ke

(E
P
D
S
-P

01
3.
80

±
3.
36
).
A
t
se
ss
io
n
8,
pa
rt
ne
r

ra
ti
ng
s
de
m
on
st
ra
te
d
go
od

ag
re
em

en
t

w
it
h
w
om

en
’s
ra
ti
ng
s
(6
.1
0
±
4.
48
).

D
S
M
-I
II
-R

D
S
M

R
ev
is
ed

T
h
ir
d
E
d
it
io
n
(A

m
er
ic
an

P
sy
ch
ia
tr
ic
A
ss
oc
ia
ti
o
n
1
9
8
7
),
D
S
M
-I
V
D
S
M

F
o
u
rt
h
E
d
it
io
n
(A

m
er
ic
an

P
sy
ch
ia
tr
ic
A
ss
oc
ia
ti
o
n
2
0
0
0
),
B
D
I
B
ec
k
In
v
en
to
ry

D
ep
re
ss
io
n
(B
ec
k
et
al
.

1
9
6
1
),
H
R
S
D
H
am

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262 M. Miniati et al.

differentiate women with moderate to severe depressive
symptoms consistent with a major depressive episode during
the postpartum period from women with mild or transient
depressive symptoms, commonly referred to as the “baby
blues.” The sample of women meeting this criterion included
13 patients in the M-ITG group, 15 in the IPT group, and 11 in
the WLC group. The two active 12-week treatments (M-ITG
and IPT) were equally effective in reducing symptoms for
women experiencing major depression during the postpartum
period, when compared with the WLC group. However, wom-
en in the M-ITG group experienced the highest level of
depressive symptoms at baseline (as measured by higher mean
BDI and Center for Epidemiological Studies Depression Scale
(CES-D) scores (Radloff 1977)) and the greatest improvement
(as demonstrated by the lowest posttreatment mean scores).
M-ITG and IPT were superior to WLC in improving the
perceptions of mothers on their newborns’ adaptability/
reinforcement value and in increasing mothers’ positive
affect/verbalization with their children. Nonetheless, despite
their improvement, some women from both treatment groups
continued to experience mild to moderate depressive symp-
toms after the 12-week treatment programs.

Reay et al. (2006) treated 18 mothers fulfilling the DSM-IV
criteria for postpartum depression, with two start-up sessions
of individual IPT, followed by 8 sessions of IPT-G.
Expectations about helpful group behaviors were explained,
including promptness, remaining focused on “here and now”
interpersonal issues, working actively on their goals between
group sessions, and refraining from contact or socializing
together during the duration of the group. The group sessions
with patients were scheduled for the first 2 weeks, and mid-
way during the group therapy, partners attended an education-
al evening with the group therapists, with special emphasis on
considering effective ways to support and respond to a woman
affected by postpartum depression. Women were asked to stay
focused on the interpersonal goals, to express their feelings
about group sessions, and to give feedback to each other, with
the aim to anticipate future difficulties. Patients were consid-
ered eligible for the study if they had an infant 12 months old
or less and continued to have a health professional involved
with whom the researchers could communicate with. An
individual session was also scheduled 6 weeks after the last
group session, with the aim to consolidate progress, to plan for
future contingencies, and to document early warning signs of
relapse or recurrence of depressive symptoms. The outcome
measures of this pilot study were the 17-item HRSD, the BDI,
the EPDS, and the SAS Self-Report (SAS-SR). As described
by the study results, scores on the HRSD, the BDI, and the
EPDS significantly decreased from pre- to posttreatment as-
sessment. Nonetheless, it is noteworthy that, for example, the
mean HRSD scores were very low at baseline (13.94±5.99),
raising questions on unusually mild severity of depressive
symptomatology in the recruited sample. Moreover, a wide

percentage of patients (67 %) were concomitantly treated with
antidepressants.

A randomized controlled trial on 50 patients with postpar-
tum depression compared outcomes from an 8-week IPT-G
for postnatal depression with “treatment as usual” (TAU),
namely, antidepressants, natural remedies, non-directive
counseling, and other interventions (Maternal and Child
Health Nurse support, community support groups, and indi-
vidual psychotherapy or group therapy) currently accessed by
women in the Australian Capital Territory (ACT) community
(Mulcahy et al. 2010). The 8-week group intervention for
postnatal depression was developed and adapted during the
pilot of the treatment, as already published by Reay et al.
(2006) A specifically targeted treatment manual described
the stages, strategies, and techniques of IPT-G for this popu-
lation and included the use of the processes of “modelling”
and “social reinforcement” by group members as well as
group brainstorming. Special attention was given in this study
in highlighting the universality of the women’s concerns and
encouraging mothers to learn vicariously through the experi-
ences of others in the group. IPT-G consisted of two individual
sessions, eight group therapy sessions (2 h duration) and an
additional 2-h partner’s evening. Women were given a per-
sonalized invitation to give to their partner and a courtesy
phone call was made by the group therapists to encourage
attendance at a partners evening. The evening was specifically
developed for the men only and involved psycho-education
about PND, with a special emphasis on effective ways to
support and respond to their partners. The study was conduct-
ed with an accurate screening of participants. Ninety mothers
initially referred to the study and were screened with a tele-
phone interview. Seventy-one subjects were suitable and
screened for the inclusion/exclusion criteria assessment. The
inclusion criteria for the study was a diagnosis of postnatal
depression based on DSM-IV criteria for major depression
and an infant aged 12 months or younger. The exclusion
criteria were the presence of severe personality disorder, acute
psychosis, suicidality, significant substance abuse, and child
abuse or neglect. Mothers were included in the study if they
fulfilled the criteria for a major depressive disorder using the
Millon Clinical Multiaxial Inventory-III (Millon et al. 1997)
and scored >14 at the 17-item HRSD. Fifty-seven mothers
were randomized (29 to IPT-G and 28 to TAU), and 50 were
included in the analyses. Seven mothers were discontinued for
several reasons (immediate improvement, relocated interstate,
preference for individual therapy, dissatisfaction for alloca-
tion, domestic violence). Three assessments were scheduled
as follows: at baseline, week 4, and week 8. Planned compar-
isons, using the EPDS and BDI-II scores, indicated a signif-
icant improvement in the depression’s scores for IPT-G par-
ticipants by the end of treatment. The TAU and the IPT-G
groups significantly improved in terms of mean HRSD scores.
However, patients treated with IPT-G improved significantly

Interpersonal psychotherapy for postpartum depression 263

more than those treated with TAU and showed a sustained
improvement after 3 months. Furthermore, women who re-
ceived IPT-G displayed significant improvement in terms of
marital functioning and perceptions of the mother-newborn
relationship if compared to TAU participants. The main
strength of this study was the presence of a strong comparison
group. Thus, TAU participants accessed a range of treatments
from primary, secondary, and tertiary services, such as antide-
pressant medication, support groups, and individual psycho-
therapy. The second strength of the study was the adoption of
a relatively short treatment schedule, if compared with other
IPT group or group therapies. The main limitation of the study
was due to the characteristics of the sample. Participants were
predominantly white Australian-born mothers, in a relatively
stable relationship with a partner and well educated. A second
important limitation of the study relates to the finding at 3-
month follow-up that a large proportion of the women over the
course of the RCT were taking antidepressant medication.
Although the sample size provided sufficient power to make
comparisons between group interpersonal therapy and treat-
ment as usual at baseline, mid-treatment, end of treatment, and
3-month follow-up, there was a limited scope to examine the
role of antidepressant medications, such as that afforded by
comparing IPT-G and medication alone, combination IPT-G
and medication with IPT-G alone, or medication alone.

More recently, the same research group (Reay et al. 2012)
investigated the presence of depressive symptoms and the inter-
personal functioning of the participants of the abovementioned
randomized controlled trial, at 2 years posttreatment. Reay et al.
examined the so-called long-term recovery trajectories, namely,
whether participants maintained their recovery status, if they
achieved later recovery or if they showed recurrences or a
persistent symptomatology. They used a case categorization
system that took into account the severity and the duration of
symptoms, according to the criteria set by Shapiro et al. (1995)
and the recommended EPDS cutoff score (EPDS=12 or less)
(Sit and Wisner 2005). Women in both conditions were com-
pared in terms of the proportions of those who: (a) “maintained”
recovery (classified “recovered” at all three follow-up points),
(b) achieved (later) recovery (“not recovered” at the end of
treatment but EPDS=12 or less at 3-month and 2-year follow-
up), (c) recurred (recovered at the end of treatment but EPDS=
13 or more at 3-month and/or 2-year follow-up), and (d) showed
a persistent (chronic) depression (not recovered at all follow-up
points). Approximately 2 years posttreatment, all women in the
original RCT (N=50) were invited to participate in a mailed
follow-up. A repeated measure analysis of variance assessed
differences between the treatment and control conditions on
depression and interpersonal scores across five measurement
occasions: baseline, mid-treatment, end of treatment, 3-month,
and 2-year follow-up. The 57 % of mothers with IPT-G main-
tained their recovery over the follow-up period, when
interviewed 2 years posttreatment. Overall, IPT-G participants

were significantly less likely to require follow-up treatment.
Mothers who received IPT-G improved more rapidly in the
short-term and were less likely to develop persistent depressive
symptoms in the long-term. Limitations included the use of self-
report questionnaires to classify recovery and the use of antide-
pressant medication. Thus, 28 of 44 women took antidepres-
sants during both the short- and long-term follow-up periods;
however, there was no statistically significant association be-
tween antidepressant use and better recovery outcomes.
Moreover, IPT-G mothers taking adjunct medication were no
more likely to be classified as having maintained or achieved
recovery compared to those receiving IPT-G alone.

Pearlstein et al. (2006) addressed “the dilemma of choosing
treatment” in an interesting study on a sample of patients with
postpartum depression recruited from a psychiatric day hos-
pital serving pregnant and postpartum women. Eligible pa-
tients were offered three treatments over 12 weeks: sertraline
alone, IPT alone, or combined (sertraline+IPT). The patients
selected treatment choice, and there was no random assign-
ment of treatment condition. Sertraline was titrated in a
flexible-dose regimen up to 150 mg daily based on clinical
response (by interview) and tolerability. Sertraline was started
at 25 mg daily and could be increased to 50 mg daily after
2 weeks, to 100 mg daily after 4 weeks, and to 150 mg daily
after 8 weeks. IPT was administered in 12 individual 50-min
sessions by one of two psychotherapists who had received IPT
training and who received regular supervision throughout the
study. Treatment outcome was monitored with the clinician-
rated 17-item HRSD, the self-rated EPDS, and the BDI ob-
tained at baseline, 4, 8, and 12 weeks. All patients experienced
a significant clinical improvement on the HRSD, BDI, and
EPDS scores, with no statistical differences between the three
groups. The most relevant finding was that women in the
study at first depressive episode, when informed of the advan-
tages and concerns of both IPT and sertraline, selected IPT
with or without the addition of sertraline. Conversely, there
was a trend for women with a history of previous depressive
episodes to choose sertraline as a treatment alone or with IPT.
Moreover, this study confirmed the trend for breastfeeding
women to be less likely to choose antidepressants than psy-
chotherapy. The authors concluded that a previous depression
or previous antidepressant treatment might be associated with
pharmacotherapy as preferred choice, while breastfeeding
might be associated with psychotherapy.

A brief culturally enhanced version of IPT (IPT-B) was
administered to a sample of 53 pregnant women meeting
criteria for depression according to the EPDS scale (score
>12 on a scale of 0 to 30), and it was continued through the
postpartum period (Grote et al. 2009). The primary aim of
this study was to assess if a culturally relevant, enhanced
brief interpersonal psychotherapy might be efficacious in
treating depression in a special population of pregnant women
of low socio-economic status. This study is different from the

264 M. Miniati et al.

previous ones, for several reasons. First, treatment was started
during pregnancy and then continued in the postpartum peri-
od. Second, the enhanced IPT-B is a multi-component model
of care consisting of an engagement session (acute IPT-B) and
maintenance IPT, augmented with culturally relevant modifi-
cations. The engagement session is based on principles of
motivational interviewing and ethnographic interviewing
and is designed to promote engagement by building trust
and addressing the practical, psychological, and cultural bar-
riers to care experienced by individuals who are socio-
economically disadvantaged. More specifically, during en-
gagement, the interviewer elicits each participant’s unique
barriers to care and engages in collaborative problem solving
to ameliorate each barrier. In addition, the interviewer ap-
proaches the participant in a culturally sensitive manner con-
sistent with the principles of ethno-graphic interviewing: the
interviewer adopts a one-down position as a learner; he/she
tries to understand the cultural perspectives and values of the
woman without bias; and he/she inquires about the woman’s
view of depression, health-related beliefs, and coping prac-
tices and asks what the woman would like in a therapist,
including the importance of race-ethnicity. This study showed
that the depressive outcome was significantly improved by
IPT if compared with “enhanced usual care” (patients who
received depression education materials and a referral to the
behavioral health center in the same obstetrics and gynecology
clinic). All patients displayed significant reductions in depres-
sive symptoms before childbirth (3 months postbaseline) and
6 months after the delivery. The main finding from the study
was that the culturally relevant enhanced IPT-B prevented
depressive relapse and improved social functioning up to
6 months postpartum in a very difficult-to-engage, non-
treatment-seeking population, raising the question of the use-
fulness of IPT as an easy tool for the reduction of racial and
economic disparities in access to and engagement in mental
health treatment. This study confirmed a previous finding of a
pilot study conducted with a brief group-psychotherapeutic
intervention based on the principles of IPT by Zlotnick et al.
(2001) The proposed approach was effective in preventing the
occurrence of major depression during the postpartum period
in a sample of 37 financially disadvantaged pregnant women,
receiving public assistance. They were randomly assigned to a
four-session group intervention or to treatment as usual
(TAU). Six of the 18 women (33 %) in the TAU condition
developed a postpartum major depressive episode; conversely,
none of the 17 women in the intervention condition suffered
for a depressive episode in the same timeframe. The efficacy
of the brief intervention was confirmed by the same authors in
a larger sample of pregnant women (n=99): within 3 months
after delivery, eight (20 %) of the women in the standard
antenatal care condition had developed postpartum major
depressive disorder, compared with two (4 %) in the interven-
tion condition (Zlotnick et al. 2001).

Two other studies (Grote et al. 2007, 2008) showed that
preventive interventions based on the principles of interper-
sonal psychotherapy intervention, as well as other preventive
group interventions (Kozinszky et al. 2012), seems to be
effective in preventing the occurrence of major depression
during postpartum period in a subgroup of financially disad-
vantaged women with PPD. On the other hand, two recent
Chinese study showed the benefit of an interpersonal-
psychotherapy-oriented childbirth education program
(consisting of two 90-min antenatal classes and a telephone
follow-up within 2 weeks after delivery) in improvement of
perceived social support postpartum depressive symptoms
and psychological well-being when compared with the control
group (Gao et al. 2010, 2012). The presence of a poor partner
support has been recently investigated as key risk factor for
depression in pregnant and postpartum women.

An adaption of IPT that included the partner as an active
participant throughout treatment (Partner-Assisted Interpersonal
Psychotherapy, PA-IPT) was tested with an experimental design
that aimed at investigating the safety, acceptability, and
feasibility of PA-IPT in perinatal women with MDD
(Brandon et al. 2012). The primary outcomes were the
ability to recruit participants, treatment response at mid-
point and final session, session attendance, and couple sat-
isfaction with treatment. Thus, the main goal of the PA-IPT
is to involve the partner as a literal therapy “partner,”
extending the therapy to life between sessions. The partner’s
role in PA-IPT is to hear the patient’s articulation of what
support she might need, learn how to respond to her so that
she might perceive the availability of requested support,
explore other resources for support for the couple, and
engage the identified individuals/avenues to secure help.
This adaptation of IPT incorporates specific elements
borrowed from Emotionally Focused Couple Therapy
(EFCT) that aims to strengthen the interpersonal bond and
address relationship distress by highlighting the attachment
needs humans have of one another and restructuring the
ways partners express these needs (Johnson 2004). Results
were promising, even if the sample was small. Fifteen
women were invited to participate. Those with interested
partners were scheduled for a second visit at which the
process of consent was completed and both partners re-
ceived the Structured Clinical Interview for the Diagnosis
of Axis I Mental Disorders (SCID-IV, Research version) and
the 17-item HRSD. They were considered study eligible if
the woman met full criteria for MDD and if her HRSD
score was greater than 16. Two women were excluded
because partners had untreated psychiatric illness and con-
tinued individual treatment. Eleven women and their part-
ners fulfilled the inclusion and exclusion criteria; nonethe-
less, one couple was disqualified after session two, at which
time partner violence (female upon male) was revealed. Two
women who met study criteria were on stable doses of

Interpersonal psychotherapy for postpartum depression 265

antidepressants (one pregnant and one postpartum) at study
entry, and one pregnant woman was on a stable dose of an
antipsychotic (continuation of drug prescribed to her from
her native country). An additional pregnant participant who
responded to PA-IPT but had history of severe postpartum
depression chose to initiate an antidepressant a few weeks
before delivery. Couples attended eight weekly psychothera-
py sessions, with 12 weeks allowed for completion of the
eight sessions to accommodate unexpected events and
changes in schedule. Results were promising: nine of 10
mothers met the criteria for clinical response (HRSD<9) at the end of acute phase treatment and eight of the nine (89 %) presenting at 6-week follow-up assessment met criteria for symptomatic recovery. Nonetheless, the study had several limitations, in addition to the small sample size. First, the sample was selected on the basis of the partner’s willingness to participate in the treatment. Moreover, the sample was widely heterogeneous in terms of parity, esti- mated gestational age, parturition, and weeks postpartum. Finally, no control or comparison group was selected, rais- ing questions on potential confounders such as time, thera- pist, and regression-to-the-mean effects.

Concluding remarks

IPT is a new studied form of psychotherapy for the postpartum
depression. We identified 11 recent clinical trials (only one
study was published before 2000) that examined the efficacy
of this individual and group psychotherapy for PPD. An open
trial also examined the efficacy of PA-IPT that required
the involvement of the partner during the therapy.
Individual and group interpersonal psychotherapy seem to
be promising interventions for mothers with postpartum
depression. Moreover, engaging relatives’ support signifi-
cantly influences treatment response. Providing exhaustive
information about postpartum depression to partners and
relatives could enhance collective collaboration and reduce
ambivalent feelings and behaviors, although the degree of
their involvement is strictly related to the chosen interper-
sonal focus. Postpartum is a prototypical example of a
series of normative role transitions that coincide with the
multiple biological changes of postpartum. The available
data suggested that the ideal time for intervention with
IPT is during the acute depressive phase. Even when IPT
is not immediately associated with more rapid remission
than an intensive clinical management, it leads to a better
mid-term/long-term outcome. Two recent meta-analyses of
psychotherapeutic treatments for PPD supported the use of
IPT for postpartum depression. The first showed that IPT
for PPD has a substantial effect size (Cuijpers et al. 2008);
the second indicated that those psychotherapeutic interven-
tions for PPD that utilized interpersonal interventions have

a greater effect size than those using cognitive interventions
(Sockol et al. 2011). Moreover, Goodman and Santangelo
(2011), in their systematic review, provided support for the
role of group therapy in the treatment of PPD, including G-
IPT. We suggest that IPT should be considered as one of the
first-line treatments for PPD (at least for mild or moderate
forms of depression) for two main reasons: data from available
studies support the efficacy of individual/group IPT for wom-
en with PPD; moreover, this special population of patients
frequently prefer psychotherapy over treatment with medica-
tions for their concerns about infant exposure to antidepres-
sants with breastfeeding.

Acknowledgments The authors gratefully acknowledge the assistance
of Dr. Giulia Gray of the University of Pisa, Italy, for the English revision.

Conflict of interests None

References

Abreu A, Stuart S (2005) Medical treatments for postpartum depression.
Psychiatr Ann 35:568–575

American Psychiatric Association (1987) Diagnostic and statistical
manual of mental disorders, 3rd edn. American Psychiatric
Association, Washington

American Psychiatric Association (2000) Diagnostic and statistical
manual of mental disorders, 4th edn. American Psychiatric
Association, Washington

Appleby L, Warner R, Whitton A, Faragher B (1997) A controlled study
of fluoxetine and cognitive-behavioural counselling in the treatment
of postnatal depression. BMJ 314:932–936

Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J (1961) An
inventory for measuring depression. Arch Gen Psychiatry 4:
561–571

Boath E, Henshaw C (2001) The treatment of postnatal depression: a
comprehensive literature review. J Reprod Infant Psychol 19:
215–248

Bowlby J (1969) Attachment. Basic Books, New York
Brandon AR, Ceccotti N, Hynan LS, Shivakumar G, Johnson N, Jarrett

RB, Proof of concept (2012) Partner-assisted interpersonal psycho-
therapy for perinatal depression. Arch Womens Ment Health 15:
469–480

Burt VK, Suri R, Altshuler L, Stowe Z, Hendrick VC, Muntean E (2001)
The use of psychotropic medications during breast-feeding. Am J
Psychiatry 158:1001–1009

Clark R, Tluczek A, Wenzel A (2003) Psychotherapy for postpartum
depression: a preliminary report. Am J Orthopsychiatry 73:441–454

Cohen LS, Viguera AC, Bouffard SM, Nonacs RM, Morabito C, Collins
MH, Ablon JS (2001) Venlafaxine in the treatment of postpartum
depression. J Clin Psychiatry 62:592–596

Cooper PJ, Murray L (1995) Course and recurrence of postnatal depres-
sion. Evidence for the specificity of the diagnostic concept. Br J
Psychiatry 166:191–195

Cox JL, Connor YM, Henderson I, McGuire RJ, Kendell RE (1983)
Prospective study of the psychiatric disorders of childbirth by self-
report questionnaire. J Affect Disord 5:1–7

Cox JL, Holden JM, Sagovsky R (1987) Detection of postnatal depres-
sion: development of the Edinburgh Postnatal Depression Scale. Br
J Psychiatry 150:782–786

266 M. Miniati et al.

Cuijpers P, Brännmark JG, van Straten A (2008) Psychological treatment
of postpartum depression: a meta-analysis. J Clin Psychol 64:
103–118

Dennis CL, Stewart DE (2004) Treatment of postpartum depression, part
1: a critical review of biological interventions. J Clin Psychiatry 65:
1242–1251

Dietz PM, Williams SB, Callaghan WM, Bachman DJ, Whitlock EP,
Hornbrook MC (2007) Clinically identified maternal depression
before, during, and after pregnancies ending in live births. Am J
Psychiatry 164:1515–1520

Field T (1995) Infants of depressed mothers. Infect Behav Dev 18:1–13
First MB, Spitzer RL, Gibbon M, Williams JBW (1997) Structured

clinical interview for DSM-IV axis I disorders: research version,
non-patient edition. New York State Psychiatric, New York

Gao LL, Chan SW, Li X, Chen S, Hao Y (2010) Evaluation of an
interpersonal-psychotherapy-oriented childbirth education pro-
gramme for Chinese first-time childbearing women: a randomised
controlled trial. Int J Nurs Stud 47:1208–1216

Gao LL, Chan SW, Sun K (2012) Effects of an interpersonal-
psychotherapy-oriented childbirth education programme for
Chinese first-time childbearing women at 3-month follow up:
randomised controlled trial. Int J Nurs Stud 49:274–281

Gaynes BN, Gavin N, Meltzer-Brody S, Lohr KN, Swinson T, Gartlehner
G, Brody S, Miller WC (2005) Perinatal depression: prevalence,
screening accuracy, and screening outcomes. Evid Rep Technol
Assess 119:1–8

Goodman JH (2009) Women’s attitudes, preferences, and perceived
barriers to treatment for perinatal depression. Birth 36:60–69

Goodman JH, Santangelo G (2011) Group treatment for postpartum
depression: a systematic review. Arch Womens Ment Health 14:
277–293

Goodman JH, Tyer-Viola L (2010) Detection, treatment, and referral of
perinatal depression and anxiety by obstetrical providers. J Womens
Health 19:477–490

Grace SL, Evindar A, Stewart DE (2003) The effect of postpartum
depression on child cognitive development and behavior: a review
and critical analysis of the literature. Arch Womens Ment Health 6:
263–274

Grote NK, Zuckoff A, Swartz H, Bledsoe SE, Geibel S (2007) Engaging
women who are depressed and economically disadvantaged in
mental health treatment. Soc Work 52:295–308

Grote NK, Swartz HA, Zuckoff A (2008) Enhancing interpersonal
psychotherapy for mothers and expectant mothers on low
incomes: adaptations and additions. J Contemp Psychother
38:23–33

Grote NK, Swartz HA, Geibel SL, Zuckoff A, Houck PR, Frank E (2009)
A randomized controlled trial of culturally relevant, brief interper-
sonal psychotherapy for perinatal depression. Psychiatr Serv 60:
313–321

Hamilton MA (1967) Development of a rating scale for primary depres-
sive illness. Br J Soc Clin Psychol 6:278–296

Horowitz JA, Cousins A (2006) Postpartum depression treatment rates
for at-risk women. Nurs Res 55:s23–s27

Johnson SM (2004) The practice of emotionally focused couple therapy:
creating connection, 2nd edn. Brunner-Routledge, New York

Keller MB, Lavori PW, Friedman B, Nielsen E, Endicott J, McDonald-
Scott P, Andreasen NC (1987) The longitudinal interval follow-up
evaluation. A comprehensive method for assessing outcome in
prospective longitudinal studies. Arch Gen Psychiatry 44:540–548

Klerman GL, Weissman MM, Rounsaville BJ, Chevron ES (1984)
Interpersonal psychotherapy of depression. Basic Books, New York

Klier CM, Muzik M, Rosenblum KL, Lenz G (2001) Interpersonal
psychotherapy adapted for the group setting in the treatment of
postpartum depression. J Psychother Pract Res 10:124–131

Kozinszky Z, Dudas RB, Devosa I, Csatordai S, Tóth E, Szabó D,
Sikovanyecz J, Barabás K, Pál A (2012) Can a brief antepartum

preventive group intervention help reduce postpartum depressive
symptomatology? Psychother Psychosom 81:98–107

Marcus SM, Flynn HA, Blow FC, Barry KL (2003) Depressive symp-
toms among pregnant women screened in obstetrics settings. J
Womens Health 12:373–380

Meltzer-Brody S (2011) New insights into perinatal depression: patho-
genesis and treatment during pregnancy and postpartum. Dialogues
Clin Neurosci 13:89–100

Miklowitz DJ, Hooley JM (1998) Developing family psychoeducational
treatments for patients with bipolar and other severe psychiatric
disorders. A pathway from basic research to clinical trials. J
Marital Fam Ther 24:419–435

Milgrom J, Negri LM, Gemmill AW, McNeil M, Martin PR (2005) A
randomized controlled trial of psychological interventions for post-
natal depression. Br J Clin Psychol 44:529–542

Miller LJ (2002) Postpartum depression. JAMA 287:762–765
Millon T, Davis R, Millon C (1997) Millon clinical multiaxial inventory-

III (MCMI-III), 2nd edn. NCS Pearson Inc, Minneapolis
Misri S, Kendrick K (2007) Treatment of perinatal mood and anxiety

disorders: a review. Can J Psychiatry 52:489–498
Misri S, Kostaras X (2002) Benefits and risks to mother and infant of drug

treatment for postnatal depression. Drug Saf 25:903–911
Mulcahy R, Reay RE, Wilkinson RB, Owen C (2010) A randomised

control trial for the effectiveness of group interpersonal psycho-
therapy for postnatal depression. Arch Womens Ment Health 13:
125–139

Nylen KJ, O’Hara MW, Brock R, Moel J, Gorman L, Stuart S (2010)
Predictors of the longitudinal course of postpartum depression
following interpersonal psychotherapy. J Consult Clin Psychol
78:757–763

O’Hara MW (1994) Postpartum depression: causes and consequences.
Springer, New York

O’Hara M, Swain A (1996) Rates and risk of postpartum depression: a
meta-analysis. Int Rev Psychiatry 8:37–54

O’Hara MW, Hoffman JG, Phillips LHC, Wright EJ (1992) Adjustment
in childbearing women: the postpartum adjustment questionnaire.
Psychol Assess 4:160–169

O’Hara MW, Stuart S, Gorman LL, Wenzel A (2000) Efficacy of inter-
personal psychotherapy for postpartum depression. Arch Gen
Psychiatry 57:1039–1045

Pearlstein TB, Zlotnick C, Battle CL, Stuart S, O’Hara MW, Price AB,
Grause MA, Howard M (2006) Patient choice of treatment for postpar-
tum depression: a pilot study. Arch Womens Ment Health 9:303–308

Radloff LS (1977) The CES-D: a self-report depression scale for research
in the general population. Appl Psychol Meas 1:385–401

Reay R, Fisher Y, Robertson M, Adams E, Owen C, Kumar R (2006)
Group interpersonal psychotherapy for postnatal depression: a pilot
study. Arch Womens Ment Health 9:31–39

Reay RE, Owen C, Shadbolt B, Raphael B, Mulcahy R, Wilkinson RB
(2012) Trajectories of long-term outcomes for postnatally depressed
mothers treated with group interpersonal psychotherapy. Arch
Womens Ment Health 15:217–228

Ross LE, Sellers EM, Gilbert Evans SE, Romach MK (2004) Mood
changes during pregnancy and the postpartum period: development
of a biopsychosocial model. Acta Psychiatr Scand 109:457–466

Shapiro DA, Rees A, Barkham M, Hardy G, Reynolds S, Startup M (1995)
Effects of treatment duration and severity of depression on the main-
tenance of gains after cognitive-behavioral and psychodynamic-
interpersonal psychotherapy. J Consult Clin Psychol 63:378–387

Sit DKY, Wisner KL (2005) Decision making for postpartum depression
treatment. Psychiatr Ann 35:577–585

Sockol LE, Epperson CN, Barber JP (2011) A meta-analysis of treat-
ments for perinatal depression. Clin Psychol Rev 31:839–849

Spanier GB (1976) Measuring dyadic adjustment: new scales for
assessing the quality of marriage and similar dyads. J Marriage
Fam 38:15–28

Interpersonal psychotherapy for postpartum depression 267

Stuart S (2006) Interpersonal psychotherapy: a guide to the basics.
Psychiatr Ann 36:542–549

Stuart S (2012) Interpersonal psychotherapy for postpartum depression.
Clin Psychol Psychother 19:134–140

Stuart S, O’Hara MW (1995) Treatment of postpartum depression with
interpersonal psychotherapy. Arch Gen Psychiatry 52:75–76

Stuart S, Robertson M (2003) Interpersonal psychotherapy: a clinician’s
guide. Edward Arnold Ltd, London

Sullivan HS (1953) The interpersonal theoryof psychiatry. Norton, New York
Tronick E, Reck C (2009) Infants of depressed mothers. Harv Rev

Psychiatry 17:147–156
Weinberg MK, Tronick EZ, Beeghly M, Olson KL, Kernan H, Riley JM

(2001) Subsyndromal depressive symptoms and major depression in
postpartum women. Am J Orthopsychiatry 71:87–97

Weissman MM, Bothwell S (1976) Assessment of social adjustment by
patient self-report. Arch Gen Psychiatry 33:1111–1115

Weissman AM, Levy BT, Hartz AJ, Bentler S, Donohue M, Ellingrod
VL, Wisner KL (2004) Pooled analysis of antidepressant levels in
lactating mothers, breast milk, and nursing infants. Am J Psychiatry
161:1066–1078

Whitton A, Appleby L, Warner R (1996a) Maternal thinking and the
treatment of postnatal depression. Int J Psychiatry 8:73–78

Whitton A, Warner R, Appleby L (1996b) The pathway to care in post-
natal depression: women’s attitudes to post-natal depression and its
treatment. Br J Gen Pract 46:427–428

Wisner KL, Hanusa BH, Perel JM, Peindl KS, Piontek CM, Sit DKY,
Findling RL, Moses-Kolko EL (2006) Postpartum depression: a ran-
domized trial of sertraline versus nortriptyline. J Clin Psychopharmacol
26:353–360

Yonkers KA, Lin H, Howell HB, Heath AC, Cohen LS (2008)
Pharmacologic treatment of postpartum women with new-onset
major depressive disorder: a randomized controlled trial with par-
oxetine. J Clin Psychiatry 69:659–665

Zimmerman M, Coryell W (1987) The inventory to diagnose depression
(IDD): a self-report scale to diagnose major depressive disorders. J
Consult Clin Psychol 55:55–59

Zlotnick C, Johnson SL, Miller IW, Pearlstein T, Howard M (2001)
Postpartum depression in women receiving public assistance: pilot
study of an interpersonal-therapy-oriented group intervention. Am J
Psychiatry 158:638–640

268 M. Miniati et al.

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• Interpersonal psychotherapy for postpartum depression: a systematic review

Abstract
Introduction
Methods
Results
Concluding remarks
References

REVIEW ARTICLE

Effectiveness of self-help psychological interventions for treating
and preventing postpartum depression: a meta-analysis

Ping-Zhen Lin1 & Jiao-Mei Xue2 & Bei Yang1 & Meng Li1 & Feng-Lin Cao1

Received: 19 October 2017 /Accepted: 21 March 2018 /Published online: 4 April 2018
# Springer-Verlag GmbH Austria, part of Springer Nature 2018

Abstract
Previous studies have reported different effect sizes for self-help interventions designed to reduce postpartum depression symp-
toms; therefore, a comprehensive quantitative review of the research was required. A meta-analysis was conducted to examine
the effectiveness of self-help interventions designed to treat and prevent postpartum depression, and identified nine relevant
randomized controlled trials. Differences in depressive symptoms between self-help interventions and control conditions, chang-
es in depressive symptoms following self-help interventions, and differences in postintervention recovery and improvement rates
between self-help interventions and control conditions were assessed in separate analyses. In treatment trials, depression scores
continued to decrease from baseline to posttreatment and follow-up assessment in treatment subgroups. Changes in treatment
subgroups’ depression scores from baseline to postintervention assessment were greater relative to those observed in prevention
subgroups. Self-help interventions produced larger overall effects on postpartum depression, relative to those observed in control
conditions, in posttreatment (Hedges’ g = 0.51) and follow-up (Hedges’ g = 0.32) assessments; and self-help interventions were
significantly more effective, relative to control conditions, in promoting recovery from postpartum depression. Effectiveness in
preventing depression did not differ significantly between self-help interventions and control conditions.The findings suggested
that self-help interventions designed to treat postpartum depression reduced levels of depressive symptoms effectively and
decreased the risk of postpartum depression.

Keywords Self-help . Depression . Postpartum . Meta-analysis . Randomized controlled trial

Introduction

Postpartum depression refers to major and minor depressive
episodes that occur within 12 months of parturition (Gavin
et al. 2005). It is a common mental illness in women, with high
prevalence rates ranging from 6.5 to 12.9% (Gavin et al. 2005).
Postpartum depression exerts negative effects including in-
creased obstetric complications in depressed mothers (Leung
& Kaplan 2009), compromised mother-child relationships,
and disturbed neurobiological, social, and cognitive develop-
ment in infants (Brummelte & Galea 2016). Consequently, the
development and validation of effective interventions and pre-
ventative programs are crucial.

Despite observation of positive effects and improvements
in depressive symptomatology with traditional treatments,
such as antidepressant medication and individual psychother-
apy, research has shown that low participation rates (5–14%)
(Andersson et al. 2003; Andersson et al. 2006; Kelly et al.
2001) limit these interventions (Bijl & Ravelli, 2000).

* Feng-Lin Cao
caofenglin2008@126.com

Ping-Zhen Lin
lpz385675123@163.com

Jiao-Mei Xue
xuejiaomeiyan@163.com

Bei Yang
yangbeilucky@126.com

Meng Li
gflemon11@163.com

1 School of Nursing, Shandong University, No. 44 Wenhua Xi Road,
Jinan 250012, Shandong, People’s Republic of China

2 Society and Law School, Shandong Women’s University,
Jinan, Shandong, People’s Republic of China

Archives of Women’s Mental Health (2018) 21:491–503
https://doi.org/10.1007/s00737-018-0835-0

http://crossmark.crossref.org/dialog/?doi=10.1007/s00737-018-0835-0&domain=pdf

Antidepressant medication is associated with adverse preg-
nancy and neonatal outcomes. Antidepressants could exert
adverse effects during pregnancy and breastfeeding on both
mother and child, such as preterm birth, reduction in maternal
weight gain and infant birth weight, and poor neonatal out-
comes (Wisner et al. 2009). Moreover, there are other disad-
vantages, such as time inflexibility, the need for health profes-
sionals’ participation, and unaffordability for many women
(Cowpertwait & Clarke 2013; Roness et al. 2005).
Therefore, self-help interventions, which involve little burden
on clinical resources, few time constraints, and accessibility
for a broad range of users (Beatty & Binnion 2016), have
attracted increased attention.

Self-help interventions refer to psychological interventions
that patients largely complete independently at home, in ac-
cordance with a standardized protocol, using written material
(e.g., books, booklets), CD-ROMs, DVDs, computerized soft-
ware packages, and websites (Cuijpers & Schuurmans 2007).
Cowpertwait & Clarke (2013) conducted a systematic review
examining web-based psychological interventions for depres-
sion and showed such interventions exerted a statistically sig-
nificant and moderately large effect, relative to that observed
in the control condition (placebo or treatment-as-usual or
waitlist), and led to a significant reduction in depressive symp-
toms. Moreover, another systematic review that evaluated the
clinical effectiveness of cognitive behavioral therapy (CBT)-
based, guided self-help interventions for anxiety and depres-
sive disorders demonstrated the effectiveness of guided self-
help at posttreatment assessment; however, this effectiveness
was considerably diminished at follow-up and in clinically
representative samples (Coull & Morris 2011). Furthermore,
self-help interventions may be more effective for treatment
rather than prevention of depression in the general population
(Gellatly et al. 2007).

The effectiveness of a wide range of self-help interventions
for postpartum depression has been demonstrated in random-
ized controlled trials (RCTs). For example, behavioral activa-
tion (BA) is an effective method for reducing depressive
symptoms when compared to treatment as usual (TAU)
(O’Mahen, 2013, O’Mahen et al. 2014). Symptoms of post-
partum depression decreased more for participants in the CBT
group compared to those participants in the waitlist control
group (Pugh et al. 2016). In addition, self-help exercise inter-
vention was more effective than wellness/support contact con-
trol condition in alleviating symptoms of postpartum depres-
sion (Lewis et al. 2014). However, some studies failed to
demonstrate that self-help interventions were superior to usual
care in the treatment or prevention of postpartum depression
(Costa et al. 2009; Daley et al. 2015a; Mohammadi et al.
2015). Moreover, with the exception of a study conducted
by Milgrom et al. (2016), research has consistently shown that
intervention effects were not sustained during follow-up pe-
riods of various durations (Costa et al. 2009; Daley et al.

2015a; Mohammadi et al. 2015; O’Mahen et al. 2014). Most
studies reported that depressive symptoms decreased signifi-
cantly from baseline to postintervention assessment (Costa
et al. 2009; Daley et al. 2015a; King 2009; O’Mahen et al.
2014; O’Mahen et al. 2014; Pugh et al. 2016), while some
others reported that symptoms decreased significantly from
postintervention to follow-up assessment (O’Mahen et al.
2014; Pugh et al. 2016). In the only published RCT to com-
pare the effectiveness of an Internet-based self-help interven-
tion with a face-to-face control intervention in the prevention
of postpartum depression, King (2009) demonstrated that re-
duction of depression from pretest to posttest of the Internet-
based program was equivalent to that of the face-to-face
intervention.

Given that different effect sizes have been observed for
various types of self-help interventions designed to reduce
postpartum depression symptoms, comprehensive and quan-
titative reviews of potential outcomes are required. Therefore,
the primary aim of the current meta-analysis was to assess the
effectiveness of a range of self-help interventions in the treat-
ment and prevention of postpartum depression observed in
RCTs.

We compared depressive symptom severity between a self-
help intervention condition and a control condition and exam-
ined the overall effect of these interventions on depressive
symptoms over time. In addition, the difference in postinter-
vention recovery and improvement rates between the two con-
ditions was also examined.

Materials and methods

Data sources and search strategy

We conducted a meta-analysis in accordance with the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
(2015) statement (Moher et al. 2015) to examine the impact of
self-help psychological interventions on postpartum depression.
Systematic literature searches of the PubMed, Scopus, Web of
Science, Cochrane Central Register of Controlled Trials,
MEDLINE databases, and ProQuest Dissertation and Theses
were performed to identify relevant RCTs. There were no re-
strictions regarding publication date. Searches were last updated
in September 31, 2017. Searches were conducted within the
domains of title, abstract, and keywords. A string was used
within each database: (Bself-help^ OR BInternet^ OR Bweb^
OR Bonline^ OR Bcomputer^ OR Bhome^ OR Btelephone^)
AND (Bpostpartum depress*^ OR Bpostnatal depress*^ OR
Bmaternal depress*^) AND (Btreatment^ OR Btherapy^ OR
Bintervention^ OR Btrial^ OR Banalysis^). In addition, we per-
formed manual searches of the reference lists in the identified
articles and publications that cited them.

492 P.-Z. Lin et al.

Literature selection and data extraction

The eligibility criteria for study selection were as follows:
Study design: Studies were eligible for inclusion if they

reported RCTs that examined self-help interventions for at
least 4 weeks that involved one of the following four factors:
routine clinical care/treatment-as-usual (TAU), receive no
treatment, join a waiting list (WL), or participate in a face-
to-face psychological intervention. Where studies reported
multiple self-help intervention groups with a control group,
they were recoded as multiple subgroups, and effect sizes
were calculated between each intervention group and control
group separately.

Participants: Included studies were based solely on women
during pregnancy or the postpartum period (defined as the
12 months following the birth of a child), regardless of gender,
race, nationality, or depressive status.

Interventions: Self-help interventions, as a type of psycho-
logical interventions (interventions which could exert influ-
ence on the mental activity, personality characteristics, or psy-
chological problems of objects under the guidance of psycho-
logical theory), are defined as an individual’s access to self-
help materials (e.g., written material and websites) in the treat-
ment of mood disorders. Maximum professional input for self-
help interventions equals to half of that for the lower range in
conventional therapy, in accordance with the recommenda-
tions of a recent systematic review examining self-help inter-
ventions for depression (Gellatly et al. 2007).

Outcomes: Measurement and reporting of postpartum de-
pression scores using a validated self-report or clinician-
administered measure at postintervention and follow-up as-
sessment. The manuscript reported that sufficient outcome
data for the calculation of effect sizes was included. When
studies did not report sufficient outcome data for the compu-
tation of effect sizes, authors were contacted to request addi-
tional data, and this information was used to calculate effect
sizes when provided.

Studies in which all female participants were classified as
depressed using diagnostic criteria or symptom severity at
baseline were eligible for inclusion in the meta-analysis of
studies involving treatment; and studies in which not all par-
ticipants fulfilled the criteria for a depressive episode or ex-
hibited clinically significant depressive symptoms at baseline
were eligible for inclusion in the meta-analysis of studies in-
volving prevention subgroups.

Search results were not limited with respect to language,
but all of the identified articles were in English. The exclusion
criteria were as follows: (1) absence of a control group, (2)
examination of methods other than self-help interventions, (3)
irretrievable intervention results, and (4) total overlap of sam-
ple and results reported in a different publication.

The data extracted from all studies were as follows: First
Author, publication date, age (mean), education (%), race (%),

employment (%), marital status (%), months since postpar-
tum, depression at entry, intervention type (exercise vs. stress
management program vs. CBT vs. BA), control type (TAU vs.
WL vs. face-to-face psychological intervention), outcome
measure (the Edinburgh Postnatal Depression Scale, EPDS
vs. the Beck Depression Inventory-II, BDI-II), intervention
approaches (Internet-based vs. telephone-based), intervention
duration (months or weeks), follow-up duration (months or
weeks), and the mean and standard deviation from each
study’s depressive symptomatology scale scores.

The systematic search and data extraction were performed
independently by two of the researchers. The risk of bias was
assessed using the Cochrane Risk of Bias Tool (Peters et al.
2015), and a third researcher checked for consistency of bias.
Divergence of opinions was resolved through consultation.

Statistical analysis

Statistical analyses were performed using Stata Version 14.0.
Pooled mean effect sizes were calculated (Hedges’ g) with
95% confidence intervals (CIs), using random effects models
based on the assumption that included studies represented the
true distribution of intervention data, to compare outcomes
between self-help interventions and control conditions and
assess changes in depressive symptoms for self-help interven-
tions. Hedges’ g values of 0.2, 0.5, and 0.8 represent small,
moderate, and large effect sizes, respectively (Cohen 1988).
Odds ratios (ORs) were calculated to compare postinterven-
tion recovery and improvement rates between the intervention
and control conditions.

Q and I2 statistics were used to assess heterogeneity, and P
values of < .100 for the Q statistic indicated high heterogene- ity levels. For the I2 statistic, scores of 25, 50, and 75% indi- cated low, moderate, and high heterogeneity levels, respec- tively (Higgins et al. 2003). As fewer than 10 studies were included in the review, we did not perform a meta-regression.

Subgroups classified according to intervention purpose,
control type, intervention type, and depression measure were
analyzed. Except for intervention purpose and intervention
type, all the other subgroup analyses did not show significant
results, which would not be displayed in the result.

In each of these analyses, outliers were identified using the
sample-adjusted meta-analytic deviance (SAMD) statistic
(Huffcutt & Arthur 1995). If the SAMD value was ≥ 2.58
and the scree plot suggested that the SAMD did not differ
from the overall distribution, the study was retained.

Publication bias was assessed via visual examination of
funnel plots, Duval and Tweedie’s (2000) trim-and-fill proce-
dure, and classic fail-safe N values (Rosenthal 1979).
According to Rosenthal’s (1991) recommendation, a value
of 5K + 10, where K is the number of observed studies, was
used as the cutoff point for an unlikely number of nonsignif-
icant studies. Given the small number of studies in the meta-

Effectiveness of self-help psychological interventions for treating and preventing postpartum depression: a… 493

analysis, these tests demonstrated low sensitivity in detecting
publication bias.

Assessment of study quality

The methodological quality of each study was assessed via the
Delphi List Criteria (Verhagen et al. 2017). The criteria in-
clude nine standard items for RCTs. Two of the nine list
criteria (i.e., BWas the intervention provider blinded?^ and
BWas the participant blinded?^) were not considered, as it is
difficult to conduct self-help intervention trials in which par-
ticipants and the intervention provider are blind to the inter-
vention (Daley et al. 2015b). Therefore, we evaluated the de-
sign of each study using seven criteria. One point was
assigned for each criterion, providing a maximum score of 7.

Results

Study characteristics

Figure 1 shows the literature search flow chart. Of the 1921
potentially eligible articles identified via the electronic
search, nine met all of the review criteria and were included
in the analysis (Costa et al. 2009; Daley et al. 2015a; King
2009; Lewis et al. 2014; Milgrom et al. 2016; Mohammadi
et al. 2015; O’Mahen et al. 2014; O’Mahen et al. 2014; Pugh
et al. 2016) after removal of duplicates, title and abstract
screening, and full-text article assessment. Most studies
were journal articles, with only one doctoral thesis included
(King 2009).

Study quality and sensitivity analysis

Table 1 shows the results regarding the methodological quality
of the included studies. Eight studies were awarded 6 points,
which indicated high methodological quality. The remaining
study (King 2009) was awarded 4 points. All studies involved
random sampling, specified eligibility criteria, and presented
point estimates and measures of variability for the primary
outcome measures.

Elimination of the data from the study that was
awarded 4 points resulted in a reduction in heterogeneity
in the overall depressive symptomatology analysis, from
I2 = 63.2% to I2 = 57.9%. In addition, the effect sizes for
the psychological interventions were maintained (Hedges’
g = 0.42; 95% CI 0.20 to 0.64) following the exclusion of
this study, and the reduction in effect sizes did not reach
statistical significance (P = .098). This study (King 2009)
was remained in the following analysis.

Study designs and participants

The characteristics of each study are presented in Table 2. All
interventions were administered after parturition, with the ex-
ception of that in one study, which was implemented between
26 and 32 weeks of pregnancy (Mohammadi et al. 2015).
Intervention durations ranged from 4 weeks to 6 months,
and the follow-up period ranged from 3 weeks to 6 months,
with the exception that three studies did not have follow-up.
The study conducted by Mohammadi et al. (2015) involved
two self-help intervention groups and a control group, which
were recoded as two subgroups: Mohammadi 2015a (antenatal
exercise intervention versus TAU) and Mohammadi 2015b

(antenatal and postnatal exercise intervention versus TAU).
Effect sizes were calculated between each intervention group
and the control group separately.

Six and four of the intervention subgroups received
Internet- and telephone-based interventions, respectively.
Control groups included TAU, WL, and face-to-face psycho-
logical intervention. Intervention subgroups involved five ex-
ercise subgroups, one stress management program, two CBT
subgroups, and two BA subgroups. The studies included six
treatment subgroups and four prevention subgroups.

Sample sizes ranged from 17 to 165. The total numbers of
participants in self-help intervention and control groups were
513 and 438, respectively. Seven studies used EPDS, and two
used BDI-II.

Meta-analysis findings

Postintervention postpartum depressive symptoms following
self-help interventions

The pooled effect size for eight subgroups was − 1.08 (95% CI
− 1.61 to − 0.55, Fig. 2), suggesting that depressive symptoms
in the self-help intervention groups decreased following the
interventions, with large effect sizes. In addition, the effect
sizes were significantly heterogeneous (χ2 = 76.19,
P < .001), indicating that potential moderators existed. One study (O’Mahen et al. 2014) reported SAMD values exceed- ing 2.58. Visual inspection of the scree plot of rank-ordered SAMD scores indicated that the value for this study was con- sistent with the overall distribution of SAMD scores. Therefore, this study was excluded from further analyses.

Postintervention effect sizes were − 0.60 (95% CI − 1.16 to
− 0.05, P = .001, I2 = 80.7%) for exercise; − 0.84 (95% CI −
1.55 to − 0.14) for the stress management program; − 1.88
(95% CI: − 2.29 to − 1.46, P = .153, I2 = 51.0%) for BA; and
− 1.50 (95% CI − 2.18 to − 0.82) for CBT.

The difference in intervention purposes between subgroups
was significant (P = .013), and Hedges’ g value for the treat-
ment subgroups (− 1.51; 95% CI − 1.90 to − 1.12, P = .004,
I2 = 73.6%) was higher relative to that observed for the

494 P.-Z. Lin et al.

prevention subgroups (− 0.29; 95% CI − 0.70 to 0.12,
P = .151, I2 = 47.1%). Significant heterogeneity was observed
for the treatment and exercise subgroups.

In the treatment studies, the fail-safe N was 654, which
exceeded the tolerance level for an unlikely number of non-
significant studies (35). In the treatment and prevention stud-
ies, the funnel plot and trim-and-fill procedures indicated that
there was no publication bias (Fig. 3).

Comparison of postpartum depressive symptoms
between postintervention and follow-up assessments
for self-help interventions

The pooled effect size for six subgroups was − 0.32 (95% CI
− 0.52 to − 0.12, Fig. 4), indicating that depression symptoms
in the self-help intervention groups decreased between post-
intervention and follow-up assessments, with small-to-

3

Full-text articles assessed for eligibility

(n=36)
Full-text articles excluded:

No RCT (n=5)

Study design (n=1)

Population (n=1)

Non-self-help (n=11)

Insufficient data (n=9)

Studies included in

treatment

meta-analysis

(n=6)

Studies included in

prevention

meta-analysis

(n=3)

Records after duplicates removed

(n=991)

Records identified though database searchin

g

＆ reference review

Title and abstract screening

(n=79)

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Fig. 1 Study selection flow
diagram

Table 1 Methodological quality of included studies

Quality characteristics Costa
2009

Daley
2015a

King
2009

Lewis
2014

Milgrom
2016

Mohammadi
2015

O’Mahen
2013

O’Mahen
2014

Pugh
2016

1. Was a method of randomization performed?

Y Y Y Y Y Y Y Y Y

2. Was the treatment allocation concealed? Y Y – Y Y Y Y Y Y

3. Were the groups similar at baseline regarding the most
important prognostic indicators?

Y Y Y Y Y Y Y Y Y

4. Were the eligibility criteria specified? Y Y Y Y Y Y Y Y Y

5. Was the outcome assessor blinded? – N – Y – N – –

–

6. Were point estimates and measures of variability
presented for the primary outcome measures?

Y Y Y Y Y Y Y Y Y

7. Did the analysis include an intention-to-treat analysis? Y Y N N Y Y Y Y Y

Total 6 6 4 6 6 6 6 6 6

Effectiveness of self-help psychological interventions for treating and preventing postpartum depression: a… 495

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496 P.-Z. Lin et al.

moderate effect sizes. There was no significant heterogeneity
observed for effect sizes (χ2 = 4.96, P = .421), and no studies
reported SAMD values exceeding 2.58 (range − 1.71 to 1.56).

Effect sizes for depression symptoms between follow-up
and postintervention assessments were − 0.21 (95% CI − 0.44
to 0.02, P = .923, I2 = 0.0%) for exercise, − 0.54 (95% CI −
1.03 to − 0.06) for BA, and − 0.93 (95% CI − 1.64 to − 0.21)
for CBT.

The difference in intervention purposes between subgroups
was nonsignificant (P = .510), with Hedges’ g values of −
0.38 (95% CI − 0.70 to − 0.07, P = .200, I2 = 35.4%) in treat-
ment subgroups and − 0.25 (95% CI − 0.58 to 0.07, P = .790,
I2 = 0.0%) in prevention subgroups. No significant heteroge-
neity was observed for the subgroups.

In the treatment studies, the fail-safe N was 12, which did
not exceed the tolerance level for an unlikely number of non-
significant studies (30). The funnel plot and trim-and-fill pro-
cedures suggested that there was no publication bias for treat-
ment or prevention studies (Fig. 3).

Comparison of postintervention postpartum depressive
symptoms between intervention and control conditions

A forest plot presenting the pooled between-group effect
sizes for postintervention depression scores is presented
in Fig. 5. The pooled postintervention between-group
effect size for nine subgroups was 0.32 (95% CI 0.09
to 0.56, P = .004), indicating that self-help interventions

produced stronger overall effects relative to those of
control interventions, which were small to moderate.
No studies reported SAMD values exceeding 2.58
(range − 2.22 to 2.24).

Postintervention between-group effect sizes for depressive
symptoms were 0.20 (95% CI − 0.06 to 0.46, P = .113, I2 =
46.4%) for exercise, − 0.35 (95% CI − 0.99 to 0.30) for stress
management programs, 0.56 (95% CI 0.37 to 0.76, P = .696,
I2 = 0.0%) for BA, and 1.06 (95% CI 0.42 to 1.70) for CBT.

The difference in intervention purposes between subgroups
was nonsignificant (P = .063), and Hedges’ g for treatment
subgroups (0.51; 95% CI 0.27 to 0.75, P = .146, I2 = 41.3%)
was higher relative to that observed for prevention subgroups
(0.05; 95% CI − 0.35 to 0.45, P = .032, I2 = 66.0%).
Significant heterogeneity was observed in the prevention
subgroups.

In the treatment studies, the fail-safe N was 64, which
exceeded the tolerance level for an unlikely number of non-
significant studies (35). In addition, the funnel plot was slight-
ly asymmetric (Fig. 3), and trim-and-fill procedures suggested
one missing study with a value to the left of the mean. The
overall effect size after trim-and-fill correction was 0.45 (95%
CI 0.19 to 0.70). This adjusted value suggested that if the
included studies reflected publication bias, it occurred in the
direction of overestimation of true effect sizes for the inter-
ventions. In the prevention studies, the funnel plot showed no
publication bias (Fig. 3), and trim-and-fill procedures sug-
gested no missing studies.

Fig. 2 Forest plot displaying
effect sizes of depression scores at
post-intervention versus at
baseline in self-help intervention
group. Note. Mohammadi
(2015)a: antenatal exercise
intervention versus treatment-as-
usual, Mohammadi (2015)b:
antenatal and postnatal exercise
intervention versus treatment-as-
usual.

Effectiveness of self-help psychological interventions for treating and preventing postpartum depression: a… 497

Fig. 3 Funnel plots to assess for
publication bias by relating effect
sizes of the studies to standard
errors

498 P.-Z. Lin et al.

Comparison of postpartum depressive symptoms
between interventions and control conditions at follow-up

The pooled between-group effect size at follow-up in six sub-
groups was 0.19 (95% CI − 0.05 to 0.43, see Fig. 6),

indicating that self-help interventions produced larger overall
effects relative to those of control conditions, which were
small to moderate. In addition, the effect sizes were signifi-
cantly heterogeneous (χ2 = 7.24, P = .203). No studies report-
ed SAMD values exceeding 2.58 (range − 1.79 to 1.61).

Fig. 4 Effect sizes of depression
scores at follow-up versus at post-
intervention in self-help
intervention group. Note.
Mohammadi (2015)a: antenatal
exercise intervention versus
treatment-as-usual, Mohammadi
(2015)b: antenatal and postnatal
exercise intervention versus
treatment-as-usual.

Fig. 5 Forest plot displaying
effect sizes of depression scores at
post-intervention comparing self-
help interventions with control
conditions. Note. Mohammadi
(2015)a: antenatal exercise
intervention versus treatment-as-
usual, Mohammadi (2015)b:
antenatal and postnatal exercise
intervention versus treatment-as-
usual.

Effectiveness of self-help psychological interventions for treating and preventing postpartum depression: a… 499

Between-group effect sizes for depressive symptoms at
follow-up were 0.03 (95% CI − 0.20 to 0.26, P = .981, I2 =
0.0%) for exercise; 0.48 (95% CI − 0.04 to 1.00) for BA; and
0.83 (95% CI 0.20 to 1.45) for CBT.

Treatment trials showed a trend toward larger overall ef-
fects for self-help treatment, relative to those in control con-
ditions, with a Hedges’ g value of 0.32 (95% CI − 0.01 to
0.65, P = .170, I2 = 40.3%). In prevention studies, the
Hedges’ g value was − 0.02 (95% CI − 0.34 to 0.31, P =
0.100, I2 = 0.0%), which was nonsignificant. Subgroup anal-
yses of intervention purposes showed no difference between
subgroups (P = .240). No heterogeneity was observed for the
subgroups.

In the treatment studies, the funnel plot showed no
publication bias (Fig. 3); and trim-and-fill procedures sug-
gested no missing studies. In the prevention studies, the
funnel plot showed no publication bias (Fig. 3), and trim-
and-fill procedures suggested that the overall effect size
did not change with one missing study (Hedges’ g = −
0.02, 95% CI − 0.28 to 0.25).

Postintervention recovery and improvement rates

A forest plot presenting the pooled between-group effect sizes
for postintervention recovery and improvement rates is shown
in Fig. 7. Participants in seven subgroups (n = 372) recovered
or showed significant improvement following self-help
interventions.

One treatment study (Milgrom et al. 2016) reported SAMD
values exceeding 2.58 and was excluded from subsequent
analyses. Following exclusion of this outlier, the average ef-
fect size was 2.50 (95% CI 1.76 to 3.55, P = .772, I2 = 0.0%),
indicating that recovery rates following self-help interventions
were significantly higher relative to those observed in control
conditions. No significant heterogeneity was observed for the
treatment studies. The fail-safe N value was 35, which
exceeded the tolerance value of 30. While the funnel plot
was asymmetric (Fig. 3), trim-and-fill procedures showed
two missing studies with values to the left of the mean. The
overall effect size following trim-and-fill correction was 2.31
(95% CI 1.53 to 3.08). This adjusted value suggested that if
the included studies reflected publication bias, it occurred in
the direction of overestimation of the true effect size for the
interventions.

One of the prevention subgroups (Mohammadi 2015b) re-
ported SAMD values exceeding 2.58 and was excluded from
subsequent analyses. Excluding this outlier, the effect size for
the subgroups was 1.13 (95% CI: 0.31 to 4.08), indicating that
improvements in depression symptoms did not differ between
the self-help prevention and control conditions in nonde-
pressed women.

Discussion

This meta-analysis summarized the effects of self-help inter-
ventions in the prevention and treatment of postpartum

Fig. 6 Forest plot displaying
effect sizes of depression scores at
follow-up comparing self-help
interventions with control
conditions. Note. Mohammadi
(2015)a: antenatal exercise
intervention versus treatment-as-
usual, Mohammadi (2015)b:
antenatal and postnatal exercise
intervention versus treatment-as-
usual.

500 P.-Z. Lin et al.

depression. The meta-analysis showed that self-help interven-
tions constituted an effective method of treatment for postpar-
tum depression. Specifically, (1) depression symptoms contin-
ued to decrease from baseline to posttreatment and follow-up
assessments in treatment subgroups. Changes in depression
scores from baseline to postintervention assessment in treat-
ment subgroups were greater relative to those observed in
prevention subgroups. (2) Posttreatment and follow-up de-
pression symptoms showed greater reductions following
self-help interventions, relative to those observed in control
conditions; and (3) self-help interventions were significantly
more effective in aiding recovery from postpartum depression,
relative to control conditions. However, their effectiveness in
improvement of depression symptoms did not differ signifi-
cantly from that of control conditions in prevention studies.

Depression scores continued to decrease from baseline to
postintervention and follow-up assessment in treatment sub-
groups, which verified the effectiveness of self-help treatment
for postpartum depressive symptoms. In treatment studies,
self-help interventions produced larger overall effects on post-
partum depressive symptoms relative to those observed for
control conditions (Hedges’ g = 0.51). In addition, effect sizes
observed at follow-up assessment (Hedges’ g = 0.32) were
consistent with those observed in previously published re-
views examining treatments for perinatal depression, which
reported an average posttreatment effect size of 0.57 for post-
partum depressive symptoms (Sockol et al. 2011). Moreover,
the effectiveness of self-help interventions in aiding recovery
from postpartum depressive symptoms was significantly

greater relative to that observed for control conditions. As
stated by Cuijpers et al. (2010), guided self-help and face-to-
face treatments for depression exhibited comparable benefits
at follow-up of up to 1 year. This pattern of results suggested
that, similar to face-to-face treatments, self-help interventions
were more effective for postpartum depressive symptoms rel-
ative to TAU or WLs, and these benefits could be maintained
in the long term.

Treatment effects were stronger, relative to prevention ef-
fects, with respect to symptomatic improvement of postpar-
tum depression from baseline to postintervention assessment.
Similar results were observed in another meta-analysis exam-
ining self-help intervention for depression in the general pop-
ulation (Gellatly et al. 2007). Moreover, no advantages of self-
help interventions for postpartum depression were observed in
prevention trials. Furthermore, it is possible that depression
symptom severity could have influenced effect sizes. In other
words, self-help interventions could have produced a signifi-
cant effect size in the treatment of women who met the criteria
for depression or displayed depression scores above the cutoff
point for clinically significant depressive symptoms at base-
line. However, the effects of the interventions could have been
limited for women with low levels of depressive symptoms
(Bortolotti et al. 2008; Cuijpers, Smit, & Van 2007a).

Self-help CBTand BA produced stronger overall posttreat-
ment effects on postpartum depression relative to those ob-
served in control conditions. Moreover, these interventions
could provide steady symptomatic improvements in postpar-
tum depression from baseline to follow-up assessment. The

Fig. 7 Forest plot of the odds
ratio of patients recovered or
improved comparing self-help
psychological interventions with
control conditions. Note.
Mohammadi (2015)a: antenatal
exercise intervention versus
treatment-as-usual.

Effectiveness of self-help psychological interventions for treating and preventing postpartum depression: a… 501

results showed that self-help CBTand BAwere more effective
for postpartum depression, relative to control conditions. A
systematic review of the effectiveness of CBT in treating
and preventing perinatal depression reported an overall effect
size of 0.65 (95% CI 0.54 to 0.76, P < .001), indicating that participants who received CBT exhibited significantly greater reductions in depressive symptoms relative to those observed in control conditions (Sockol 2015). Another meta-analysis examining BA for depression in adults showed that BA was as effective as cognitive therapy and other psychological treat- ments for depression, with a large effect size of 0.87 (Cuijpers, Van & Warmerdam 2007b). There is strong evidence indicat- ing that dysfunctional patterns of cognition constitute a key risk factor for emotional distress (Beck & Haigh 2014). In addition, CBTwas an effective treatment, as it helped patients to identify, evaluate, challenge, and modify dysfunctional be- liefs. The current meta-analyses showed that while relatively few studies had examined each condition, the overall numbers of studies and participants provided sufficient power for the identification of differences in effectiveness between treatments.

The meta-analysis was subject to several limitations.
For example, the sample size was small; therefore, the
results should be interpreted with caution. In addition,
the body of existing research examining this topic is rel-
atively small, and all of the studies included in the review
focused on the effects of self-help interventions for post-
partum depression. Therefore, the homogeneity of the
sample limited generalization of the results and exposed
the shortage in existing research. Another limitation that
should be noted is the existence of publication bias in the
included studies. Trim-and-fill procedures suggested that
the publications showed significant positive intervention
effects. In addition, following correction for publication
bias, the overall effects of the interventions remained sig-
nificant, but null findings from well-designed studies are
required to enhance understanding of these interventions.

In summary, self-help interventions were more effec-
tive, relative to TAU and WLs, and as effective as face-
to-face psychological interventions in treating postpar-
tum depression. Considering the advantage of conve-
nience, self-help interventions, such as self-help, CBT,
and BA, have the potential to be effective therapy
methods for the treatment of postpartum depression.

Funding information This work was financially supported by grants
from the Science and Technology Major Project of Shandong
Province (grant number: 2015ZDXX0801A01).

Compliance with ethical standards

Conflict of interest The authors declare that there is no conflict of
interest.

References

Andersson L, Sundström-Poromaa I, Bixo M, Wulff M, Bondestam,
ÅStrö M (2003) Point prevalence of psychiatric disorders during
the second trimester of pregnancy: a population-based study. Am J
Obstet Gynecol 189:148–154. https://doi.org/10.1067/mob.2003.
336

Andersson L, Sundström-Poromaa I, Wulff M, Åström M, Bixo M (2006)
Depression and anxiety during pregnancy and six months postpar-
tum: a follow-up study. Acta Obstet Gynecol Scand 85:937–944.
https://doi.org/10.1080/00016340600697652

Beatty L, Binnion C (2016) A systematic review of predictors of, and reasons
for, adherence to online psychological interventions. Int J Behav Med
23:776–794. https://doi.org/10.1007/s12529-016-9556-9

Beck AT, Haigh EAP (2014) Advances in cognitive theory and therapy:
the generic cognitive model. ANNU REV CLIN PSYCHO 10:1–24.
https://doi.org/10.1146/annurev-clinpsy-032813-153734

Bijl RV, Ravelli A (2000) Psychiatric morbidity, service use, and need for
care in the general population: results of The Netherlands Mental
Health Survey and Incidence Study. Am J Public Health 90:602–
607. https://doi.org/10.2105/ajph.90.4.602

Bortolotti B, Menchetti M, Bellini F, Montaguti MB, Berardi D (2008)
Psychological interventions for major depression in primary care: a
meta-analytic review of randomized controlled trials. Gen Hosp
Psychiatry 30:293–302. https://doi.org/10.1016/j.genhosppsych.
2008.04.001

Brummelte S, Galea LAM (2016) Postpartum depression: etiology, treat-
ment and consequences for maternal care. Horm Behav 77:153–
166. https://doi.org/10.1016/j.yhbeh.2015.08.008

Cohen J (1988) Statistical power analysis for the behavioral sciences. J
Am Stat Assoc 2:19–74

Costa D, Lowensteyn I, Abrahamowicz M et al (2009) A randomized
clinical trial of exercise to alleviate postpartum depressed mood. J
Psychosom Obstet Gynaecol 30:191–200. https://doi.org/10.1080/
01674820903212136

Coull G, Morris PG (2011) The clinical effectiveness of CBT-based guid-
ed self-help interventions for anxiety and depressive disorders: a
systematic review. Psychol Med 41:2239–2252. https://doi.org/10.
1017/s0033291711000900

Cowpertwait L, Clarke D (2013) Effectiveness of web-based psycholog-
ical interventions for depression: a meta-analysis. Int J Ment Health
Addict 11:247–268. https://doi.org/10.1007/s11469-012-9416-z

Cuijpers P, Schuurmans J (2007) Self-help interventions for anxiety dis-
orders: an overview. Curr Psychiatry Rep 9:284–290. https://doi.
org/10.1007/s11920-007-0034-6

Cuijpers P, Smit F, Van SA (2007a) Psychological treatments of sub-
threshold depression: a meta-analytic review. Acta Psychiatr Scand
115:434–441. https://doi.org/10.1111/j.1600-0447.2007.00998.x

Cuijpers P, Van SA, Warmerdam L (2007b) Behavioral activation treat-
ments of depression: a meta-analysis. Clin Psychol Rev 27:318–
326. https://doi.org/10.1016/j.cpr.2006.11.001

Cuijpers P, Donker T, Van SA, Li J, Andersson G (2010) Is guided self-
help as effective as face-to-face psychotherapy for depression and
anxiety disorders? A systematic review and meta-analysis of com-
parative outcome studies. Psychol Med 40:1943–1957

Daley AJ, Blamey RV, Jolly K, Roalfe AK, Turner KM, Coleman S,
McGuinness M, Jones I, Sharp DJ, MacArthur C (2015a) A prag-
matic randomized controlled trial to evaluate the effectiveness of a
facilitated exercise intervention as a treatment for postnatal depres-
sion: the PAM-PeRS trial. Psychol Med 45:2413–2425. https://doi.
org/10.1017/S0033291715000409

Daley AJ, Foster L, Long G, Palmer C, Robinson O, Walmsley H, Ward
R (2015b) The effectiveness of exercise for the prevention and

502 P.-Z. Lin et al.

https://doi.org/10.1067/mob.2003.336

https://doi.org/10.1067/mob.2003.336

https://doi.org/10.1080/00016340600697652

https://doi.org/10.1007/s12529-016-9556-9

https://doi.org/10.1146/annurev-clinpsy-032813-153734

https://doi.org/10.2105/ajph.90.4.602

https://doi.org/10.1016/j.genhosppsych.2008.04.001

https://doi.org/10.1016/j.genhosppsych.2008.04.001

https://doi.org/10.1016/j.yhbeh.2015.08.008

https://doi.org/10.1080/01674820903212136

https://doi.org/10.1080/01674820903212136

https://doi.org/10.1017/s0033291711000900

https://doi.org/10.1017/s0033291711000900

https://doi.org/10.1007/s11469-012-9416-z

https://doi.org/10.1007/s11920-007-0034-6

https://doi.org/10.1007/s11920-007-0034-6

https://doi.org/10.1111/j.1600-0447.2007.00998.x

https://doi.org/10.1016/j.cpr.2006.11.001

https://doi.org/10.1017/S0033291715000409

https://doi.org/10.1017/S0033291715000409

treatment of antenatal depression: systematic review with meta-anal-
ysis. BJOG 122:57–62. https://doi.org/10.1111/1471-0528.12909

Duval S, Tweedie R (2000) Trim and fill: a simple funnel-plot-based
method of testing and adjusting for publication bias in meta-analy-
sis. Biometrics 56:455–463. https://doi.org/10.1111/j.0006-341X.
2000.00455.x

Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G,
Swinson T (2005) Perinatal depression: a systematic review of prev-
alence and incidence. Obstet Gynecol 106:1071–1083. https://doi.
org/10.1097/01.aog.0000183597.31630.db

Gellatly J, Bower P, Hennessy SUE, Richards D, Gilbody S, Lovell K
(2007) What makes self help interventions effective in the manage-
ment of depressive symptoms ? Meta-analysis and meta-regression.
Psychol Med 37:1217–1228. https://doi.org/10.1017/
S0033291707000062

Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring
inconsistency in meta-analyses. Br Med J 327:557–560

Huffcutt AI, Arthur W (1995) Development of a new outlier statistic for
meta-analytic data. J Appl Psychol 80:327–334

Kelly RH, Russo J, Katon W (2001) Somatic complaints among pregnant
women cared for in obstetrics: normal pregnancy or depressive and
anxiety symptom amplification revisited? Gen Hosp Psychiatry 23:
107–113. https://doi.org/10.1016/s0163-8343(01)00129-3

King E (2009) The effectiveness of an internet-based stress management
program in the prevention of postpartum stress, anxiety and depres-
sion for new. Walden University, Mothers

Leung BMY, Kaplan BJ (2009) Perinatal depression: prevalence, risks,
and the nutrition link—a review of the literature. J Am Diet Assoc
109:1566–1575. https://doi.org/10.1016/j.jada.2009.06.368

Lewis BA, Gjerdingen DK, Avery MD, Sirard JR, Guo H, Schuver K,
Marcus BH (2014) A randomized trial examining a physical activity
intervention for the prevention of postpartum depression: the healthy
mom trial. Ment Health Phys Act 7:42–49. https://doi.org/10.1016/j.
mhpa.2013.11.002

Milgrom J, Danaher BG, Gemmill AW, Holt C, Holt CJ, Seeley JR, Tyler
MS, Ross J, Ericksen J (2016) Internet cognitive behavioral therapy
for women with postnatal depression: a randomized controlled trial
of MumMoodBooster. J Med Internet Res 18(54):e54. https://doi.
org/10.2196/jmir.4993

Mohammadi F, Malakooti J, Babapoor J, Mohammad-Alizadeh-
Charandabi S (2015) The effect of a home-based exercise interven-
tion on postnatal depression and fatigue: a randomized controlled
trial. Int J Nurs Pract 21:478–485. https://doi.org/10.1111/ijn.12259

Moher D, Shamseer L, Clarke M et al (2015) Preferred reporting items for
systematic review and meta-analysis protocols (PRISMA-P) 2015
statement. Syst Rev 4(1). https://doi.org/10.1186/2046-4053-4-1

O’Mahen HA, Woodford J, McGinley J, Warren FC, Richards DA, Lynch
TR, Taylor RS (2013) Internet-based behavioral activation–
treatment for postnatal depression (Netmums): a randomized con-
trolled trial. J Affect Disord 150: 814-22. https://doi.org/10.1016/j.
jad.2013.03.005

O’Mahen HA, Richards DA, Woodford J, Wilkinson E, McGinley J,
Taylor RS, Warren FC (2014) Netmums: a phase II randomized
controlled trial of a guided Internet behavioural activation treatment
for postpartum depression. Psychol Med 44:1675–1689. https://doi.
org/10.1017/S0033291713002092

Peters J, Booth A, Peters R (2015) Potential for specific dihydropyridine
calcium channel blockers to have a positive impact on cognitive
function in humans: a systematic review. Ther Adv Chronic Dis 6:
160–169. https://doi.org/10.1177/2040622315582353

Pugh NE, Hadjistavropoulos HD, Dirkse D (2016) A randomised con-
trolled trial of therapist-assisted, Internet-delivered cognitive behav-
ior therapy for women with maternal depression. PLoS One 11:1–
14. https://doi.org/10.1371/journal.pone.0149186

Roness A, Mykletun A, Dahl AA (2005) Help-seeking behaviour in
patients with anxiety disorder and depression. Acta Psychiatr
Scand 111:51–58

Rosenthal R (1979) The file drawer problem and tolerance for null results.
Psychol Bull 86:638–641

Rosenthal R (1991) Meta-analytic procedures for social research. Sage,
Newbury Park, CA

Sockol LE (2015) A systematic review of the efficacy of cognitive be-
havioral therapy for treating and preventing perinatal depression. J
Affect Disord 177:7–21. https://doi.org/10.1016/j.jad.2015.01.052

Sockol LE, Epperson CN, Barber JP (2011) A meta-analysis of treat-
ments for perinatal depression. Clin Psychol Rev 31:839–849.
https://doi.org/10.1016/j.cpr.2011.03.009

Verhagen AP, de Vet HCW, de Bie RA, Kessels AGH, Boers M, Bouter
LM, Knipschild PG (2017) The Delphi list. J Clin Epidemiol 51:
1235–1241. https://doi.org/10.1016/S0895-4356(98)00131-0

Wisner KL, Sit DKYY, Hanusa BH et al (2009) Major depression and
antidepressant treatment: impact on pregnancy and neonatal out-
comes. Am J Psychiatry 166:557–566. https://doi.org/10.1176/
appi.ajp.2008.08081170

Effectiveness of self-help psychological interventions for treating and preventing postpartum depression: a… 503

https://doi.org/10.1111/1471-0528.12909

https://doi.org/10.1111/j.0006-341X.2000.00455.x

https://doi.org/10.1111/j.0006-341X.2000.00455.x

https://doi.org/10.1097/01.aog.0000183597.31630.db

https://doi.org/10.1097/01.aog.0000183597.31630.db

https://doi.org/10.1017/S0033291707000062

https://doi.org/10.1017/S0033291707000062

https://doi.org/10.1016/s0163-8343(01)00129-3

https://doi.org/10.1016/j.jada.2009.06.368

https://doi.org/10.1016/j.mhpa.2013.11.002

https://doi.org/10.1016/j.mhpa.2013.11.002

https://doi.org/10.2196/jmir.4993

https://doi.org/10.2196/jmir.4993

https://doi.org/10.1111/ijn.12259

https://doi.org/10.1186/2046-4053-4-1

https://doi.org/10.1016/j.jad.2013.03.005

https://doi.org/10.1016/j.jad.2013.03.005

https://doi.org/10.1017/S0033291713002092

https://doi.org/10.1017/S0033291713002092

https://doi.org/10.1177/2040622315582353

https://doi.org/10.1371/journal.pone.0149186

https://doi.org/10.1016/j.jad.2015.01.052

https://doi.org/10.1016/j.cpr.2011.03.009

https://doi.org/10.1016/S0895-4356(98)00131-0

https://doi.org/10.1176/appi.ajp.2008.08081170

https://doi.org/10.1176/appi.ajp.2008.08081170

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• Effectiveness of self-help psychological interventions for treating and preventing postpartum depression: a meta-analysis

Abstract
Introduction
Materials and methods
Data sources and search strategy
Literature selection and data extraction
Statistical analysis
Assessment of study quality
Results
Study characteristics
Study quality and sensitivity analysis
Study designs and participants
Meta-analysis findings
Postintervention postpartum depressive symptoms following self-help interventions
Comparison of postpartum depressive symptoms between postintervention and follow-up assessments for self-help interventions
Comparison of postintervention postpartum depressive symptoms between intervention and control conditions
Comparison of postpartum depressive symptoms between interventions and control conditions at follow-up
Postintervention recovery and improvement rates

Discussion
References