CBT Best for Perinatal Depression Prevention, USPSTF Says

Batya Swift Yasgur, MA, LSW

February 13, 2019

The US Preventive Services Task Force (USPSTF) has issued a final recommendation statement and evidence summary on interventions to prevent depression in women during pregnancy and/or following childbirth.

Based on "convincing evidence," the Task Force recommended counseling — specifically, cognitive behavioral therapy (CBT) and interpersonal therapy — as effective for preventing perinatal depression.

These modalities are recommended especially for women with a history of depression, current depressive symptoms, or economic risk factors such as low income or young or single parenthood.

"[Perinatal depression] is a very common problem. Our evidence review suggests that one in seven pregnant women will become depressed and up to 40% will have an episode of depression during the 1-year postpartum period," Task Force member and coauthor Karina Davidson, PhD, MASc, told Medscape Medical News.

"Effective counseling interventions, in particular CBT and interpersonal therapy, can help prevent perinatal depression before it develops," she added.

The recommendations were published online February 12 in JAMA.

Response to Feedback

USPSTF has a "very transparent and open process" that leads to the "contemplation of new recommendations," Davidson said.

The new recommendation was finalized following a draft version that was available for public comment from August 28, 2018 to September 24, 2018.

"We welcome public suggestions and society suggestions, and we regularly review literature in areas related to screening and prevention to see if there is a new topic to be developed."

"When we issued our 2016 recommendations on screening all adults — including pregnant women — for depression, we got feedback from clinicians that we were very helpful in telling them what to do if a patient screened as likely depression — in other words, to do a further diagnostic workup and treat depression if it were there," she recounted.

"But there is, of course, a very large group of people who are not currently depressed but have some depressive symptoms and are at risk of depression, including women during the perinatal period," she continued.

Since the role of the USPSTF is to make recommendations about the effectiveness of preventive care services for patients without obvious related signs or symptoms, it turned its attention to this population, she said.

Risk Factors

The USPSTF "recommends that clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions."

This population consists of pregnant women or women who are less than 1 year postpartum and do not have a current diagnosis of depression but are at increased risk.

The recommendation is categorized as Grade B, meaning "there is high certainty that the net benefit is moderate, or there is moderate certainty that the health benefit is moderate to substantial."

Clinical risk factors that may be associated with the development of perinatal depression include:

  • A personal or family history of depression

  • Physical or sexual abuse

  • Having an unplanned or unwanted pregnancy

  • Current stressful life events

  • Pregestational or gestational diabetes

  • Complications during pregnancy (eg, preterm delivery or pregnancy loss)


Social risk factors include:

  • Low socioeconomic status

  • Lack of social or financial support

  • Adolescent parenthood

Pragmatic Approach

The authors caution there is "no accurate screening tool for identifying women at risk of perinatal depression and who might benefit from preventive interventions."

Nevertheless, they encourage a "pragmatic approach based on the populations included in the systematic evidence review."

This would involve providing counseling interventions to women who have one or more of the following:

  • History of depression

  • Current depressive symptoms (that do not reach a diagnostic threshold)

  • Socioeconomic risk factors (eg, low income, adolescent/single parenthood, recent intimate partner violence)

  • Mental health-related factors (eg, elevated anxiety symptoms)

  • History of significant negative life events

Effective Interventions

The main interventions included in studies about prevention of perinatal impression were CBT and interpersonal therapy.

CBT "focuses on the concept that positive changes in mood and behavior can be achieved by addressing and managing negative thoughts, beliefs, and attitudes and by increasing positive events and activities," the authors explain.

Interpersonal therapy "focuses on treating interpersonal issues thought to contribute to the development or maintenance of psychological disorders," they state.

"We reviewed studies of other interventions, such as physical activity education, pharmacotherapy, dietary supplements, and health system interventions, but did not find sufficient evidence to judge that these were beneficial," Davidson reported.

She added that the Task Force "looks forward to seeing further research in those areas."

The therapeutic programs included in the review were primarily in-person and used an in-group session format, with counseling sessions ranging from four to 20 meetings (median, eight meetings) and lasting for 4 to 70 weeks.

Intervention staff included psychologists, midwives, nurses, and other mental health professionals.

The authors provide several examples of therapeutic programs, including the "Mothers and Babies" program, which uses a cognitive behavioral approach and the "Reach Out, Stand Strong, Essentials for New Mothers (ROSE)" program, which uses an interpersonal therapy approach.

More Than the 'Baby Blues'

"I can tell you from other evidence bases that researchers have studied comparative effectiveness of online vs in-person formats and in-person vs telephone deliveries, but we didn't find evidence of those types of delivery modes [online or telephone-based] in our review."

She added that they would "certainly welcome more research so that we can evaluate other approaches for their effectiveness."

The authors note that there are no data available on the "ideal timing" for offering or referring patients for counseling interventions, although most were initiated during the second or third trimester of pregnancy.

"Ongoing assessment of risks that develop in pregnancy and the immediate postpartum period would be reasonable and referral could occur at any time," they state.

Davidson emphasized that postpartum symptoms, sometimes called the "baby blues," are different from true clinical depression.

"Generally, the 'baby blues' are a transient period of irritability, crying, and sleep changes, while depression continues for more than 2 weeks, is accompanied by anhedonia or depressed mood, and involve other additional symptoms," she said.

"The critical differentiator for clinicians is whether there are symptoms that are clinically impairing for the patient, and if the symptoms endure, clinicians have to start thinking diagnostically if they meet criteria for depression," she added.

Real-World Challenges

Commenting on the recommendations for Medscape Medical News, Marlene P. Freeman, MD, associate professor of psychiatry, Harvard Medical School and associate director, Ammon-Pinizzatto Center for Women's Mental Health, Boston, Massachusetts, who was not involved with the Task Force, said that "the new guidelines have the potential to help many women and their children."

However, although the potential benefits are "notable," there are "major challenges to the implementation of the guidelines," warned Freeman, who is the author of an accompanying editorial.

One challenge is that it is "easier to screen for acute perinatal depression than for women at risk," since there are "easy-to-use screening tools for acute depression that have been used in the obstetrical setting" but currently no "simple scales" or "simple standards" for preventive screening.

Moreover, screening for perinatal depression is "just a first step," and after screening, "it is important that women are given treatment referrals, that those referrals are accessible and utilized, and there is follow-up in place to ensure that women who are suffering from perinatal depression improve," she said.

This is challenging because the specialized psychotherapies may not be available to the large number of women who may benefit from them, as "access to mental health care remains a major challenge in this country," she observed.

For this reason, "it will be imperative for multidisciplinary healthcare providers, advocacy groups, and other stakeholders to brainstorm together on how to make sure that women who are identified as 'at risk' receive appropriate referrals and are able to engage in care."

She noted that it is important to consider the many factors that will inform which strategies will work best for which particular groups of women, including cultural, geographic, educational, and socioeconomic differences, as well as health insurance coverage.

"It is likely that creative solutions will need to be found to make sure that treatments are available to women who need them," she said.

Davidson agreed that it may be challenging for healthcare providers to offer or refer patients to these interventions because "there isn't easy access to this kind of care everywhere."

She noted that the USPSTF recommendation offers suggested resources for clinicians, including the Substance Abuse and Mental Health Administration (SAMHSA) and Health Resources and Services Administration (HRSA) Center for Integrated Health Solutions, which provides resources that integrate primary and behavioral health; the SAMHSA website, which provides resources for locating mental health services; and the Mothers and Babies Program website.

Additionally, Davidson encouraged clinicians to use the USPSTF's recommendation for screening for depression in adults.

The USPSTF is an independent, voluntary body. The US Congress mandates that the Agency for Healthcare Research and Quality support the operations of the USPSTF. No disclosures are listed for Davidson. Disclosures for the other Task Force members are listed here. Freeman has reported participating in investigator-initiated trials/research for Takeda, JayMac, and Sage; serving on advisory boards for Otsuka, Alkermes, Janssen, Sage, and Sunovion; serving on an independent data safety and monitoring committee for Janssen (Johnson & Johnson); and editing the GOED (Global Organization for EPA & DHA Omega-3) newsletter. Freeman's additional disclosures are listed with the original article.

JAMA. Published online February 12, 2019. Guidelines, Editorial 1, Editorial 2, Editorial 3, Editorial 4, Patient Page

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