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USPSTF: Refer pregnant, postpartum women at increased risk for perinatal depression to counseling
The U.S. Preventive Services Task Force recently gave a ‘B’ level recommendation to referring pregnant women and women less than 1-year postpartum at increased risk of perinatal depression for counseling-based interventions.
The recommendation, published in JAMA, is the first the USPSTF made for this condition.
There is no accurate screening tool for ascertaining who is at risk for perinatal depression, but some risk factors have been identified: intimate partner violence, stressful events, history of physical or sexual abuse and depression, unwanted or unplanned pregnancy, and complications during pregnancy, Katherine O’Connor, PhD, of the Kaiser Permanente Research Affiliates Evidence-Based Practice Center in Oregon, and colleagues wrote.
Women with low socioeconomic status, who lack of social support and who gave birth as a teenager are a greater risk for developing perinatal depression after delivery, they added.
O’Connor and colleagues reviewed 50 studies. Of the interventions studied, counseling-based interventions were associated with a lower likelihood of perinatal depression onset vs. controls (pooled RR = 0.61; 95% CI, 0.47-0.78). The absolute difference in risk for perinatal depression ranged from 31.8% greater reduction in the intervention group vs. 1.3% in the control group.
“Counseling interventions can be effective in preventing perinatal depression, although most evidence was limited to women at increased risk for perinatal depression. A variety of other intervention approaches provided some evidence of effectiveness but lacked a robust evidence base and need further research,” O’Connor and colleagues wrote.
In a related editorial, Marlene P. Freeman, MD, of the department of psychiatry at Massachusetts General Hospital, wrote that there are barriers to overcome before applying the USPSTF recommendations in clinical practice.
“Feasibility will require a commitment of resources and continued research into how to one: identify at-risk women, two: connect identified women to evidence-based treatments, and three: assess outcomes,” she wrote.
The ways to help these females will not be run-of-the-mill and will likely involve some effort to come to fruition, Freeman added.
“The delivery of effective care on a large scale will require creative solutions. The counseling interventions with the most robust efficacy ... require education and training. ... Options such as training of lay personnel or large-scale telehealth or internet- and smartphone-based platforms should be considered. Also, multidisciplinary teams should be involved in the care of women at the highest risk of severe illness and specialty consultation should be available for women who develop acute psychiatric illness and require more complex care,” she wrote. – by Janel Miller
References:
Freeman MP. JAMA. 2019;published online ahead of print.
O'Connor E, et al. JAMA. 2019;doi:10.1001/jama.2018.20865
U.S. Preventive Services Task Force. JAMA. 2019;doi:10.1001/jama.2019.0007.
Disclosures: Please see the studies and editorial for the authors relevant financial disclosures.
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I do believe that connecting women at risk for developing postpartum depression to evidence-based counseling is the best solution since it has no adverse effects and has proven efficacy.
However, there are some limitations. For example, not all women want therapy. Also, there are access issues based on limited workforce availability in some geographic areas, insurance coverage restrictions and problems with obtaining child care and transportation to get to therapy. In rural areas, with their limited workforces, long distances to clinics, weather conditions, lack of transportation, gas costs, etc., primary care physicians especially have a large problem connecting women to counseling and therapy. Therefore, alternative delivery options should be explored further such as integrating counselors directly in obstetric clinics or delivering counseling to the patients’ homes through telehealth or home visiting programs. Such efforts are already underway but are not universally available to all who may need it.
Given that counseling with evidence-based therapies is not available everywhere, I recommend that PCPs encourage also the use of the less researched approaches that the USPSTF identified. It is likely that in the collective all these other approaches do help as well. I tell all the PCPs I consult with to encourage exercise, yoga, omega-3 and vitamin D supplementation, and use of mindfulness apps, etc. Women want to self-select what feels right to them, not only what the research suggests. That’s the pragmatic approach I take.
The only treatments I would not recommend prophylactically — because there is no evidence for benefit and there is potential harm — are medications like selective serotonin reuptake inhibitor and hormones. Only if the woman is already depressed (for, example, has an elevated score on the Edinburgh Postnatal Depression Scale [EPDS] of 13 or more), then it is recommended to discuss adding medicines to her treatment regimen with her as well. For women who are in the grey zone, for example, have mild depression with EPDS scores between 9 and 12, but have lots of stress in their environment, limited coping, and no resources for other treatments, then medicines may also be an only good option.
We urgently need universally accessible systems for screening, not only for depression, but also for all the other identified risk factors (such as life stress, intimate partner violence, etc); such screening could be technology-based and should be easily integrated with standard electronic medical records. Such screeners could alert integrated clinicians in primary care settings who then would deliver counseling to at risk patients on the spot. We have some models, but they are not universally implemented. I, and others, are currently working on such models of universal technology-based screening and integrated clinical service (counseling) via telehealth to match need and ease access.