Psychological care | Cochrane Equity

Psychological and psychosocial interventions reduce symptoms of depression by 52% in postpartum mothers.

baby

Photo credit: Curt Carnemark

Why are psychosocial or psychological interventions important?

Postpartum depression is a major health issue for women of many cultures. Women suffering from postpartum depression experience disabling symptoms such as uneasiness, confusion, forgetfulness, irritability, fatigue, insomnia, anxiety, guilt, inability to cope, and thoughts of suicide. There may also be effects on the infant because of impaired maternal-infant interactions. Antidepressant medications are not widely used for postpartum depression because of concerns regarding whether they are transmitted to breast-fed infants. Therefore non-pharmaceutical treatments are important.

Do psychosocial or psychological interventions work?

Psychosocial and psychological interventions reduce depressive symptoms by 52%. Psychosocial interventions, such as peer support and non-directive counseling were slightly more effective than psychological interventions (cognitive behavioural therapy and psychodynamic therapy).

Equity: do psychosocial or psychological interventions work in the disadvantaged?

None of the included studies were conducted in low or middle income countries and does not provide a description of the participants according to the PROGRESS-Plus criteria (see notes in the right-hand column). However, the results are likely applicable for disadvantaged mothers.

Intervention Delivery

Psychosocial interventions included peer support and non-directive counseling. These interventions were provided by trained health visitors, nurses, or peer volunteers.
Psychological interventions included cognitive behavioural therapy or psychodynamic therapy and were provided by health professionals. One intervention was group-based.
All interventions were provided face-to-face except for one telephone-based peer support intervention.

Population and Setting

Women had either received a clinical diagnosis for depression or had self-reported depressive symptomatology.
All included studies were conducted in high-income countries: Australia, Canada, Sweden, United Kingdom, United States

Summary of Findings [SOF] Tables:

Patient or population: Mothers with postpartum depression in high-income countries
Settings: High income countries – Australia, Canada, Sweden, United Kingdom, United States
Intervention: All interventions, psychosocial only, psychological only
Comparison: Usual postpartum care

Outcomes	Anticipated absolute effects per year		Odds Ratio (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)
	Risk without psychosocial or psychological interventions (Control)	Risk difference with psychosocial or psychological interventions (95% CI)
All Intervention: Evidence of depression at final assessment within 1 year
- any measure of depressive symptomatology	52.8 per 100	15.8 fewer per 100 (from 10.0 to 21.1 fewer)	OR 0.48 (0.37-0.62)	956 (9)	Moderate
- Edinburgh Postnatal Depression Scale (EPDS) >12	56.1 per 100	31.4 fewer per 100 (from 11.2 to 42.6 fewer)	OR 0.26 (0.10-0.67)	81 (1)	Low
- Individually based interventions	52.2 per 100	15.1 fewer per 100 (from 9.4 to 20.4 fewer)	OR 0.49 (0.37-0.68)	917 (8)	Moderate
- Group-based interventions	63.2 per 100	28.39 fewer per 100 (from 45.5 fewer to 6.3 more)	OR 0.31 (0.08-1.16)	39 (1)	Low
Psychosocial interventions – evidence of depression at final assessment within first year	45.8 per 100	17.86 fewer per 100 (from 2.8 to 27.9 fewer)	OR 0.54 (0.37-0.77)	506 (5)	Moderate
Psychological interventions – evidence of depression at final assessment within first year: Cognitive-behavioural therapy	43.95 per 100	12.31 fewer per 100 (from 4.4 to 18.9 fewer)	OR 0.61 (0.42-0.89)	482 (5)	Moderate
Psychological interventions – evidence of depression at final assessment within first year – Cognitive behavioural therapy and interpersonal psychotherapy	52.0 per 100	13.0 fewer per 100 (from 6.2 to 19.2 fewer)	OR 0.61 (0.44-0.84)	602 (6)	Moderate
Adverse Events:
About quality of evidence (GRADE) High quality (High): Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality (Moderate): Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality (Low): Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality (Very low): We are very uncertain about the estimate.

1. The authors assessed the papers as low methodological quality.

2. Only one study with low sample size.

Relevance of the review for disadvantaged communities Psychological and psychosocial interventions reduce symptoms of depression by 52% in postpartum mothers. None of the studies were conducted in low-resource settings but the results are likely applicable.
Findings	Interpretation
Equity - Which of the PROGRESS groups examined
The studies included postpartum women who had been diagnosed or self-reported as depressed.	This review aimed to assess the effectiveness of interventions to treat postpartum depression but does not provide evidence for preventing postpartum depression. Another Cochrane systematic review addresses prevention.
Equity Applicability
All included studies were conducted in high-income countries.	The interventions may have different effectiveness within different settings depending on the social, cultural, and organizational environments. Psychosocial and psychological interventions are likely to be effective in disadvantage populations.
There are many barriers to postpartum depression treatment including stigma, transportation, and childcare.	Policymakers implementing interventions to treat postpartum depression need to ensure these barriers are addressed to ensure treatments are accessible. Alternative treatments, such as telephone based counseling or support, are options to overcome these barriers.
Cost-equity
None of the included studies examined the costs of psychological and psychosocial interventions.	The interventions are labour intensive and therefore could have high costs. The costs of treatment need to be determined and weighed against the benefits of the treatment. For individual patients, certain interventions, for example, telephone peer support could be more cost-equitable than medications or counseling.

Comments on this summary? Please contact Jennifer Petkovic