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Cognitive behavioural therapy best prevents postpartum depression
R NewmanMedical University of South Carolina, Charleston, SC, USA
Linked article: This is a mini commentary on Carrick-Sen DM et al., pp. 1302–1310 in this issue. To view this article
visit http://dx.doi.org/10.1111/1471-0528.12728.
Published Online 19 May 2014.
Multiple birth is associated with a
doubling of the risk of maternal
mental health disorders. This investi-
gation recognises the substantial
impact that maternal depression can
have on successful parenting, child
health, and family functioning.
The authors explore whether a sup-
portive/educational midwifery inter-
vention can reduce the risk of
postpartum depression (PPD). I pro-
vide this commentary believing that
nurse midwives bring substantial
value to the care of women with
twins (Ellings et al., Obstet Gynecol
1993;81:387–91).Unfortunately, the author’s results
are not conclusive. Women received
care in an antenatal multidisciplinary
twin clinic with specialist midwives
and additional pre- and postnatal
visits. Participants and spouses in the
intervention group attended a series
of educational programmes on par-
enting multiples. The intervention
group reported greater maternal
wellbeing, family support, mood,
self-confidence, and felt better pre-
pared for parenting; however, the
primary outcome was a reduction in
maternal depression as measured by
the Edinburgh Postnatal Depression
Scale (EPDS). The mean maternal
EPDS was lower at 26 weeks post-
partum, but it was not significantly
different from the control group
scores. Nor were there any differ-
ences in maternal anxiety or parent-
ing stress. Unfortunately, the study
was substantially underpowered.
A recent meta-analysis of 19 stud-
ies (5806 patients), including seven
designed to prevent PPD, reviewed
the efficacy of cognitive behavioural
therapy (CBT) or interpersonal psy-
chotherapy (Cuijpers et al., Am J
Psychiatry 2008;165:1272–80). These
interventions were associated with an
overall 22% reduction in the inci-
dence of depressive disorders. The
number needed to treat (NNT) to
prevent one depressive disorder
was 22. Psychological interventions
worked best for those at highest risk,
and interpersonal psychotherapy may
be slightly more effective than CBT.
It concluded that prevention of
depressive disorders is possible, and
is associated with an enormous
reduction in public health burden.
Another relevant study screened
first-time pregnant women and
randomised the women who screened
positive to a Preparing for Parent-
hood educational programme
designed to increase social support
and problem-solving skills. Assign-
ment to the intervention group did
not significantly affect postnatal
depression at 3 months (Brugha
et al., Psychol Med 2000;30:1273–81).In the absence of a specific therapy
designed to reduce maternal stress,
the likelihood of preventing PPD with
education and support alone is proba-
bly low.
Another systematic review of 15
trials (7697 women) offering psycho-
logical interventions revealed a
non-significant reduction (RR 0.81,
95% CI 0.65–1.02) in the frequency of
depressive disorders. The most effec-
tive intervention was intensive post-
partum support provided by a health
professional (RR 0.68, 95% CI 0.55–0.84), and individually based inter-
ventions were more effective than
group interventions (Dennis, BMJ
2005;331:7507–15).Women carrying twins are at high
risk for PPD and good candidates for
preventative interventions. The devel-
opment of novel, cost-effective inter-
ventions deserves further research
attention. This intervention may have
shown greater efficacy by focusing on
even higher risk multiples such as
those with a history of mental illness,
prior fetal or infant death, or antena-
tal depression. CBT interventions
designed to reduce postnatal maternal
stress and/or anxiety appear to be
more effective than education-based
interventions. Midwives involved in
pre- and postnatal care could abso-
lutely be trained to provide CBT, and
are likely to be more acceptable to
parturients than either psychologists
or psychiatrists.
Disclosure of interestsThe author has no conflict of inter-
ests or disclosures.&
1311ª 2014 Royal College of Obstetricians and Gynaecologists
Newcastle twin study