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